On March 29, 2019, a mother rushed her 14-month-old daughter, the youngest of three children, back to the pediatric emergency department at Yale-New Haven Hospital where the child had been evaluated–and discharged–just one day earlier. By this time the child had a three day history of persistent fever, vomiting and poor feeding, all of which began shortly after she underwent a routine tube placement procedure in her ears on March 26. The child was admitted to the pediatric service under the care of pediatric doctors. Laboratory testing revealed two common cold viruses. However, additional testing revealed the presence of procalcitonin: an early indicator of systemic bacterial infection used also to differentiate between bacterial and viral infections. Although the Hospital’s laboratory protocols stated that repeat procalcitonin testing should be done every two days until a specified decrease is observed, repeat testing was not done. Instead, the child was discharged the next morning. Three days later, with symptoms persisting, the child’s pediatrician recommended urgent return to the hospital. Shortly after arriving at the hospital the child began exhibiting signs of neurological problems, which ultimately led to a diagnosis of bacterial meningitis, strokes, and resulting brain damage. Now, with an ongoing seizure disorder, impaired cognition and speech (currently she’s non-verbal), and impaired mobility, coordination, strength, balance, and motor function, the child likely need medical care, therapies and supports for the rest of her life.