Following a cesarean delivery, the wife of our client developed an infection of the incision. She was released by the doctor from the hospital with a fever and a draining wound, and continued to worsen over the next three days. When she saw the doctor at his office in the early afternoon three days later she reported a moist and smelly incision line, elevated temperatures and unexpected fatigue. The doctor noted abdominal swelling and prescribed an antibiotic. On the early evening she was admitted to the hospital on an emergent basis with sepsis and respiratory collapse. She died several days later. A recovery was obtained for her husband and infant daughter.