A Texas newborn underwent a Norwood procedure at one week. She suffered from a hypoplastic right heart and double inlet left ventricle. At three months of age, she was taken to the ER for the third time, where she was recognized as having no pulses in her lower extremities and aortic arch coarctation status post stage I. Seven hours later she was transferred to another medical center in cardiogenic shock and acute renal failure. An echocardiogram revealed poor left ventricle function with tight aortic coarctation. She underwent a cardiac catheterization with balloon dilation, which resulted in improved perfusion. Post-op lab reports indicated hepatic and renal failure. She died two days later. A medQuest pediatric cardiologist reported that at the first medical center the infant's symptoms indicated heart failure. There was a negligent failure to take appropriate action, such as an echocardiogram, before the transfer. With timely diagnosis and treatment, the infant's life may have been saved.