A 23-year-old woman who was pregnant with her first child was being monitored weekly to ensure that she did not develop preeclampsia, a serious obstetrical condition. At approximately 36 weeks gestation, she presented to the doctors’ office for a scheduled appointment complaining of symptoms consistent with preeclampsia and with high levels of protein in her urine. She was sent straight to the labor and delivery unit of the hospital. Her baby was monitored and labs were ordered to rule out preeclampsia. After several hours, the patient was discharged. Prior to discharge, the lab results, which showed critical values confirming the patient had developed HELLP syndrome, were never read by the nurse or the nurse midwife. The lab results were never reported to the patient and several days later, the patient returned to the hospital in critical condition and was advised that her baby had died.