The Outcome: Our client was a 41 year old female who underwent an operative procedure that involved extensive lysis of adhesions. Within hours after the surgery, she became short of breath and tachycardic. She exhibited altered mental status, fever, and abdominal pain, meeting all of the SIRS criteria over the following days. A pelvic CT scan showed extensive free air and fluid in the abdomen and the report indicated this was worrisome for a bowel perforation. A repeat pelvic CT imaging study with contrast was suggested. No repeat study was done, nor was any surgical consult. Instead, our client was sent home from the hospital where within several days she became septic and suffered serious injuries.