A critically ill patient is admitted with end-stage renal disease, pulmonary fibrosis, and heart failure. His skin is intact on arrival. Over the next three months, his condition spirals through ICU transfers, respiratory failure, a stroke, and sepsis — and a pressure injury develops that progresses from a minor skin tear to a Stage IV ulcer with exposed bone. He dies on Christmas Eve. This is the clinical story that became a multi-year malpractice case — and it starts here.

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