In 2020, Mr. Cox and co-counsel brokered a confidential settlement for the family of a young woman who died of an aortic dissection while at her third emergency room visit within 5 days. At her first ER visit, after being admitted with severe pain in her ear and jaw, radiating into her chest, the emergency room doctor ordered a chest x-ray, which he advised the woman was normal despite a radiologist informing him the next morning showed a prominent thoracic aortic arch with descending aortic ectasia, which are both indications of a life-threatening aortic dissection demanding immediate attention. Despite this abnormal finding, neither the ER doctor nor the hospital made contact with the woman to advise of the results. When the woman returned to the emergency room several days later with similar complaints, another emergency room doctor did not look at the chest x-ray. Furthermore, the radiologist’s report making note of the emergent finding was not in the chart. When the woman returned to the emergency room for a third time two days later, a third emergency room doctor reviewed the chest x-ray film and report, but took no action. While in the process of discharging the woman, she died.This tragedy was a complete system failure of the doctors and hospital network. The woman’s death was entirely preventable and would not have occurred but for the multiple layers and episodes of negligence. If the woman had been properly advised of the abnormal x-ray even hours before her death, she could have immediately been taken into emergency surgery with an excellent chance of survival.As part of the settlement, Mr. Cox and his co-counsel insisted on changes in effective communication between emergency room doctors, hospitals, and patients.