title: Loss prevention case of the month. Rare but deadly to delay.
authors.affiliation: State Volunteer Mutual Insurance Company, Brentwood, USA.
authors.forename: J K
authors.initials: JK
authors.lastname: Avery
mesh_terms: D001017:Aortic Coarctation / Q000175:diagnosis*; D003951:Diagnostic Errors / Q000331:legislation & jurisprudence / Q000517:prevention & control*; D017809:Fatal Outcome; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008318:Malpractice