Drew Hughes, 13, died unexpectedly and tragically a few hours after sustaining a head injury while skateboarding. A young life ended that brought undeniable balance to his family. Drew was full of life that brought laughter and light to all who knew him. Every patient is somebody's father, mother, daughter, or son. During the patient transport, Drew had to be re-intubated, although he had previously been awake and talking, and as a result of an improperly placed ET tube he arrive at the trauma center with an anoxic brain injury. Drew's death is just one case, but we know that it is not the only case where patient harm was the result of multiple points of failure within a system of care. This presentation examines the case and exploits the failure points and how we can build defenses to prevent failure in the future.