Abstract: At 8:30 a.m. on October 21, 1999, Employee #1, a carpenter for a framing contractor, was working alone at a single-family house under construction. He had completed finish-nailing the wood trusses to the top plate when he went to the job trailer and complained of shoulder pain. At that time, he stated that the pain began when he pulled himself up, but it was not clear whether he meant pulled himself up a ladder that was on site, pulled himself up by grasping the truss as he ascended the ladder, or pulled himself up while standing on the ground. The foreman, who was also his father, took him to Sutter Roseville Medical Center, where he was treated for an acromioclavicular separation of the left shoulder and released that afternoon. That evening, he was seen at Oroville Hospital for pain and released. On October 23, 1999, his family again took him to Oroville Hospital due to his deteriorating condition. The doctor identified multi-systemic problems and arranged to have him flown to U.C. Davis Medical Center, where he died that evening. The death certificate listed the immediate cause of death as sepsis due to necrotizing fasciitis due to left shoulder trauma. The coroner's office interpreted this as infection and flesh-eating bacteria due to the dislocated shoulder. Due to the unusual cause of death, an independent physician reviewed the treatment records of the three hospitals involved and found that death had been caused by the dislocated shoulder.