Abstract: On December 27, 2012, Employee #1, a 42-year-old drywall installer employed by Grayhawk LLC, was working at a commercial building. He was working from a baker scaffold, at an elevation of approximately 23 inches, as he attempted to install wood sheathing (plywood) across a temporary exterior wall opening. Employee #1 did not have the scaffold's casters in the locked position. As he attempted to screw in the plywood, he reached forward, away from the scaffold. The scaffold began to roll out from underneath him. Employee #1 fell forward off the scaffold. His left thigh struck a structural upright member of the scaffold, causing a large contusion and swelling. He finished his shift and commuted home. Later that evening, Employee #1 went to the hospital complaining of pain and swelling in his left leg. He was admitted, and surgery was performed to correct bleeding and a tear in his left superficial femoral artery. Employee #1 remained hospitalized due to the formation of blood clots in his legs and lungs. On January 2, 2013, Employee #1 suffered a cardiac arrest, likely due to the pulmonary clotting, and died.