A 27 year old man had a dual chamber pacemaker implanted in his right atrium and right ventricle at Kaiser Hospital, Oakland, California on June 15, 1987. Five months later on November 13, 1987, it was discovered by a chest x-ray that the wire in the right ventricle had formed a loop that had prolapsed near the outflow tract, leading to the pulmonary artery. Although the radiologist accurately reported the finding in a typed summary, the finding was never made known to the patient's treating physicians and was never told to the patient until April 2006, 19 years later. There were many subsequent x-rays, showing the position of the pacemaker wire, but none of the treating physicians looked at these chest x-rays and no-one informed the patient of the malposition and its possible consequences. Each time a chest x-ray was taken over 19 years, the radiologists reported no change in position from the previous x-ray. In March 2004 he had chest pain with exertion and signs of a systolic ejection murmur in the left sternal border that indicated a possible right ventricular outflow tract obstruction. This was the first time that the patient suffered appreciable harm from the earlier negligence of Kaiser physicians and we argued this event started the three year statute of limitations to run. It was not until 2006 that Kaiser physicians discovered that the right ventricular pacing lead had looped and prolapsed into the right ventricular outflow tract, causing tissue reaction that caused the obstruction. The obstruction had to be surgically removed in a high risk open heart surgery in August 2006 that was successful. Kaiser refused to compensate the patient for their failure to recognize and treat this problem. We proved at arbitration that the pacemaker wire could have been correctly positioned without surgery if it was done in 1987 and the patient would not have suffered the severe disabling effects that caused him to lose his position as the head pastor of a large Oakland church and required a life threatening surgery. Kaiser made no offer to settle the case and we won an award of $889,061 after several days of arbitration.