A neonatal foal presented to the Equine Hospital at Cornell University on May 28th, 2016 as a healthy companion to his dam. During parturition, the dam suffered from a rectal prolapse and was ultimately euthanized. A nurse mare was brought in for the foal who remained in the hospital to address bilateral forelimb contracture. The treatment plan included intravenous administration of oxytetracycline. Several days later a focal swelling was noted around the catheter site and the catheter was removed. The foal eventually developed a fever and effusive hock joints. Initiating prompt treatment within 24 hours is of particular significance in foals with signs of septic arthritis¹. Despite aggressive and timely treatments, radiographs eventually revealed multiple fracture lines and bone lysis within the hocks bilaterally. Euthanasia was elected and the foal was submitted for necropsy. This foal had adequate passive transfer (1600 mg/dL), showed no respiratory or GI signs and began aggressive, multimodal therapy within 24 hours. So the question remains: what went wrong? Various circumstances of this case resulted in an unfortunate outcome and are important to acknowledge for future implications.