Minutes after routine surgery for acute appendicitis in October 2003, Staff Sgt. Dean Witt, 25, was being moved to a recovery room at a Northern California military hospital when he gasped and stopped breathing.

A student nurse assisting an understaffed anesthesia team tried to resuscitate Witt and failed. Inexplicably, Witt’s gurney was wheeled into a pediatric area. Lifesaving devices sized for children, not a 175-pound adult, proved useless, according to an internal report on the incident.

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