D-transposition of the great arteries (d-TGA) is a congenital heart defect. Failure to detect it prenatally may lead to rapid neonatal decompensation, severe hypoxia, and increased mortality. Conversely, prenatal cardiac diagnosis allows for planned delivery at a tertiary care centre and the timely performance of life-saving procedures such as balloon atrial septostomy (BAS). Despite its clinical significance, global prenatal detection rates for d-TGA often remain below 50% because the four-chamber view frequently appears normal. This case report highlights existing systemic gaps that have subsequently led to medical malpractice lawsuits filed by parents. In this manuscript, we present the perspectives of medical staff from a tertiary fetal cardiology centre and a lawyer. We address this publication to all our readers and invite their feedback: should information about the value of fetal echocardiography be part of perinatal care for every pregnant woman, or only for those at high risk (IVF pregnancy, family history, maternal chronic diseases, or any abnormality detected by obstetric ultrasound)? In your practice, does a missed prenatal diagnosis of d-TGA, or any other cardiac problem, prompt an analysis of the entire diagnostic process and healthcare system?

The failure to diagnose d-TGA prenatally is associated with complex technical, educational, and organisational factors. While modern medical approaches advocate for a “patient safety culture” focused on continuous system improvement rather than individual blame, the legal framework takes a more stringent stance. According to rulings by the Polish Supreme Court, physicians have a strict statutory obligation to continuously update their professional knowledge and thoroughly inform patients about available specialised diagnostic methods. Eliminating organisational and educational gaps within the perinatal care system is essential for improving d-TGA detection rates. However, a physician cannot legally justify a misdiagnosis by citing systemic flaws if they have not adequately informed the patient about the availability and significance of a specialised fetal cardiac examination.