Abstract
INTRODUCTION: Congenital heart diseases are non-communicable diseases of high incidence in the pediatric population, with variable severity spectrum. The suspicion of congenital heart disease diagnosis begins in the intrauterine period. CASE REPORT: A child was diagnosed at three years and nine months of age with complex congenital heart disease. He did not undergo the heart test in the maternity hospital, was not followed-up during childcare, and when he presented cardiac symptoms, he was evaluated by professionals with no experience with children. DISCUSSION: It is evident that the whole socioeconomic context influenced the delay in diagnosis. In addition, pediatric follow-up by untrained professionals may lead to misconduct, harming the patient. CONCLUSION: The failure of primary care can delay therapy, prolonging symptoms and increasing the risk of morbidity and mortality in the pediatric population, with risks that have not yet been measured.