Despite a transformation in health services, Nepal continues to endure health system challenges at all levels. Several contributing factors include lack of transportation, poor quality roads, unavailability of quality healthcare facilities, low health literacy, and lack of communication which all play significant roles in the delay of diagnosis and treatment. This study aims to investigate the unexpected death of a nursing mother traveling on the bus in the remote hilly region of Nepal to highlight deficits in the healthcare system and the possibility this death could have been prevented. The starting point of the investigation was done through secondary sources of information such as online media. Also, an in-depth face-to-face interview was conducted with the victim’s husband. The main finding of this study showed the woman who died on the bus while nursing her child highlighted a serious health system challenge. The exact cause of the mother’s death was unrecognized. Early case identification and proper management at the local level were deemed to be a context-specific corrective measure to prevent death. This paper aims to demonstrate the unexpected and untimely death of a nursing mother, due to multiple factors including gaping deficits in the healthcare system across Nepal.