For 50 years Linda Sue Brown's nine siblings fiercely protected her, facing down anyone who would taunt her or seek to exploit the disability that left her with the mental capacity of a 12-year-old.
That sense of responsibility only grew after their 81-year-old mother, Brown's lifelong caretaker, was stricken with Alzheimer's disease, leaving her unable to tend to her daughter.
So when Brown's lower legs swelled last summer and she grew short of breath, her eldest sister rushed her to a place the family knew and trusted: Brotman Medical Center in Culver City. One of Brown's sisters, Thelma Allen, worked there as a nurse; another, Rosslyn Diamond, had previously been a nurse there. And Brown had been treated there, successfully, for years.
At the 420-bed hospital, tests revealed that Brown had an enlarged heart, fluid in her lungs and severe anemia, medical records show. She received blood transfusions and, two days later, an emergency hysterectomy. Afterward, Allen was given an unorthodox, but welcome, assignment: She was to be one of Brown's nurses.
On July 4, after her shift ended, Allen watched TV with Brown, then kissed her good night.
By the time she returned the next morning, her sister was dead.
The death was probably caused by a pulmonary embolism, a clot of blood blocking an artery to the lungs, Diamond recalled the surgeon saying. If so, nothing could have saved her.
For most grief-stricken relatives, the questions would have ended here. Patients die unexpectedly in hospitals every day. If families have vague doubts about why and how, they typically lack the knowledge and access to get answers.
But Diamond, 60, and Allen, 59, vowed to find out what happened to their sister.
Along the way, they discovered that their decades of experience afforded them little advantage over any other bereaved family. Instead, almost everything they believed about the medical profession was turned on end. And ultimately, the answers they battled to get have provided little comfort.
After months of investigation, state health inspectors determined that Brown's death was nothing so random as an embolism.
Brotman staffers, the inspectors found, had failed Brown in virtually every way: Her nurses -- Allen's colleagues -- appear to have forged consent forms and had Brown sign agreements that she couldn't understand. One failed to call for help as Brown's vital signs plummeted.
