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.
Her doctors didn't investigate signs of heart failure, performed a risky emergency surgery with no clear justification and then didn't intervene as her condition deteriorated. And hospital officials didn't even look into what went wrong until inspectors inquired.
"That is just a pretty phenomenal failure," said Dr. Eric J. Thomas, an associate professor of medicine at the University of Texas, Houston, and a patient safety expert who reviewed Brown's medical records and the state report for the Los Angeles Times.
"Certainly anyone would classify it as a preventable death," he said.
Brotman leaders said that Brown was in precarious health, with ailments that included an enlarged heart, and that nothing staffers did could have changed the outcome. Health inspectors also judged Brotman staffers too harshly, they said, failing to consider some mitigating information.
If mistakes were made, said Brotman's chief executive, Howard H. Levine, "you have to realize that in a hospital, any time you have the human element involved in care, there's going to be an error or two, unfortunately."
According to the 72-page report by the state Department of Health Services, three of Brotman's physician leaders separately told state inspectors that they had a "concern for the quality of care" provided to Brown throughout her stay.
In the months after Brown's death, her sisters heard nothing about such problems. They knew only that she died somewhere they thought she would be safe, a place that had begun treating them as outsiders.
At the beginning, Diamond said, "our goal was just to find out what happened to my sister."
Now, "I want to see someone in handcuffs. Someone should be in handcuffs."
Brown, the seventh of 10 children, was the family's heart. Hooked up to her headphones, the 5-foot, 150-pound powerhouse would bellow along to the tunes of Elvis, the Beatles and the Ikettes -- oblivious to her surroundings and her less-than-harmonious voice.
"She couldn't sing a lick," Diamond said. Every year, she lighted candles to mourn the anniversaries of the deaths of Elvis and John Lennon.
Brown knew she was different, her sisters said. A medication side effect caused her to lose her hair as a teen, so she wore wigs. She had a seizure disorder and, as she got older, hypertension and diabetes.
She once told Diamond that after she died, she'd like to come back as "normal." Perhaps to compensate, she'd sassily assert "I know that" to whatever anyone told her.