Wrongful Death / A Memoir : Four years ago, Elliot Gilbert died in the recovery room at UC Davis Medical Center after routine surgery. To this day, no one from the hospital has told his family how or why he died.

Sunday, February 10, 1991, 7 p.m.

First thing tomorrow morning my husband, Elliot, is scheduled for a routine prostatectomy at the medical center associated with the university where he and I teach. We just spoke with our son, Roger, who lives on the East Coast. Our two daughters, Kathy and Susanna, are watching TV with us in his hospital room when John A. Reitan, the chair of anesthesiology, comes by in blue jeans to chat about the surgery.

Since the two men are colleagues (my husband is chair of the English department), they enter into an amiable discussion. My husband asks him about the state of medicine. Reitan explains that malpractice suits have recently become serious problems for physicians, noting that “we all have to practice defensive medicine nowadays.”

My husband, a robust, gray-bearded man of 60, laughs and agrees. He has been on at least one university committee dealing with this issue. He is looking especially handsome, or so it seems to me, in the striped robe that I bought him for Christmas.

*

Monday, Feb. 11, 1991, 8:15 p.m.

My husband is dead in the recovery room, after what we had been told was successful surgery.

We don’t know this right away. The surgeon, UCDMC Chief of Urology Ralph W. deVere White, has spoken to us several times during the day, assuring us that everything is all right and urging us to leave the hospital, where we’ve been waiting since Elliot was taken to the operating room at 6 in the morning. Telling us to go out for lunch, for a nap, for dinner.

In fact, it isn’t until 9 p.m., Feb. 11, that deVere White strides into the hospital lobby, flanked by his white-coated resident and a harried-looking woman carrying stacks of papers. The surgeon, an Irishman, becomes oddly hearty.

“We’ve had a problem, luv, a big problem,” he begins briskly, as he steers me down a hall to the door of a room I’ve never seen before.

I manage to say “What -- what --?”

“Dad’s had a heart attack,” he replies, shaking his head with what seems to be strange ruefulness.

In the background, from the pastel depths of the lobby, I hear the screams of my daughters, who are talking to the white-coated resident. I begin to cross myself compulsively. “Are you trying to tell me, doctor,” I whisper, “that my husband is dead?”

I am still crossing myself as the doctor and the harried-looking woman and I finally enter the secret chamber, a small reception area with straight chairs ranged stiffly along the walls. As the woman comes toward me to take my hand, I see that she is wearing a badge that says “Carolyn, Office of Decedent Services,” and she is carrying a folder labeled “Bereavement Packet.”

My daughters are brought in by Udayshanka Poonamallee, the resident, who hovers beside them in uneasy silence. Looking around the room, I notice that there are no tables or magazines in here at all, nothing that we associate with “waiting rooms.” This is the room, I realize, where you don’t wait anymore. This is the room where they tell you that people are unexpectedly dead.

And this is the room where you may begin to understand what medical “negligence” might really mean.

Although we don’t yet suspect it, we are going to learn that my husband didn’t die from a “heart attack.” On the contrary, he may have died because someone in the recovery room failed to get the results of a simple blood test.

Had something gone wrong in the surgery? If so, why hadn’t we been told? How could the doctor have repeatedly urged us to leave the hospital when my husband wasn’t (to say the least) doing well? And why had he told us that Elliot had had a heart attack when, as he must have understood, we’d soon find out he hadn’t?

Most horrifyingly, why and how had a supposedly sophisticated team of nurses, residents, surgeons and anesthesiologists let things get to such a pass that when, at 7:20 p.m., they finally invoked “the code” (to bring in a rescue team), it was too late to resuscitate someone who had 24 hours earlier been vigorously healthy?

These are questions that will haunt us for years to come. What Reitan had called “defensive medicine” has turned into offensive medicine. And it has changed my life, along with the lives of my children, forever.

*

Monday, Feb. 11, 1991, 9:45 p.m.

We are standing beside my husband’s body, in a small private room on the surgery floor, I am still crossing myself compulsively out of some archaic impulse from my Catholic childhood, whispering fragments of the “Our Father” and the “Hail Mary” to myself.

Cold. He is warm but getting colder. I kiss his mouth, his beard, his beautiful thick gray curls. The clean white coverlet has been tucked around his neck, like a bib or a ruff. My daughters are sobbing and gasping next to me. We stand in a row on the side of the bed nearest the door, clinging to the iron bedrail that has been drawn up on both sides of his body.

DeVere White, his silent, staring resident and the woman from Decedent Affairs face us from the other side of the bed.

Just eight hours ago, deVere White had told us Elliot’s surgery was successful, and we’d jubilantly begun to tell friends and relatives. Tokens of love have already arrived. Now Kathy is carrying a potted plant that someone sent, and Susanna is clutching the string of a helium balloon that says “Get Well Soon!”

“What happened? What happened?” Susanna demands. Her eyes are swollen and red. The balloon bobs with every move she makes.

DeVere White shrugs his shoulders, hangs his head. “I don’t know, luv,” he says almost plaintively. “He was making good water, the anastamosis was fin. But his pressure dropped . . . His heart . . . “ He pauses a moment, then adds, “Nothing like this has ever happened to me.”

“We must have done the wrong thing,” I say in an urgent undertone to deVere White. “He should have had radiation instead. He shouldn’t have had surgery.”

DeVere White shakes his head with surprising passion. “No, no, it was the right decision.”

“Daddy, Daddy, my daddy . . .” Kathy is breaking down, weeping uncontrollably.

“Baby, my baby, why did you do this stupid thing? What kind of stupid thing have you done, baby, sweetheart?” I say this over and over again, in a low rapid murmur, as if it were another prayer, like the “Hail Mary.” Evidently, with so many other survivors of a shock like this, I believe the whole business is Elliot’s fault. “How could you do it, darling, baby?” I whisper.

“Perhaps you . . . would you like a glass of water?” The woman from Decedent Services leans toward me nervously. Poonamallee, the resident, still stands like a stone next to deVere White, gazing wide-eyed at us.

“I know, I know, for you this is unpleasant, awful,” the doctor resumes, clumsily, “but believe me, for me it’s shattering.”

Kathy has pulled herself together and is placing calls from a phone at a desk at one end of the room. “Don’t worry about the long-distance charges,” says the woman from Decedent Services.

So far, Kathy has reached her brother, Roger, who, 3,000 miles from here in Ithaca, N.Y., has started weeping and booking flights. The “arrangements,” I realize in the part of me that notices things, have begun. But most of me just keeps on murmuring to my husband, stroking him, murmuring to him.

Susanna and the doctor are conferring with the Decedent Services woman, but I can’t listen to what they’re saying. Only the resident seems as rooted to the floor as I am.

Now we’re all moving toward the door, somehow they’ve pried me away from the bed, and now we’re all standing in the parking lot. Our battered Toyota pulls up, with Kathy looking puzzled in the driver’s seat, as if she’s surprised that such ordinary objects as steering wheels are still left in the world.

Oddly, Susanna hands me the long string that holds the “Get Well” balloon. I decide to let go of it. It rises eerily over the parking lot, and we all follow its wavering ascent until it disappears.

Now I am sitting in the front seat of the car, next to Kathy, and Susanna is in the back with the “Bereavement Packet” and the potted plant. DeVere White bends toward me, elbows on the door frame, and leans in. “I couldn’t feel worse if it were me own father,” he says. Then, as Kathy steps on the gas, he adds, “Safe home.”

*

Monday, July 23, 1991, 3 p.m.

“Close that notebook. This minute.” Attorney Daniel J. Kelly’s voice is frighteningly sharp. He glares at me like a fifth-grade teacher who’s caught me playing tick-tack-toe during a spelling lesson.

“I was just going to write down a few, take a few, you know, notes on what we’re talking about here.” My nervousness surprises me.

“Not here, you don’t. Not if I’m going to represent you in this case.”

Ranged around the conference-room table on either side of me, my children look shocked. They’re used to the professorial mother getting relatively deferential treatment. Susanna leans forward, frowning, as if to rebuke Kelly. Kathy’s voice rises: “My mother is a writer. She’s a scholar and a researcher, she always writes things down -- “ Roger, who has traveled from New York state for this meeting, looks gloomily out the window at San Francisco Bay.

Kelly is unfazed. A graying, compact man, he had greeted us smilingly in the reception room of his San Francisco firm. Now, though, he’s scowling. “First rule,” he says, banging alarmingly on the polished walnut. “If I’m to be your attorney, you do what I tell you to do.”

Like Roger, I gaze at the view, green-gold hills, the blue bay. “OK,” I concede. “It’s up to you.”

Actually, I want my daughters to back off. We don’t even know if Kelly has accepted our case, and I am certain that, no matter how irascible he may seem, we need him. He was highly recommended, and we have to have a lawyer, for ourselves, for our own emotional and spiritual survival, and most of all for Elliot.

To my relief, Kelly softens. “The things is,” he explains, “you can’t take notes or the other side could subpoena them.”

Again I nod deferentially.

“And another thing.” He jabs at the air with a pencil. “You musn’t discuss the case with anybody. Nobody. We don’t want anything getting back to the other side.”

The “other side.” I find the phrase chillingly definitive, especially when I think of my husband’s fondness for his doctor colleagues. I remember his friendly last chat with Reitan, and how he used to joke that “the chair of urology can’t kill the chair of English.” Now “they” -- Reitan and surgeon deVere White and hospital resident Poonamallee and the entire UC Board of Regents, even perhaps my own chancellor, are all on the “other side.”

I smile at Kelly, stiffly I suppose. “Can I at least doodle?” I ask, biting my ballpoint pen.

“Doodling is allowed,” Kelly grins back.

I fix my eyes on my notebook and begin drawing black X’s as he launches into a lecture on the ins and outs of a case like ours. If we go forward with our suit, he tells us, by the end of August our claim will be filed in Sacramento. Four to six weeks later, we’ll be required to respond to written interrogatories from the other side. A few months after that, we’ll be deposed -- that is, interviewed under oath by the university’s lawyers. Still later, our attorneys will depose relevant parties on the other side. Medical experts will probably testify for both sides.

Experts. I bite down again on my ballpoint pen. Experts have already testified. That’s why we’re here today.

*

Monday, March 11, 1991, 6 p.m.

Monday the 11th: It’s exactly one months to the day since my husband died. But that night it was clear, breezy, while tonight it’s raining gently, just the way it did yesterday at his public memorial service on campus at Davis.

My kids had to leave soon after the service, to get back to school or work, but my best friend, Susan, hasn’t gone home to Indiana yet, and a few other friends have joined us for dinner.

I swivel toward my living-room windows and stare out at the deck. Even here, I can hear Susan’s voice rising and falling. She’s on the phone in the kitchen, talking to my college roommate Leah and Leah’s husband, Dick Asofsky, a research pathologist for the National Institutes of Health in Bethesda, Md.

Although Elliot’s been dead for a whole month, no one from the UCDMC has yet told us anything about what happened to him. Finally, Dick offered to read the records, and we Fed Ex’ed them to him a few days ago. All weekend, while we coped with public ceremonies, Dick did his private research. For the past 40 minutes, he’s been telling Susan what he learned.

And now I can hear Susan hanging up in the kitchen, going over to the stove to stir something, moving back to the counter to pour herself a glass of wine. My other guests and I fall silent in the living room, waiting for her to report on her conversation.

But when she appears, she’s wordless, grim.

“Well, what did Dick have to say?” I ask with an effort at joviality.

Susan motions toward me with one hand. “Come in the kitchen a minute, please, Sandra,” she answers quietly.

“That’s ridiculous,” I reply. “Why don’t you just tell all of us about it?”

“Just come into the kitchen a minute, please, Sandra,” she repeats.

I glance from her to the others with mock disgust and follow her reluctantly.

For some odd reason, we stand facing away from the rest of the house, looking out the kitchen door at the rain. Susan puts an arm around me.

“Dick isn’t 100% sure what happened,” she says, “but Elliot was given a lot of blood. He must have been bleeding a lot.”

“Well, I know they had to give five unites in the OR,” I assure her.

“No.” She lowers her voice. “It’s worse than that. And Dick thinks it’s strange that they didn’t tell you. They gave seven more units of blood in the recovery room. By the time he died, Elliot had been given 12 transfusions.”

“Twelve?” I’m finding it hard to breathe. “Why would they give that much?”

“Bleeding,” she murmurs. “Hemorrhaging.”

“But why --?”

“Dick isn’t sure. He’s still having trouble putting it all together, and he seems pretty upset himself. But he’ll call back tomorrow.”

I’m silent for a minute. And then I’m kicking the kitchen door and screaming and cursing. “Why didn’t they tell me? Why didn’t they tell me? What happened? What did they do to my husband?”

*

Thursday, March 21, 1991, 5:30 p.m.

Leah is concerned about me, I know. “Are you sure you don’t want to wait till this morning?” She’s just gotten here from Bethesda to stay for a week, and she’s brought Dick’s summary of the medical notes with her.

“I’m sorry, but I just have to read it now,” I tell her.

Susanna comes over to the table, wiping her hands on a dish towel and looking vaguely ill. “I’m going to read it along with you, Mom,” she says. “I have to read it too.”

Dick’s prose, I notice, is impressively detached and scientific, but I know how painful he must have found it write this.

“Dr. Elliot Gilbert was admitted to the hospital on 2/10/91 to undergo radical retropubic prostatectomy for carcinoma of the prostate. He was in good health at the time of admission.”

Dr. Elliot Gilbert was. Was. Was in good health.

“The prostatectomy was begun the morning of 2/11/91, and apart from a somewhat large loss of blood . . . the operation appeared to go well, judging from the OR record. Vital signs were all in the stable range throughout.”

The morning of 2/11/91. The operation appeared to go well. That’s right, Elliot. We sat in the lobby. I tried to read Newsweek. Somebody came up to us and delivered a silver “Get Well” balloon.

“Dr. Gilbert was admitted to the recovery room around 2 p.m. or a little later. At this time his vital signs were good and remained so for the next 45-60 minutes. A hematocrit obtained around the time of admission to the recovery room was 32 . . . indicating that transfusions in the OR had returned the red cells about to normal levels.”

Susanna and I look at each other meaningfully. We have just learned about hematocrits, which measure the level of red blood cells in a patient’s blood stream. They are used to test for anemia and, in or after surgery, to test for internal bleeding or surgical shock.

“At 3:05 there was a sharp drop in blood pressure to 72/48 from a level of 132/98. This hypotension was treated vigorously with fluids and plasma expanders, and blood pressure was restored to acceptable levels (98/60 by 3:15, and to normal levels (113/67) five minutes later. The notes indicate that a hematocrit was sent to the laboratory at 3:05; there is no report of this hematocrit in the record. Note that a ‘Critical Lab Report’ dated 2/11/91 lists no hematocrits between 2:45 and 6:30 p.m. . . .

“At 6 p.m., a blood pressure of 54/0 was recorded. Treatment with fluids and plasma expanders was again accelerated, with a transient rise in blood pressure to 99/41 at 6:21, but normal blood pressure was never restored thereafter.”

Normal blood pressure. Never restored. “What happened, doctor, what happened?” Susanna had screamed. “I don’t know, luv, his pressure dropped.”

Dick’s words begin to blur on the page. A hematocrit of 17 was recorded at 6:30. “It is not clear when this sample was obtained, since there was no order for one and no notation of ‘hematocrit sent’ as there was at 3:05. I presume that the sample was obtained at 6, since the drop in blood pressure would essentially have required it.” Orders to transfuse were written in at 6:50 p.m. There was also an order to “hold heparin” (heparin is an anticoagulant used to prevent clots). “These orders indicate that the physicians are concerned that the patient may be bleeding.”

Bleeding. Bleeding secretly. Bleeding to death.

I grab Susanna’s hand and squeeze it hard. “Code team notes began at 7:30,” Dick continues, as he describes the efforts of those who tried in vain to save my husband’s life. “They found . . . a hematocrit of 13. Despite their vigorous efforts to revive the heart . . . and the administration of 5 units of (packed red blood cells) from 7:31 to 7:52 in order to correct the anemia, there was no response. Dr. Gilbert was pronounced dead at 8:15. It should be noted that at 7:52 the surgical drains . . . were attached to suction, and that at 8:05, ‘JP drains 2450 red blood’ was recorded.

8:15. Pronounced dead. I was in the lobby, I think. We’d come back from the Chinese restaurant. Stuffed with won-tons, tired.

“There is little doubt,” concludes Dick, “that the major clinical problem was bleeding. Loss of blood is the most reasonable explanation for the simultaneous sharp drop both in the blood pressure and the hematocrit. If I’ve read the code team’s notes correctly concerning the drains, this bleeding was massive -- 2450 cc is a little less than half the blood in the body . . . “

*

Monday, July 23, 1991, 3:30 p.m.

A little less than half the blood in the body, I think, drawing black X’s in my notebook.

And now as to damages, Kelly is saying. The formula for calculating economic damages is an unfair one, he remarks rather bitterly, but it’s fixed: Roughly speaking, economic damages are based on the decedent’s salary at the time of his death, multiplied by the number of years that he might have been expected to live and work. But there are no allowances for raises he might have received, had he continued on the job (as Elliot would have) for, say, another 10 years. In addition, the projected cost of the dead person’s annual “consumption” must be subtracted from these damages.

I use one of the few official legal terms I already know. “What about pain and suffering?” I ask. Aren’t victims of medical negligence routinely awarded money for what they have suffered? I often read about such awards in the papers. According to many columnists and politicians, huge sums for “pain and suffering,” gratuitously awarded to greedy plaintiffs, account for the escalating cost of medical malpractice insurance and drive all our doctors’ bills up.

“Not compensable in California,” Kelly answers curtly. “In wrongful death, pain and suffering aren’t compensable. He’s dead, so he can’t recover. His pain and suffering are irrelevant.”

I bend closer to the page on which I’m doodling black boxes. Half the blood in the body. Not compensable.

“Your pain and suffering are not compensable either,” Kelly is saying in answer to a question from one of the kids, “unless you were witnesses to the event. And you weren’t.”

“But that’s not right, is it?” Susanna begins. “I mean, we have suffered, my mother has suffered -- “

“A flat sum.” Kelly looks severe. “In cases of wrongful death, the state of California allows the survivors a flat sum for loss of care, comfort and consortium.”

“And punitive damages?” I ask, staring at Kelly’s dark lapels.

He looks back at me blandly. “No punitive damages for medical negligence in the state of California, no matter how egregious the negligence may have been, absent of showing willful misconduct or malicious intent -- which is extremely difficult to prove.”)

Kathy and Susanna gasp; Roger frowns.

“Why not? I thought that in all these cases -- at least from what I’ve read -- “ I start another line of black X’s.

“Not in the state of California,” Kelly says sardonically. “Not for medical negligence. In almost every other case of personal injury, but not against a hospital, not a doctor. No way.”

“What’s the reason for all of this?” Roger is frowning more deeply.

Kelly produces a bark of a laugh. “The doctors’ lobby. They got to the Legislature.”

“Well, of course money isn’t the issue,” I tell him, forcing myself to adopt my own lecturing tone. “But how do you ensure accountability without punitive damages? I mean, no sum of money can replace my husband, but -- “

I hear my voice skid to a halt. No sum of money. I stare at my hands, Kelly’s hands, the hands of my children. All alive, in motion, clasped around pens or touching the table, sensitive, sentient, nervous, blood flowing through them. Unlike Elliot’s hands in his coffin, grayish-white, rigidly clasped.

How would one calculate a sum to replace the dead person? Would some jury decide on, say, $100,000 for his hands, $50,000 for his beard and his thick, dark eyebrows, $75,000 for his hazel eyes?

“Tough,” Kelly is saying. “These cases are tough, they’re hard to win. You’re going to be put through it; experts are often reluctant to testify, the doctors stonewall. I’ll tell you,” he shakes his head, “ a lot of these doctors can be really something. I only wish they’d level with people; half the time they wouldn’t get to this kind of point, things like this wouldn’t come to my office.”

“They didn’t tell us anything, “ I say slowly. “They still haven’t told us anything.”

*

Friday, July 24, 1992, 10 a.m.

Bright and hot, even through the shades, and the windows wide open, so birds rustling in the oaks, squirrels leaping among the leaves, are too loud. As is the ringing. I want to stay asleep. I’ve had trouble waking up in the morning, ever since February, 1991, but the ringing is piercing, and for some reason I don’t want to leave the problem to the answering machine the way I usually do.

I drag the phone toward me.

“Dan Kelly here. Do you have a minute?” He barks out a laugh. “I just had a call from Tom Minder. We’ve got a real cliffhanger here.”

“A cliffhanger?” I’m dazed with heat and sleep.

“Yeah. We’ve been preparing one of our medical experts here in San Francisco to testify, and out guy” -- a familiar note of bitterness creeps in “our guy is being very conservative. And Tom Minder, the lawyer for the other side, is in his car, right this minute, on his way down 80 from Sacramento to do the deposition in our office, and he just picked up his car phone to offer us a settlement. How do you like that?”

“Conservative? What do you mean conservative?” I’m wide awake now. “My husband was a healthy man, Dick says -- “

“Hey, haven’t I told you all along? These guys don’t like to testify against each other, they’re very very careful about what they say. So it’s a cliffhanger, OK?”

“But the deposition, I mean just the other day the surgeon -- “

Just the other day. Just the other day Kelly had called, sounding unusually elated. “Your Dr. deVere White was very charming,” he’d said. “Just as you told me he’d be.” The exuberance in the lawyer’s voice was irrepressible. “It would’ve been better if he’d had two heads or something,” he had confided. “I mean, I can see where a jury would find him charming, too. But he didn’t to his side a lot of good this morning. He was very disingenuous.”

“Really? How?” My palm had been sticky on the receiver.

“Waffling, waffling on everything. Claimed the surgery couldn’t have gone better and strangely enough insisted that the 2400 ccs of blood suctioned from the drains was ‘tinged fluid.’ Tinged fluid!” Kelly had snorted triumphantly. “That’s not going to go down with a jury.”

“But did he say anything about what did happen? Why did he think my husband died? What was his opinion?”

“Stonewalling,” Kelly said curtly. “Just the way I told you he would. But he hung his head at the end, when I asked him about the last note on the chart.” The lawyer had chuckled. “The one where someone said your husband was OK on Feb. 12, when he’d actually been dead for almost 12 hours.”

“Oh, my God.” I hadn’t known about that, and I’m not sure I want to know about it even now.

Kelly’s voice darkens. “Now these are the terms, and I think they’re OK,” he notes, then outlines the offer.

I gaze at the glitter of light around the shades, the glitter Elliot will never see again. Get up, I tell myself, and raise the shades. Try to call the kids.

Amazingly, in all their different time zones, they are home, and they all agree with Kelly that the offer is OK.

But Susann’s plaintive comment speaks for everyone. “Mom,” she wonders, “Mom, does this mean we’ll never know -- never really find out what happened to Dad?”

“So that’s it? That’s all?” I say to Kelly when he calls back. “What happens next.”

He’s businesslike. “We should get the formal papers in about a week. And you’ll get a statement from us within a week, too.”

“And that’s it? That’s all?”

“That about wraps it up.” He’s obviously relieved.

Midday. The house is quiet. Even the birds and squirrels have stopped their chattering and chirping for the moment.

“What ceremony else?” I ask myself, quoting a line from “Hamlet” that my husband loved to declaim with theatrical irony whenever rituals seemed skimpy to him.

The doctor of divinity who’s in charge of buying Ophelia has an answer that’s relevant here, too. “her obsequys have been as far enlarged/As we have warranty. Her death was doubtful.”

He means, as we English professors sometimes have to explain to students, that because Ophelia might have been a suicide, she isn’t entitled to the church’s full “obsequys” -- its funerary rituals.

Like me, Laertes is panicky. “Must there no more be done?” he ask plaintively. He stands by his sister’s grave, silent and sullen. I sit silent and sullen on the edge of my bed. “No more be done,” replies the indifferent doctor in “Hamlet.”

No ceremony else, my love.

*

Postscript, Jan. 23, 1994.

Since I began writing about my husband’s death, I have discovered that, by conservative estimates, one out of 100 Americans will suffer from the effects of medical malpractice, yet only 2% will file lawsuits, and a much smaller percentage than that will prevail. Now I know that the people who sue probably aren’t “greedy,” but rather they are angry, vulnerable and desperately wishing that someone had practiced “defensive medicine.”

Researching the malpractice “crisis” -- which I would now define differently from the way most current commentators see it -- I have amassed a small library of medical-journal articles, newspaper reports and research findings. One recent entry in my collection comes from the Nov. 7, 1993, Sacramento Bee. It’s entitled “‘What Really Happened to My Baby’: A Mother Fights for the Truth,” and it tells of 4-year-old Camelia Plaza, who was allegedly the victim of several acts of medical negligence, from an ambulance company and from the UC Davis Medical Center, in December, 1991.

Camelia is severely brain damaged: “She cannot hear. She cannot speak,” says the article. Her mother, Andrea Plaza, filed suit; when the case was settled, no one admitted guilt. What had especially tormented Andrea Plaza, according to the Bee, was UCDMC’s refusal to tell her what had happened: “I asked them crying, and I asked them OK, and I asked them mad. And they didn’t tell me.”

The story continues: “The charge that Plaza was not fully informed of what happened to her daughter does not fit with the medical center’s existing policy. That policy requires that families always be kept informed of such things, said Carol Robinson, (a) medical center official. ‘They’re always told when there’s an error, and they’re always told when that error has been associated with an apparent consequence,’ she said. ‘There are no reasons for not telling a patient.”’

To this day, I study these sentences with amazement. It is nearly three years since my husband’s death, and half that since my case was settled, since my kids and I officially “absolved” the doctors and nurse and administrators at UCDMC of blame. And still they have told me nothing.

And still, almost every evening this time of year, I study the light -- how blue is it? How gray? How bright or dull? I want to be certain of the exact time when we returned to the hospital on Feb. 11, 1991, to be told we couldn’t see my husband and told, soon after, that the doctor was coming down to see us.

It was probably a lot darker than it is right now; it was a gray-black nighttime minute, when the elevator doors slid open and the surgeon, the resident and the Decedent Services woman hurried out into the lobby to inform us of my husband’s shattering, inexplicable death.