Editor’s Note: Ten days after this story about the death of Laura Levis was published on BostonGlobe.com, the leaders of Somerville hospital’s parent company, Cambridge Health Alliance, met with her husband , Peter DeMarco, at the Globe’s Boston office. DeMarco, who had talked about the story on NBC Nightly News and other outlets, had asked CHA nearly a month earlier to answer questions about his wife’s death.

911 operator: “This line is recorded. Where is your emergency?”

Laura: “I’m at Somerville Hospital.”

911 operator: “I’m sorry. Where are you?”


Laura: “Somerville Hospital.”

911 operator: “OK, what’s the emergency?”

Laura: “I’m having an asthma attack. I’m dying.”

911 operator: “Whereabouts are you at the hospital?”

Laura: “Emergency room.”

911 operator: “OK.”

Laura: “I can’t get in.”

911 operator: “Let me get you into Somerville. You’re outside?”

Laura: “Mm-hm.”

911 operator: “Are you in the parking lot?”

Laura: “Yeah.”

911 operator: “Are you in a vehicle?”

Laura: “No. I’m just outside it.”

911 operator: “At the door?”

Laura: “Asthma. Asthma.”

911 operator: “Are you at the door?”

Laura: “Yeah.”

911 operator: “Yes?”

Laura: “Yes, I’m just at the door. I feel like I’m dying.”

* * *

MY NAME IS Peter DeMarco, and I am Laura’s husband. And I didn’t know any of this.

When I finally arrived at the emergency room that morning, I was told that Laura never made it there. That she collapsed on a street leading to CHA Somerville Hospital, or possibly in a parking lot on the outskirts of the property. No one in the emergency room could tell me the full story, as there had been a shift change at 7 a.m., and everyone who’d treated her was gone. All they knew was that my wife had called 911 just after 4 a.m., before she lost consciousness, but she wasn’t able to give her exact location.


It took emergency responders a long time to find her, they told me.

“She was in the last place they looked,” someone in the emergency room said.

Some 10 minutes passed between the time Laura called 911 and the time she was found, in cardiac arrest following a devastating asthma attack. Those 10 minutes meant her life.

We didn’t know at first how many of those minutes she’d gone without oxygen to her brain, so for most of the seven days Laura spent in the intensive care unit at CHA Cambridge Hospital, where she was transferred, there was a glimmer of hope. If Laura had been conscious after making the 911 call for even three or four minutes, she had a chance to pull through.

Her doctors told us we could only wait, because her brain was swelled, preventing a clear CT scan. Each day, they would lift her eyelids and shine a light straight into her pupils, looking for movement. There was a small flicker early on, but little more.

Laura Levis, the love of my life, my wife, died September 22, 2016. She was 34. Her death certificate says she died the day before, of hypoxic brain injury, but that was just when Dr. Duncan Kuhn brought Laura’s father, my father, and me into a private waiting room in the intensive care unit. In a gesture of humility, Kuhn sat on the floor, looking up at us as he told us Laura wasn’t coming back.


VIDEO: WHY WASN’T ANYONE ABLE TO SAVE LAURA?

Why wasn’t anyone able to save Laura? Share Email to a Friend Embed How cracks and flaws in our health care system — communication errors, overburdened staffs, lack of fail-safes — snowballed into one woman’s unimaginable death.

Laura was still on a respirator, still breathing, her hands and body still warm, her hair still soft. Her organ donor surgery couldn’t be scheduled until the next day, which is the day I consider to be her last on this earth. She died minutes after I let go of her hand in the third-floor hallway of that hospital, after a team of doctors wheeled her through a set of double doors into an operating room, cutting into her beautiful body so that others could have life and sight from her gifts, including her heart.

This part of our story, I have shared before. I wrote a letter thanking the doctors and nurses who tried to save Laura’s life that The New York Times decided to publish. “Every single one of you,” I wrote to the medical staff, “treated Laura with such professionalism, and kindness, and dignity as she lay unconscious.” The letter was featured on NBC Nightly News, shared across Facebook, and republished on websites across the world. Less than three weeks after Laura’s death, millions were touched by her life.

But that was not the whole story. Far from it.

As any husband would, I blamed myself for not being with her when the attack struck, for not being able to help my wife in that moment. I asked God, Why? Why? Why?


I knew that one day I would have to find the spot where she collapsed. That I would lie down on that spot, to be with her spirit, to comfort her because she must have been so, so scared.

I have since learned where that spot is. But it did not turn out to be on a street leading to Somerville Hospital, or some obscure location.

Laura made it to the doorstep of the emergency room that day, on her own two feet, just as she said in her dying words. She stared through a plate-glass window into the emergency room waiting area — she could see the red-and-white emergency room sign inside — but she could not get in. To her dismay, the door was locked.

Her attack intensifying, she called 911, telling the operator she was right there but could not get in.

Help was just a few feet away, on the other side of that door.

But, incredibly, that help never came.

This is the story of how my wife’s life was wasted by the actions of people whose job it is to save lives. It is the story of how our entire emergency-response system can completely fail us, from the moment we dial 911 and the satellite GPS “ping” of the cellphone can get our location wrong by hundreds of feet. It is the story of how cracks and flaws not just at Somerville Hospital, but throughout our health care system — communication errors, overburdened staffs, lack of fail-safes — can snowball into someone’s unimaginable death.


And it is the story of how there will be no justice through our legal system for what happened to Laura, as public hospitals in Massachusetts, and throughout most of America, are largely protected by state laws against malpractice and negligence claims, leaving thousands who rely on such institutions little recourse when harmed or lied to.

Even when a 34-year-old woman is left to die outside an emergency room, destroying the lives of the people who loved her.

Shortly before her death, Laura Levis, an Emerson College graduate, received a promotion at Harvard, being named the editorial production manager of the school’s news website, the Harvard Gazette. Peter DeMarco

* * *

WHO WAS LAURA Beth Levis?

She was beautiful, I can tell you that — and the funniest girl I ever met. She routinely overslept and was hardly what you would call neat, but was so smart and talented, and a journalist, like me, with an Emerson College writing degree. We met in the newsroom of The Boston Globe in 2004. She asked me out, though she would always roll her eyes when I told people that. I was 10 years older, so I assumed she was too young for me. She knew better.

Laura went on to work for Harvard Magazine, and then Harvard University’s main office of public affairs and communications. She’d gotten a big promotion just a few months before her death, becoming the editorial production manager of the school’s news website, the Harvard Gazette.

Laura was also the most fit person I knew, even with asthma. She worked out six days a week, doing everything from hard-core spin classes to hot yoga, but her true passion was weight lifting. Though just 5-foot-2-inches tall, she was very strong, competing in organized powerlifting competitions, where she could bench press more than she weighed — a difficult task for the average woman.

The thank-you letter published in the Times was accompanied by a photo of us from 2015, hiking in Scotland as newlyweds. We hiked many places, my wife’s asthma never impeding her. Laura was vigilant about carrying inhalers. As I began to box up her clothes last fall, I found more than 20 of them, in jacket pockets, in purses, in backpacks, in gym bags. With each discovery, I cried a little inside.

RELATED: My thank you to Cambridge Hospital’s doctors and nurses still stands

On rare occasion, an attack intensified to the point where we sought further care. During those times, I drove Laura to Mount Auburn Hospital in Cambridge, our preferred hospital, where she was given prednisone, a nebulizer treatment, or both. The trip usually took about 15 minutes by car, and we always had enough time.

But I wasn’t with my wife that September day to drive her to Mount Auburn. And the reason for that, I’ll have to live with forever.

* * *

THE STORY I TOLD most people — or what they simply assumed — was that Laura had suffered her asthma attack while walking to work that Friday morning. On the odd chance someone asked for more details, I said it was too difficult for me to talk about.

If only they really knew.

At the time Laura collapsed, we were going through a rough patch in our relationship and were spending some time apart. We were seeing a couples counselor and had been in daily contact with each other by phone, e-mail, or text. We had dinner plans on the day she collapsed, and that weekend, we’d planned on going apple picking at Cider Hill Farm in Amesbury, one of our traditions. But we had spent the night before her death apart. She was sleeping, as fate would have it, in an apartment just a few blocks from Somerville Hospital.

I feel so incredibly guilty about not being with her, even though couples often go through such difficulties, even though no one could have predicted her life would end before I ever saw her again.

Our separation that night also explains why Laura walked, alone, to the hospital the next morning when her attack struck just after 4 a.m.

Laura’s attacks would always build, slowly, in intensity, so she probably figured she had plenty of time to walk there. Calling a cab or Uber at that hour of the morning likely would have taken longer.

That Laura packed a backpack with gym clothes before heading out the door to the hospital, apparently figuring she might as well get in an early workout if she was going to be up for the day, gives some sense of how gradually her attack came on.

According to police records, Laura placed her 911 call from outside the emergency room at one second before 4:24 a.m. The hospital was virtually deserted at that time. The timing of her attack almost couldn’t have been worse, and so much more was about to go wrong.

“Pete, I have the most terrible thing to tell you,” my father-in-law said. “They killed Laura.”

Both Laura’s parents and my parents knew our situation, but we had told few others. Those who didn’t know that Laura’s attack occurred in the hours before dawn were often left wondering how someone could die of asthma in this day and age. People, of course, do die from asthma, a disease that affects 20 million adults and 8 million children in the United States alone. According to the most recent data from the Centers for Disease Control and Prevention, more than 3,500 succumb to attacks each year, though in Laura’s age group, the death rate is less than 1 per 10,000 asthmatics. It’s especially rare in those as healthy and active as she was.

Laura’s death, and the circumstances surrounding it, deeply bothered her uncle, Robert Levis. If Laura had called 911, he reasoned, maybe there would be a police report that could help explain what happened.

Five weeks after her death, Uncle Bob decided to call the Somerville Police. Yes, they told him, there was a report — two reports, actually, including one very extensive one. And they mailed them to him.

He shared the reports with Laura’s dad, Dr. William Levis, a former officer with the US Public Health Service. I will never forget my father-in-law’s voice, cracking apart, when he called me.

“Pete, I have the most terrible thing to tell you,” he said. “They killed Laura.”

* * *

The emergency entrance at Somerville Hospital before new signs were added. John Phelan

LIKE A NUMBER of area hospitals, it seems, Somerville Hospital sits upon a hill, Spring Hill. It is one of seven hills for which Somerville, a hotbed for young professionals, urban cyclists, and pricey condo conversions, is known. Established in 1891 and rebuilt in 1976, the hospital is the only one serving the city’s 81,000 residents, though Boston’s renowned medical institutions — Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, among them — are just a few miles away. Somerville borders Boston, so when locals need care, they might seek treatment at one of the larger hospitals.

For Laura that morning, though, there seemed no need to do that.

Dressed in purple sneakers, jeans, and her favorite black, zip-up hoodie from a Spartan Race we ran together in 2013, Laura began walking up Spring Hill to the hospital’s main entrance and emergency room. It’s about a 375-foot walk to the top, up a road called Tower Street. The hospital’s surveillance cameras first caught sight of her at 4:21 a.m., her backpack in tow.

As Laura arrived at the front of the hospital, she found a semicircular driveway in front of its doors, and two separate hospital entrances.

The entrance on the far left was the hospital’s main entrance. A second doorway, directly outside the hospital’s emergency room, was at the far right. The doorways were about 100 feet apart, connected by a straight sidewalk. Four waiting benches, each with a flat, stone top, were evenly spaced along the sidewalk between the two entrances.

Signs pointing to the emergency room had led Laura up the hill, but inexplicably, the trail seemed to disappear there. Neither entrance to the hospital — neither the left, nor the right — was adorned with an emergency room sign she could see from the driveway. There were no signs of any kind, for that matter, above either doorway; just blank metal facades and overhangs. Only after Laura’s death would Somerville Hospital add an illuminated “EMERGENCY” sign near one of the entrances, according to internal hospital documents.

With no clear indication of where to go, Laura had to choose one door or the other. On the surveillance video, Laura pauses about 50 feet from the hospital as she decides. The entrance on the right side of the driveway was more brightly lighted, “and may be why she went there first,” according to the hospital’s own incident review.

At 4:21 a.m., Laura is captured on security cameras (1) after walking up Tower Street. She hesitates before choosing an entrance, then walks to Entrance A and tries the door (2). It is locked. H.Hopp-Bruce/Globe Staff

As she approached it, her choice seemed correct. Plate-glass windows lined the first floor of the hospital between the two entrances, almost touching the back sides of the waiting benches. When Laura peered through the glass, she saw a lighted corridor with an “EMERGENCY CHECK-IN” sign and some armchairs, the emergency room’s de facto waiting area. All that separated her from the emergency room itself was that corridor. And, of course, the door — technically, one large, glass, automatic sliding door.

She stepped in front of the door, but it did not open.

Surprised, she put both hands on the door and moved her face toward it to peer through the glass. It still did not open. She turned again toward the plate-glass windows, looking for someone to let her in. But the corridor, and the waiting room, were empty.

Panic can accelerate an asthma attack by causing airway muscles to tighten, constricting air flow even further. Finding that door locked, Laura almost certainly panicked.

Maybe that is why she didn’t comprehend the instructions posted on that sliding door, in simple white lettering, explaining that it was for ambulance access only. To enter the emergency room, the instructions read, patients needed to use the main hospital entrance — the door to the far left. The door she had not chosen.

Or perhaps she finally did notice those instructions. In the surveillance video, Laura turns and begins walking toward the main entrance, about 100 feet away. She could see it clearly from the ambulance-access door — it was a straight shot. Except Laura did not make it there.

A series of images from surveillance video shows Laura Levis as she approaches a door at Somerville Hospital and finds it locked.

She walked past the first waiting bench between the two sets of doors. She passed the second bench. But when Laura reached the third waiting bench, just 29 feet from the main entrance of the hospital, she sat down. The attack had become so intense, she could not walk those extra 29 feet.

But she could still think clearly: Call 911.

Her voice, on the phone with the dispatcher, is filled with fear.

“I’m at Somerville Hospital,” were Laura’s first words. “I’m having an asthma attack. I’m dying.”

In just 41 seconds, Laura managed to relate seemingly everything the operator needed to know. Laura said she was having an asthma attack, one so severe that she felt she was going to die; she said she was at Somerville Hospital, outside the emergency room, and that she couldn’t get in. Laura was an amazing communicator — it was her profession — and, with her life on the line, she did not waste a single word.

If only she had been talking to the right person.

Unable to get in through Entrance A, Laura walks toward Entrance B. Her asthma attack intensifies; she stops at a bench (3) and calls 911 at 4:23:59 a.m.

Laura’s cellphone call, as can be the case, was routed to a regional 911 operator. The operator, sitting in a Massachusetts State Police operations center some 18 miles away, was merely a call screener who couldn’t send direct help — essentially, a middleman. When Laura finished speaking, the regional operator told her to stay on the line as she connected Laura to the local police in Somerville.

When they picked up, a new operator asked her to explain all over again what her emergency was, as if she had never even called.

But by then, she could barely speak.

“She’s outside of the Somerville Hospital,” said the regional operator, jumping in while still on the line. “She’s having an asthma attack. She can’t get into the hospital there.”

It should have been so easy for the two operators to locate Laura without further explanation, since both had Laura’s cellphone number. A satellite ping of her GPS coordinates provided by her cellphone carrier would make Laura a digital dot on their computer-screen street maps. But, as can frequently be the case with cellphone 911 calls, her location on their screens was wrong.

Laura’s cellphone pings inaccurately at 68 Tower Street (1). Police dispatch Cataldo Ambulance and firefighters from a nearby station, but they head to the wrong hospital door (2).

While an Uber or Lyft driver seems to know where you’re standing, and marketers can track your every step via apps on your phone, the same often can’t be said for police and fire responders who receive 911 cellphone calls, because our nation’s 911 infrastructure hasn’t adapted nearly fast enough to our wireless world.

When you use an app involving your location, your phone constantly transmits where you are, in a way like a homing beacon. But when you make a 911 voice call, that doesn’t happen. Instead, a satellite must be pinged, and that information is integrated with other bits of data your carrier knows about your phone to trace where you’re calling from, a more complex and often inexact process. Federal Communications Commission rules merely require carriers to locate 911 calls “generally to within 50 to 300 meters” of a 911 caller’s location. So potentially, a caller can be more than three football fields from the location of the ping, in any direction — a vast area for emergency responders to search for someone in trouble.

In the 911 tape, you hear Laura’s voice again. “I’m outside,” she starts to say, before struggling to make another sound. It is 4:25 a.m. and 36 seconds. It is the last time Laura speaks.

Laura’s ping registered at 68 Tower Street, at a nondescript street corner at the top of the hill, some 200 feet from the hospital’s front door. So Somerville’s police dispatcher asked Laura to clarify where she was:

“Ma’am, where are you located there? You’re the one — you’re at 230 Highland Ave., right?”

It is the hospital’s official mailing address, but on a completely different side of the building, nowhere near the main doors or the emergency room. It was the only address the dispatcher had for the hospital; no one’s ever bothered to assign the emergency room a specific Tower Street address, according to city records and the hospital’s own website.

It would have been the perfect moment for the original 911 operator, whom Laura actually spoke with, to have relayed more information, such as the fact that Laura twice said she was outside the door of the emergency room, or that she twice said she was dying. But that operator had already hung up, without telling the local police those potentially lifesaving details — without even saying the words “emergency room.”

In the 911 tape, you hear Laura’s voice again. “I’m outside,” she starts to say, before struggling to make another sound. It is 4:25 a.m. and 36 seconds. It is the last time Laura speaks.

It was the moment her life hinged upon. Within a minute or so, her heart would stop beating, and oxygen would stop going to her brain.

On the surveillance video, about 30 seconds later, Laura slumps on the stone bench, her arms falling to her sides. A glowing object, her cellphone, falls to the ground.

And then . . . stillness.

I will never know what my wife thought about in her final moment of consciousness — me, her parents, our cat, Cola. But, having made that 911 call, I think it was this:

“Help is on the way.”

* * *

Laura, who grew up on Staten Island in New York City, loved working out, doing everything from hard-core spin classes to hot yoga. Peter DeMarco

IT’S UNCLEAR HOW LONG it takes your brain to die without oxygen, though there are some common estimates based on medical research. If your brain goes without oxygen for three minutes or less, you might fully recover. Between three and six minutes without oxygen, your chances drop — but still, recovery can be possible. Beyond six minutes, there’s little chance your brain won’t be severely damaged, with death a much more likely outcome.

Laura’s countdown likely began a few seconds after 4:26 a.m., when she dropped her cellphone to the ground, although it’s possible her heart kept beating for another minute after she’d lost consciousness, according to asthma experts. Every second from the moment she dropped her phone was vital to her survival. Yet so many would be wasted.

After realizing Laura couldn’t speak anymore, Somerville Police’s dispatcher told Laura to hold while she called Cataldo Ambulance Service. Normally there’s nothing more important than getting an ambulance en route to a medical emergency, but in Laura’s case, she just needed someone to come rushing out of the hospital to find her.

That call to Cataldo Ambulance took more than a full minute — a minute that Laura would never get back.

The police next called the Somerville Fire Department, which has a station just 1,000 feet from the hospital. But they, too, weren’t given all the information they needed. The police dispatcher who made that call merely related that Laura “must be on Tower side,” failing to say her cellphone pinged at 68 Tower Street, at the top of the hill.

Without an exact street address, or details putting Laura at the emergency room, the Fire Department’s dispatcher had to guess where Laura was outside the hospital. He knew from experience that a set of daytime doctors’ office doors at the bottom of the hill is locked overnight — and that someone was once locked out there. So he appeared to go with that hunch.

“Attention Engine 7. Respond to the Somerville Hospital, 230 Highland Avenue . . . We believe this is possibly on the Medical Arts Building side,” he says on the recording, never even mentioning Tower Street.

Somerville Hospital is the last to be reached. There was no direct phone line to the emergency room, apparently, even for police, so a night receptionist had to patch the call through. The transfer took about 30 seconds; more time wasted.

Finally, nearly two minutes after Laura had lost consciousness, at 4:27 a.m. and 56 seconds, a phone in the Somerville Hospital emergency room rang. A nurse, who for now I’ll call Nurse X, answered.

She was, according to records, the “charge nurse” that night, meaning she was the supervising nurse, the one entrusted with the most responsibility. The nurse who should have known best how to handle such an emergency call.

“Hi, it’s Somerville Police. Are your doors locked by any chance?” were the dispatcher’s first words.

“No. Why?” responded Nurse X.

“Because there’s a female who’s having an asthma attack. . . . She’s pinging off Tower Street, and she’s saying the emergency room is closed. So I don’t know where she is,” the dispatcher continued.

“I’ll go look,” said Nurse X.

If a guard had been sitting at the security desk in the hospital’s main lobby, that person could have been radioed, and within seconds, could have walked out the main entrance door, looked to his left, and seen Laura lying on that waiting bench, just steps away.

Perhaps the guard would have already known Laura was there, having watched her approach the hospital on the surveillance camera’s video feed, as investigators later did. He could have seen Laura trying to open the door outside the emergency room, seen her lie on the bench, and realized something was very wrong.

But the security desk, when Laura arrived that morning, was deserted. According to investigators, both security guards on duty were required to be inside the emergency department on “patient watch,” even though that meant abandoning the security desk.

Still, there was Nurse X. Hanging up the phone, she walked out of the emergency room and into the corridor that Laura had peered into, through those plate-glass windows. From the emergency room’s charting desk, where its central phone is located, it was a mere 20-foot walk to the corridor.

A few seconds later, Nurse X reached the ambulance-access door, which she found locked, and opened it from the inside.

Laura was just about 70 feet from her; you see them both in the same frame of the surveillance video, shot from overhead.

At 4:28:47 a.m., a nurse emerges from Entrance A to look for Laura, who is on the bench marked with the red rectangle. But the nurse doesn’t step very far from the door. She goes back inside the hospital after 12 seconds.

It’s the pivotal moment, as Laura has been unconscious less than three minutes. It has been possibly less than two minutes since her heart stopped beating. The odds were still strong she could have been saved, if only Nurse X walked a few feet to find Laura on that bench.

But Nurse X did not do that.

On the surveillance video, you see Nurse X take one step outside the ambulance-access door, going no further than an arm’s reach from it. In the predawn darkness, Nurse X cranes her neck a bit to see, but she doesn’t spot Laura on the bench, which is almost straight ahead of where she’s looking, albeit in a shadow.

There were only two entrances, within 100 feet of each other, that could have led to the emergency room.

Surveillance footage shows Nurse X stepping about an arm’s reach outside the hospital doors.

But Nurse X never strayed from the sliding door, as if she were afraid it would close on her.

On the video, the ambulance-access door opens at 4:28 a.m. and 47 seconds. When Nurse X steps back inside it is 4:28 a.m. and 59 seconds.

A 12-second search, for a woman having an asthma attack so dire that she’s come to an emergency room at 4 a.m. for help.

Nurse X would, months later, tell investigators from the Massachusetts Department of Public Health that it was “pitch black” outside, preventing her from seeing Laura. There was enough light, however, for a surveillance camera mounted at some distance to record Laura on her bench, even in the shadows. The corridor inside the plate-glass windows was aglow, also emitting light. An internal review days later by hospital officials would deem the lighting outside the door “appropriate,” though it was later enhanced, according to hospital documents.

Nurse X told investigators that she checked the main doorway of the hospital for Laura as well. Indeed, on the surveillance video, you see Nurse X close the ambulance-access door and, seconds later, a person — presumably Nurse X, though the image shot through the plate-glass windows is not clear — walks toward the main door via the inside corridor. The corridor runs parallel to the sidewalk and the benches, so on the video, you see Nurse X walk past Laura slumped on her bench. If Nurse X had looked out the window, maybe she would have seen her.

According to investigators, Nurse X undertook Laura’s search alone, even though both hospital security guards were just steps away in the emergency room on that patient watch. Nurse X said nothing about Laura’s call to the very people trained to patrol the hospital.

One of those guards, identified as Patrol Officer #2 in the state’s report, “said he overheard the nurse say something about the police and someone being outside,” and decided to follow Nurse X out of the emergency room into the corridor. According to the report, he watched Nurse X open the ambulance-access door and take a step outside. But he never asked Nurse X what she was doing. Nor did she tell him.

If only that guard had known about Laura, he might have saved her.

“I started to bang on the glass with my ring and from in the back I heard someone yell, ‘Relax’ in a very [annoyed] tone, and then as she turned the corner and saw me she said, ‘Take it easy.’ . . . I was standing there in full uniform and could not believe the attitude on this woman.” Detective James Slattery, Somerville Police

“Patrol Officer #2 said he was not aware of the whole situation until the following day when his manager asked why the event had not been entered into the Patrol Officer’s log,” reads the state’s report. “Patrol Officer #2 said had he been made aware, the policy for him would be to safely break off the patient watch and patrol the hospital grounds; however this did not occur.”

Laura had one more chance, even after everything that had gone against her. After Nurse X checked both sets of doors, she returned to the emergency room and placed a call back to the Somerville Police.

“I looked outside up here but I didn’t see anything,” she told the dispatch officer.

For whatever reason, Nurse X did not tell the police that it was too dark outside for her to see, or that one of the two doors to the emergency room was locked as Laura had stated — facts that may have drawn emergency responders to the top of the hill. When the dispatcher suggested that Laura was perhaps where those daytime doctors’ offices are at the bottom of the hill, Nurse X simply agreed.

Before ending the call, Nurse X told the dispatcher she’d call Laura’s cellphone, in an attempt to tell her where to go. Seconds later, on the surveillance video, you see Laura’s phone light up on the ground. If Nurse X had been calling from the ambulance-access door on her own cellphone, maybe she would have seen it light up, too, or possibly heard it ring. But she’d returned to the ER, which is where she stayed.

She was told that a police cruiser was being sent, which she apparently took to mean that her role in Laura’s search was over.

“All right, thanks,” said Nurse X, before hanging up.

* * *

FAILING TO FIND LAURA at those daytime doctors’ office doors, Engine 7’s firefighters followed in her footsteps up the hill, eventually reaching the emergency room. Firefighter David Farino was the first to spot Laura, rushing to her body and ripping her Spartan hoodie in two to start CPR. But he was too late.

At 4:33:54 a.m., firefighter David Farino walks toward the emergency entrance searching for Laura and finds her on the bench where she called 911.

Farino had taken just three minutes to walk up Tower Street. But those three minutes were just long enough for her life to slip away. It had pushed the time Laura had gone without oxygen to her brain to upward of seven minutes, and while a heart can be restarted at that point, as hers was, people rarely survive. She didn’t.

The emergency responders who found Laura on that stone bench appear to have known the precise value of those minutes, too, according to police and fire reports. Somerville Police Detective James Slattery, who’d been searching for Laura on the back side of the hospital and in an auxiliary parking lot, could not believe what he discovered.

“I was dispatched to the area of the Somerville Hospital to assist a female having an asthma attack who stated the hospital door was locked and she could not get in,” his incident report began. “As I turned into the main entrance I observed firefighters frantically performing CPR on a female, on the sidewalk in front of the main windows. She was in between the main entrance and the Ambulatory Emergency Entrance. I exited the cruiser and one of the firefighters asked me to go inside and let them know we were out there because, ‘They have no idea we are out here.’

“I ran inside and no one was at the security desk. I ran to the entrance of the Emergency Room and looked inside the windows and did not see anyone. I started to bang on the glass with my ring and from in the back I heard someone yell, ‘Relax’ in a very [annoyed] tone, and then as she turned the corner and saw me she said, ‘Take it easy’ in that same annoyed tone. I was standing there in full uniform and could not believe the attitude on this woman. I said, ‘Are you kidding me, the firefighters are working on someone on the sidewalk and need help and a stretcher.’”

Firefighter Farino, and later an ambulance EMT who arrived on the scene, spent eight minutes giving CPR to Laura before her heart started beating again, I learned. A stretcher was brought, and Laura at last was taken into the emergency room of the Somerville Hospital. It was approximately 4:39 a.m., some 15 minutes after she’d placed her call to 911 from outside its doors.

“I found the woman’s phone on the ground and brought it inside,” Slattery wrote. “I was so disgusted at the way I was treated I had to leave the Emergency Room.

“As I was walking outside,” he added, “I overheard someone say that a nurse said she went out and checked, but did not see anyone.”

* * *

Peter and Laura hiking in the Scottish Highlands in 2015. From Peter DeMarco

IT WAS 7:15 A.M. on an overcast Friday. I’d just gotten up to feed our cat when our apartment phone rang.

I’d had a late night playing for my men’s league baseball team. At 10:39 p.m., I texted Laura that we’d lost. “Sorry,” she wrote back. At 11:06 p.m., I texted her again, to tell her the Boston Red Sox, my favorite team, had just staged an incredible comeback against the New York Yankees, Laura’s hometown team.

Yes, a Red Sox fan actually married a Yankees fan.

“Holy shit — did you see sox yanks ending?” I asked.

“Sucks, but congrats to you,” Laura replied.

At 11:12 p.m., she texted me for the last time. “Going to beddy. See u @ 830.”

I was supposed to pick Laura up and drive us to a couples counseling session at 9 a.m.

Instead, I looked at the caller ID on our phone, a landline, which read, “Somerville Hospital.”

Perplexed, and only half awake, I answered.

“Does a Laura Levis reside here?” a woman asked.

“Uh, yes. Why?” I said.

“Whom am I speaking with?” she said.

“This is her husband. What is this about?” I asked.

“This is the Somerville Hospital emergency room. Your wife has gone into cardiac arrest. She’s being transferred to the intensive care unit at Cambridge Hospital.”

For a moment, I couldn’t comprehend what she was telling me. Laura, a heart attack? She was 34. That was impossible.

Not knowing what else to say, I asked where to go: to Somerville Hospital or Cambridge Hospital?

“If you can get to Somerville Hospital within the next 10 minutes, you can ride in the ambulance with her there,” the woman said.

Somerville Hospital is a little over 1 mile from our apartment, so I threw on jeans and raced out the door. I got there in time and was brought to Laura, who was unconscious and intubated. A special cold blanket soon would be placed over her body to keep her temperature low, a standard protocol intended to focus blood flow to vital organs and reduce brain swelling, I was told.

Later, the shock of it all would set in. But for those minutes, I tried to stay focused: I needed to know what had happened, and how to help my wife.

The emergency room had just had a shift change, so there was no one I could speak with who’d actually been there when Laura was brought in, I was told. At the time, that didn’t seem too strange. But now, I wonder, why did the emergency room wait 2½ hours after Laura was admitted to contact me? Was it merely a coincidence that I was called 15 minutes after the night-shift staff had left the building?

The senselessness of my wife’s death clearly had struck a nerve with Detective James Slattery and his fellow officers. I assume that is why Somerville Detective Michael Perrone conducted a full investigation.

I was told by various people in the emergency room that Laura had collapsed on a street near the hospital, or possibly somewhere on the grounds of the hospital where emergency responders couldn’t easily find her. They told me that Laura had called 911, but unfortunately she wasn’t able to give the operator her exact location.

I don’t remember any of those people’s names or faces. Minutes away from boarding an ambulance with Laura to Cambridge Hospital, I just wanted to get as much information as I could before we left.

And it’s not like I thought anyone would lie to me.

I do remember someone, possibly an EMT or ambulance driver, mentioning that fire and police responders could have given up their search but kept going, finding Laura in “the last place they looked.”

“You might want to thank them one day,” that person said. I wonder, now, how much that person knew.

Somerville Hospital and Cambridge Hospital are both owned by the same health care organization, Cambridge Health Alliance. We spent seven days in the ICU; for the last five, I didn’t leave my wife’s bedside for more than an hour a day. During all that time, no one mentioned anything to me about Laura making it to the doorstep of Somerville Hospital’s emergency room.

No one mentioned anything to me when, days later, I e-mailed my thank-you letter to some 25 doctors, nurses, respiratory therapists, and other staff members who cared for us. Or after the Times published the letter. Or after we were on the national news. Or after Laura’s obituary was featured on the front page of the Globe.

RELATED: Death of 34-year-old Laura Levis reaches far beyond friends and family

More than a month passed, and no one from Cambridge Health Alliance said a word to me about Laura being locked outside that door. Nor, I imagine, would they ever have.

But the senselessness of my wife’s death clearly had struck a nerve with Slattery and his fellow officers. I assume that is why Somerville Detective Michael Perrone conducted a full investigation, even though his department didn’t require written reports for medical calls. He interviewed the firefighters who found Laura and one of the guards who’d left the security desk unattended and, most importantly, viewed surveillance footage from the hospital’s cameras, describing all he observed in writing, in case that footage was ever erased.

On Friday, October 28, five weeks after Laura’s organ-donor surgery, her father, Bill, shared the police reports with me. They were shocking, and I sobbed as I read them, feeling as though Laura had somehow just died all over again.

Then I called the law offices of Lubin & Meyer, the largest medical malpractice firm in Boston, and booked an appointment for Monday morning.

* * *

A RECEPTIONIST LED ME into a fancy conference room in Lubin & Meyer’s office, overlooking Boston’s City Hall Plaza. Left alone for a few minutes, I read the newspaper clippings on bronzed plaques hanging on the walls. They told of the multimillion-dollar cases and settlements the firm had won or obtained for its clients. “$13.5M Awarded in Hospital Death” particularly caught my attention.

What would getting that much money from the hospital do, I wondered?

It would not give Laura the chance to live her life, to be a mother, to grow old with me — but you know that. Still, if Somerville Hospital were made to pay millions in damages, it would potentially send a message to hospitals across the country to reevaluate their emergency room procedures and staffing levels, and train employees in how to properly respond to distress calls such as Laura’s.

A huge settlement would encourage other hospitals to invest in more sophisticated surveillance systems, maybe ones that would allow security guards to access video from their cellphones when they leave their post. To create more comprehensive and unmistakable signage leading patients directly inside emergency rooms. And to install panic buttons or even simple doorbells outside emergency-room and hospital doors that are locked in the middle of the night.

By making the hospital pay, I thought, maybe Laura’s death would stand for something. And I could put that money toward good. It’s my dream to establish a foundation in her honor, Lift4Laura.org, whose aim will be to provide free personal training sessions at gyms for underprivileged and abused women.

My new lawyers said they needed time to gather evidence and research the case. But I was not to say anything publicly until we filed a suit, as anything I said, regardless of my intentions, could be used against us in court. I agreed to stay silent, even though I wanted to shout to the world that Laura never should have died.

“Live your life, but don’t live your life for the lawsuit,” Adam Satin, a partner at Lubin & Meyer, advised me. “Do whatever you need to do to grieve, and whatever you feel you need to do, when you are ready, of course, to move on in your life.”

And so I began my grieving process all over again, trying my best to honor my wife’s memory through it all.

We held a special boot camp class in Laura’s memory at our local gym, Boston Sports Clubs in Davis Square. More than 30 people wearing “Lift4Laura” T-shirts greeted me as I walked into the main workout studio. The shirts were purple, Laura’s favorite color, and I broke down in tears.

The manager of the historic Somerville Theatre gave me the entire main auditorium, with its Art Deco murals and wooden stage, in which to hold a memorial service. With the lights turned low, video clips of Laura from our years together filled the giant movie screen as “Seasons of Love” from Rent, her favorite musical, and Josh Ritter’s “Change of Time” played. For a few fleeting moments she was literally larger than life, and I sat spellbound, wishing somehow it would never end.

Friends and family turned out for a special boot camp at Boston Sports Clubs in Davis Square. Peter is establishing a charity in Laura’s honor, Lift4Laura.org.

On what would have been our third wedding anniversary, I invited more than a dozen friends to watch our wedding video, which Laura and I had yet to see. It was a difficult request, but they came. I knew I would cry at the first glimpse of my wife in her backless wedding dress, descending a spiral stone staircase to our spot along the Atlantic Ocean. But I also felt joy, because we were both just so happy.

Magically, we all started to relax and even laugh at people’s crazy dance moves. When the video was over, a friend turned to me. “It was actually cathartic,” he said.

All the while, as I mourned and remembered her, the case against Somerville Hospital began to mount.

* * *

THE MASSACHUSETTS DEPARTMENT of Public Health, responding to a complaint I filed, thoroughly investigated Laura’s death, eventually citing the hospital for failing to provide a safe environment and for “poor quality of pre-hospital care.”

Through numerous letters and phone calls, I obtained the grainy, horrible surveillance video showing Laura outside the hospital. I obtained from the State Police the shattering recording of Laura’s 911 call and recordings of phone conversations between the Somerville Police, the emergency room, and all of the emergency responders that morning.

I sought out every document I could find related to Laura’s death: police and fire reports, ambulance reports, state investigators’ reports, field notes from hospital inspections, and internal hospital documents, which I requested through the Freedom of Information Act. All of which I passed to my lawyers.

Laura at home with her parents, Bill and Georgia Levis, in their Manhattan apartment. Laura’s mother passed away this July, after a long battle with cancer. Peter DeMarco

A week before this past Christmas, I got a stunning phone call from the US Department of Health and Human Services, Office of Inspector General, in Washington, D.C. Somerville Hospital had been accused of violating federal law by denying Laura access to emergency care and had agreed to pay $90,000 to the government in a settlement agreement.

Hospitals that receive Medicare payments (as most do), it turns out, are responsible for the well-being of patients even when they don’t actually make it inside an emergency room. Under the Emergency Medical Treatment and Labor Act, better known as EMTALA, Somerville Hospital should have searched for Laura anywhere “within 250 yards of the hospital,” including the sidewalk, parking lots, driveways, and any other buildings on its campus.

“A hospital’s EMTALA obligations extend beyond the four corners of a building,” Sandra Sands, a senior counsel in the Office of Inspector General, told me. “It certainly includes right outside the ambulance-bay doors.”

“From our point of view,” she continued, “the search was not done appropriately, and the overall hospital’s response was negligent in terms of the timing of getting to the patient.”

Every malpractice lawyer in Massachusetts knows that you can’t get far suing a public hospital, or any of its employees, no matter what they do, because of “the cap.”

Four weeks after Laura died, about half of the emergency department’s staff, including full-time nurses, per diem nurses, a floating nurse, and even a nurse from a temporary help agency, attended a meeting at which, according to minutes quoted in the DPH report, “there was a robust discussion regarding collaboration with Public Safety, the expectations of staff and public safety partners, and providing a safe environment for both staff and patients.” But when investigators later interviewed staff members, they were hard-pressed to think of anything that discussion had actually changed.

And Nurse X wasn’t even at the meeting.

“She said she heard about a meeting with the Public Safety Officers, but was unable to attend,” reads the DPH’s report. There was no reason given, though Nurse X was later briefed on it.

The Department of Public Health turned up half a dozen other patient-safety violations at Somerville Hospital beyond Laura’s case and found that the hospital’s parent, Cambridge Health Alliance, had failed to even notify emergency room staffs at their Everett and Cambridge hospitals about Laura’s death. Nor were the circumstances of Laura’s death reported to public health officials, as was required.

Taken together, the state’s investigation and the federal government’s allegation painted a picture of a hospital whose culture failed to properly emphasize patient safety. Nurse X’s mistakes were indicative of larger, systemic problems that all played roles in Laura’s death — communication breakdowns, unmanned security desks, staffers rushing through tasks, administrative lapses, and missing emergency room signs.

Sands, from the inspector general’s office, told me the federal settlement would appear on her office’s website for all the Internet to see. The statute included a provision allowing families to sue in civil court whenever a violation occurs; she added that I might want to get a good attorney, if I hadn’t already.

I called my lawyers at Lubin & Meyer, thinking a federal investigation into Laura’s death, and Somerville Hospital’s agreement with the Office of Inspector General, would cement our case.

Incredibly, though, even those extraordinary events would prove almost insignificant.

Cambridge Health Alliance, a $671 million organization that runs hospitals as well as primary care practices, is considered a public entity, as established under a 1996 state charter. And every malpractice lawyer in Massachusetts knows that you can’t get far suing a public hospital, or any of its employees, no matter what they do, because of “the cap.”

Peter and Laura, who met while working at the Globe, at a cafe on one of their many travels. Peter DeMarco

* * *

SATIN AND HIS CO-COUNSEL, Maria Mazur, were sympathetic, delivering the bad news with pained expressions. Laura’s death was unjust, and the hospital’s mistakes unconscionable, they told me. But a law enacted in the 1970s that protected public hospitals from being sued for more than $100,000, and indemnified their employees, would nevertheless stand in our way.

Massachusetts General Laws, Chapter 258, Section 2, was virtually unassailable. It protected Nurse X. It protected the security guard who could have asked Nurse X whom she was looking for. It protected the hospital administrators who allowed safety deficiencies to exist.

Other families harmed by the system have previously tried overturning the state cap — many with even stronger cases than ours — only to fail. In some cases, after wasting a decade of their lives fighting in court.

RELATED: Why malpractice suits in Mass. are not worth the legal fees

My lawyers had mentioned the existence of the cap, albeit briefly, going back to our very first meeting, when I had no clue about what a malpractice case entailed or that malpractice caps even existed in Massachusetts. They had hoped all along to find a private, third party we could sue — if the hospital had outsourced its security, for instance — that wasn’t protected by the state cap. Or some evidence or case law that would have allowed us to circumvent it, going so far as to examine whether they could charge the hospital with violating Laura’s constitutional right to “life, liberty, and the pursuit of happiness.” But nothing had panned out.

Without the cap, we’d likely be looking at a multimillion-dollar verdict, assuming we won.

With the cap, Laura’s death, in the eyes of the law, hardly seemed to matter.

“It’s just bad luck that this is the hospital she went to,” were Satin’s first words to me that day.

Malpractice firms typically operate on contingency fees, collecting money from a client only when they prevail. It’s a good gamble when millions of dollars are at stake, as a firm takes a sizable percentage of whatever money is awarded or settled upon. But $100,000, in terms of a malpractice suit, just isn’t a lot of money. Lubin & Meyer’s share of a maximum $100,000 verdict — around $40,000 — wouldn’t even cover the firm’s costs to bring Laura’s case to court.

If it went that far, my lawyers said, I would have to pay the firm — in advance — the costs of taking the case to trial. Those costs could, quite possibly, exceed any amount I could hope to receive in a capped verdict: even if we won, I could actually lose money suing the hospital.

This, according to Massachusetts state law, was justice.

Leaving my lawyers’ offices that day, I trudged into a cold December air, taking a lonely, bitter subway ride home. There would be no lawsuit against Somerville Hospital, and I would have to live with Laura’s death, forever, knowing it wouldn’t inspire any meaningful change. That somewhere, someone else would die outside a locked hospital door, and there was nothing I could do about it.

Well, there was one thing I could still do.

* * *

Devoted to fitness, Laura worked out six days a week and competed in organized powerlifting competitions. Peter DeMarco

WHEN I LEARNED THE TRUTH about what had happened to Laura, I started having nightmares. Awakening in the middle of the night, I would imagine how frightened Laura was, how alone she must have felt those last minutes of her young life. “No! No! No!” I would scream inside my head, locking that horror inside a mental box, struggling sometimes until dawn not to open it.

Though I knew she’d called 911, I couldn’t bring myself to listen to the recording, to actually hear her last words.

This spring, while writing this story, I reached the point where I needed to know exactly what Laura had said — there were just too many holes I couldn’t explain. My lawyers provided me with a written transcript; my two therapists sat alongside me for emotional support.

I’d immersed myself in her tragedy for months, but reading how she related, with such unmistakable clarity, that she was both outside the emergency room, and that she was “dying,” changed everything once more. I was despondent, and went walking aimlessly for hours. Stumbling upon a street named Acadia Park, I began crying uncontrollably. We’d gotten married in Bar Harbor, Maine, home to Acadia National Park.

The FCC estimates that 10,000 lives could be saved annually if emergency responders could get to 911 callers just one minute faster.

Reading her words made me realize, for the first time, how mistakes were made from the moment she dialed 911 on her iPhone. How seemingly our entire emergency-response system, and our emergency health care system, had let her down. How they could fail anyone seeking lifesaving care. I started to see just how many ways Laura’s story could be a catalyst for change.

The FCC estimates that 10,000 lives could be saved annually if emergency responders could get to 911 callers just one minute faster, and even that figure, based on the methodology I’ve read, could be vastly conservative, as it assumes delays in locating just 5 percent of callers. What could be done to save those lives, to make sure that no one else dies the way Laura did?

There are a number of possible solutions, but a few stand out to me.

I hope that regional 911 call centers, cost-saving economies of scale aside, become a thing of the past. Had Laura’s call gone directly to the Somerville Police, I am convinced that game of telephone wouldn’t have resulted in disaster. A local dispatcher, familiar with the hospital, would have asked Laura whether she was at the top or bottom of that hill. It isn’t just my view — 911 calls misrouted to wrong call centers are a national issue. Massachusetts cities, meanwhile, are increasingly adopting “Wireless Direct” 911 systems in which cellphone calls are routed to local dispatch offices, just like landline 911 calls are. Somerville, in October, joined that list.

Millions of 911 cellphone calls across the country register inaccurate locations each year, as Laura’s did, due to such factors as tree interference, poor atmospheric conditions, and radio signal challenges, according to the National Emergency Number Association, or NENA, a Washington, D.C.-based nonprofit that has led the charge for advancing 911 technology. Locations are so often wrong that, according to one survey, 82 percent of 911 operators doubt the location information they receive. Incredibly, Laura’s location would have been considered “accurate” according to FCC standards, even though it led police and fire responders astray.

A national push is underway for states to adopt a far more advanced 911 system — “Next Generation 911” — in which callers will not only be able to speak with a 911 operator, but also send text messages, photos, and video to help emergency responders locate them and assess their crises. If such a system were in place, Laura could have sent a photo of the ambulance-access door to her 911 operator, who in turn could have texted it to Engine 7’s crews, or even to Nurse X.

But without federal leadership or funding, most states are still years away from implementing such important advances.

A national push is underway for states to adopt a far more advanced 911 system — “Next Generation 911” — in which callers will not only be able to speak with a 911 operator, but also send text messages, photos, and video.

The other solution to 911’s location problems is right at our fingertips.

Thanks to major software upgrades, both Android and Apple phones can now automatically relay a smartphone’s GPS coordinates whenever a caller dials 911, much like when you send your location to be picked up by Uber — a huge improvement over cellphone providers primarily relying on pings to satellites and cell towers to find a 911 caller. They can even relay information to help determine which floor of a building you’re on, something even your Uber app doesn’t do.

Implemented in Europe and in some US test markets, the systems aren’t perfect. But Apple says its new phone software consistently pinpoints a caller’s coordinates within 165 feet of his or her location. Google says nearly half of all 911 calls on Android phones can be traced to within 60 feet — less than the distance between Somerville Hospital’s two doors.

In September, America’s four largest cellphone carriers — AT&T, Verizon, Sprint, and T-Mobile — said they will begin passing Apple and Google’s cellphone-location data on to 911 operators. That has to happen, without any glitches or delays, for all our sakes.

Laura backpacking across Scotland's Isle of Skye. Peter DeMarco

I am not going to sue the Somerville police or fire departments, or the State 911 Department — nor can I, as state laws grant them powerful immunity regarding 911 response errors. But the mistakes made in the transferring of information between emergency responders that morning also dictated Laura’s fate.

I hope emergency operators and dispatchers who read this story learn from those grave mistakes, make efforts to react with greater urgency to asthmatic callers, and establish protocols for reaching out not just to ambulance companies, but to the nearest possible source of help when that’s the best chance someone has of surviving.

Mistakes happen, in every walk of life. That’s why it’s important, particularly in health care, to create environments that minimize mistakes. I hope that hospital administrators who learn of Laura are reminded of how important redundancies can be regarding patient care. In her case, something as simple as requiring two people to conduct a search — a second set of eyes — could have made the difference. And that health care organizations stress “closed-loop” communications, in which at least two people on a staff must confirm that critical tasks are done accurately.

And, as Dr. Atul Gawande said nearly a decade ago in his renowned book The Checklist Manifesto, that doctors and nurses reduce commonplace errors simply by reminding themselves never to skip a single step in whatever they’re doing. Such as walking 100 feet, between two sets of doors.

Medical errors have become the country’s third-leading cause of death, resulting in as many as 250,000 deaths per year, according to a study by Johns Hopkins University School of Medicine. Another study estimates the number could be as high as 440,000. Patient safety needs to be improved everywhere, not just at Somerville Hospital.

As a nation, we have far to go to provide proper and equal care to all, no matter what hospital one chooses. That both Somerville and Cambridge hospitals are managed by the same health care organization shows how splintered our health care system is. Our experience at Cambridge Hospital, whose ICU staff could not have been more compassionate, is what health care needs to strive for; the lack of care exhibited at Somerville Hospital is what it needs to avoid.

What else could Laura’s story change?

Public caps exist in some 40 states, according to the American Association for Justice, a trade-group organization for trial lawyers based in Washington, D.C. In some states, you can’t sue a public hospital at all. I hope state legislators, in Massachusetts and elsewhere, who read how Laura’s life was wasted, revisit such laws, particularly when they block families from obtaining any meaningful restitution in the face of terrible tragedy.

Some states have compensation pools to pay victims in excess of the amount individual hospitals are capped at paying. Some states waive caps in the most egregious instances, when negligence leads to catastrophic outcomes; others have review boards that allow only the strongest of cases to go forward. Changes can be made without disrupting the entire system.

In Massachusetts, there’s already such an exception on the books. Although the limit for malpractice suits against public hospitals is $100,000, it rises to $500,000 for private medical institutions. However, under “special circumstances” in which a severe loss is suffered, a jury can award whatever amount it sees fit against a private medical institution to justly compensate a plaintiff.

Why deprive any citizen of that right just because they choose a public hospital or, because of their economic circumstances, have no choice but to seek care at a “safety net” Medicaid/Medicare provider such as Somerville Hospital?

That the hospital misled me wasn’t even mentioned in DPH’s report. (“Did they lie to you, or did they just omit the truth?” a DPH official asked me.)

Lastly, there’s her asthma.

For the one-year anniversary of Laura’s death, I reserved the back room of our favorite Somerville Irish pub, The Burren, for a private toast to my wife. On a large flat-screen television I played a video no one had seen, from a trip we’d taken to Spain.

It begins with Laura explaining to the camera how she’d gotten pickpocketed by some street urchins and how she, alone, chased after them through the crooked streets and back alleyways of Seville to get her money back. She reenacts the entire episode as I film her, running, for effect, in her flip-flops to the spot where she tackled the last kid, who dropped her cash and fled.

It is truly an incredible vacation movie, and were you to see it, you’d know why I fell in love with this amazingly determined woman.

I think about that adventure in Spain when I picture Laura that September morning two years ago, leaving for Somerville Hospital with her gym clothes in her backpack. She was confident, indestructible, and maybe . . . too impulsive for her own good.

Laura did not miscalculate that morning, but she should have been far more careful. She should have told someone immediately that she was having an attack, regardless of what time in the morning it was, and should never have walked alone to the hospital. It is a message that I pray everyone who reads this passes along to the people in their lives who have asthma. A message that Dr. Sumita Khatri, a national asthma expert and co-director of the Cleveland Clinic Asthma Center, stressed to me when explaining just how quickly asthma can turn fatal.

If an attack strikes when you are alone, let someone know.

Because even if you reach the door of a hospital, you might not get in.

A view outside Somerville Hospital a year after Laura died shows the bench where she collapsed, and (circled) one of the new emergency signs the hospital added. Peter DeMarco

* * *

ABOUT THAT door . . .

The renovations began late last summer, with the finishing touches completed around this time last fall. Today, when you approach the front of Somerville Hospital, the entrance on the right that Laura found locked is now the main public doorway to the emergency room, just as it always should have been.

There’s a large, illuminated “EMERGENCY” sign above it, as well as several additional signs on the property pointing patients to use that entrance, which is now never locked. The bench where Laura sat is now, at night, bathed in bright light.

When I approached Cambridge Health Alliance officials with questions about those changes at Somerville Hospital and about Laura’s death, they said they couldn’t comment because of potential litigation. Technically, state law allows a three-year window for a victim’s family to file a malpractice or negligence claim, and for us, it’s only been two years. I told the hospital that while I did retain an attorney, I now have no intention of ever filing a lawsuit against them. They still declined to comment.

Though I’m grateful the Massachusetts Department of Public Health investigated Laura’s death, the department failed to issue a single punitive sanction against Cambridge Health Alliance. That the hospital misled me wasn’t even mentioned in its report. (“Did they lie to you, or did they just omit the truth?” a DPH official asked me. “Is there a difference?” I responded.) Because of the cap, it’s unlikely Somerville Hospital will ever be found liable for negligence in a court of law. Even in the settlement agreement with federal lawyers, Cambridge Health Alliance’s attorney made it very clear that the hospital would admit no wrongdoing in Laura’s treatment.

“I want to avoid even implied admissions by CHA,” wrote Andrew Fuqua, Cambridge Health Alliance’s senior vice president and general counsel.

But that new emergency room entrance, well, I think it speaks volumes.

So, who is Nurse X?

For the longest time, her name was redacted in every document, and my requests to release her name were denied. The system protected Nurse X’s identity, even from me. But in late June the Department of Public Health decided to grant my final appeal, informing me it would be providing me a copy of the investigation in which Nurse X’s name would appear.

It was the moment I’d waited for.

And . . . I have yet to open that e-mail.

For me to face this person will take time. Nurse X knows Laura died; she knows she left her out there; I believe she even cared for Laura once she was brought into the ER. She lives with those thoughts, just as I do. Opening that e-mail, and publishing her name, won’t change that hospital, and it won’t change the system, but it could ruin her life.

For similar reasons, with the consent of my editors, I have not shared here the real name of Laura’s first 911 operator or any of the other operators or the security guard whose mistakes each played a role in this tragedy. Revealing their names won’t bring anything but more pain to more people.

And at this point, I just don’t think that will make me feel any better.

A Cambridge Health Alliance billboard overlooks a parking lot where Peter DeMarco plowed snow last winter. Peter DeMarco

AFTER LAURA DIED, I gave up writing professionally. To pay the bills, I work alongside my father in our family business, snow plowing. Last winter, I drove a pickup truck, plowing Malden parking lots, usually in the middle of the night. A billboard overlooked one of the lots, adorned with, of all things, an advertisement for Cambridge Health Alliance, touting its stellar emergency room care.

“When emergencies happen,” the billboard read, “we’re right by your side.”

Laura’s death has, in many ways, become part of my daily life. Sometimes I find myself counting off 10 minutes on a clock, imagining her lying there, waiting to be found. As I play baseball, I think of those 29 feet. It’s not even halfway from home plate to the pitcher’s mound.

I have yet to view the surveillance videos of Laura outside the hospital, relying on descriptions from investigators’ reports, my lawyers, and the detailed notes of an old journalism friend, Jay Lindsay, a 15-year Boston Associated Press reporter, who was kind enough to watch the tapes for me. Despite all I’ve uncovered, I’m still afraid to watch her die. Maybe the publication of this story will give me the strength I need to cross even that chasm.

Laura’s death has, in many ways, become part of my daily life. Sometimes I find myself counting off 10 minutes on a clock, imagining her lying there, waiting to be found.

In my grief one day, I started running as fast I could to Laura’s favorite park along the Charles River, so exhausted by the time I reached it that I collapsed there on a flat stone bench. Lying on my back, I stared into a canopy of beautiful, swaying trees. I like to think that Laura had once stared up at those same trees and that she thought of them, of their peacefulness, when she closed her eyes for eternity on that other bench.

That other bench . . .

For a full year, I avoided even driving past Somerville Hospital. But on the morning of September 16, 2017, I went there.

At 4:24 a.m.

I sat down next to Laura, one year too late.

In my imagination, I held my wife’s hand and stroked her lovely face. I told her how much we all missed her and still loved her. I glowered at the now-unlocked and well-marked emergency room door, so impossibly close.

I wept, as deeply as I have ever wept.

I was there only a few minutes when a security guard came out of the hospital and approached me.

“Are you waiting for someone?” he asked.

“Yes, I am,” I said, coldly.

But I didn’t feel like playing games.

“A year ago I lost my wife here.”

The guard patted my shoulder.

“I’m sorry for you. Take all the time you want,” he said. “If you need anything, I’ll be right inside.”

After he’d gone, and most of the tears were out, I just sat there, drained of my anger, my grief, my sadness, my pain. Not knowing what else to do, I turned to the empty space next to me on the bench, and started talking to my wife.

“So, how are you?” I asked.

I got out my phone and showed her all the pictures and videos I’d taken since she’d been gone. Pictures of all the incredible people, friends and family, who’d helped me get through it; the mountains I hiked, toting her backpack for us both; her nephews and nieces lifting weights in their purple Lift4Laura shirts; Bill, her father, with me at a Yankees game, with my new Yankees cap on; Georgia, her mother, modeling her pink “pussyhat” as she underwent chemotherapy; the services we held, at both the movie theater and Poly Prep Country Day School, Laura’s high school in Brooklyn, filled with so much love; and, of course, a clip of our cat, Cola, running crazily around the apartment.

Laura’s asthma never impeded her. She was vigilant about carrying inhalers. Peter DeMarco

For the first time in an entire year, we had a real conversation. Laura was with me, listening, commenting, laughing along. I felt her spirit beside me, inside me, more so than I had since the moment I let her go.

We talked, if you can believe it, for hours, until it was dawn.

“What now?” I finally asked, as I do every waking day without her.

I swear, I heard her speak:

“Coffee!”

On the stone bench, I left a bouquet of purple flowers, a paper lantern from the night I proposed, and a Mason jar, just like the ones we had at our wedding reception. I’d found a tea-light candle to place in the jar, but the battery was old, so it had long since gone dark.

I kneeled down to say my goodbye, kissing the slab of stone, as if meeting her lips. And the candle in the jar, to my surprise, suddenly flickered once more.

Peter DeMarco lives alone in Somerville. Send comments to magazine@globe.com. Get the best of the magazine’s award-winning stories and features right in your e-mail inbox every Sunday. Sign up here.