For 50 years Linda Sue Brown’s nine siblings fiercely protected her, facing down anyone who would taunt her or seek to exploit the disability that left her with the mental capacity of a 12-year-old.

That sense of responsibility only grew after their 81-year-old mother, Brown’s lifelong caretaker, was stricken with Alzheimer’s disease, leaving her unable to tend to her daughter.

So when Brown’s lower legs swelled last summer and she grew short of breath, her eldest sister rushed her to a place the family knew and trusted: Brotman Medical Center in Culver City. One of Brown’s sisters, Thelma Allen, worked there as a nurse; another, Rosslyn Diamond, had previously been a nurse there. And Brown had been treated there, successfully, for years.

At the 420-bed hospital, tests revealed that Brown had an enlarged heart, fluid in her lungs and severe anemia, medical records show. She received blood transfusions and, two days later, an emergency hysterectomy. Afterward, Allen was given an unorthodox, but welcome, assignment: She was to be one of Brown’s nurses.


On July 4, after her shift ended, Allen watched TV with Brown, then kissed her good night.

By the time she returned the next morning, her sister was dead.

The death was probably caused by a pulmonary embolism, a clot of blood blocking an artery to the lungs, Diamond recalled the surgeon saying. If so, nothing could have saved her.

For most grief-stricken relatives, the questions would have ended here. Patients die unexpectedly in hospitals every day. If families have vague doubts about why and how, they typically lack the knowledge and access to get answers.


But Diamond, 60, and Allen, 59, vowed to find out what happened to their sister.

Along the way, they discovered that their decades of experience afforded them little advantage over any other bereaved family. Instead, almost everything they believed about the medical profession was turned on end. And ultimately, the answers they battled to get have provided little comfort.

After months of investigation, state health inspectors determined that Brown’s death was nothing so random as an embolism.

Brotman staffers, the inspectors found, had failed Brown in virtually every way: Her nurses -- Allen’s colleagues -- appear to have forged consent forms and had Brown sign agreements that she couldn’t understand. One failed to call for help as Brown’s vital signs plummeted.


Her doctors didn’t investigate signs of heart failure, performed a risky emergency surgery with no clear justification and then didn’t intervene as her condition deteriorated. And hospital officials didn’t even look into what went wrong until inspectors inquired.

“That is just a pretty phenomenal failure,” said Dr. Eric J. Thomas, an associate professor of medicine at the University of Texas, Houston, and a patient safety expert who reviewed Brown’s medical records and the state report for the Los Angeles Times.

“Certainly anyone would classify it as a preventable death,” he said.

Brotman leaders said that Brown was in precarious health, with ailments that included an enlarged heart, and that nothing staffers did could have changed the outcome. Health inspectors also judged Brotman staffers too harshly, they said, failing to consider some mitigating information.


If mistakes were made, said Brotman’s chief executive, Howard H. Levine, “you have to realize that in a hospital, any time you have the human element involved in care, there’s going to be an error or two, unfortunately.”

According to the 72-page report by the state Department of Health Services, three of Brotman’s physician leaders separately told state inspectors that they had a “concern for the quality of care” provided to Brown throughout her stay.

In the months after Brown’s death, her sisters heard nothing about such problems. They knew only that she died somewhere they thought she would be safe, a place that had begun treating them as outsiders.

At the beginning, Diamond said, “our goal was just to find out what happened to my sister.”


Now, “I want to see someone in handcuffs. Someone should be in handcuffs.”

5-foot powerhouse

Brown, the seventh of 10 children, was the family’s heart. Hooked up to her headphones, the 5-foot, 150-pound powerhouse would bellow along to the tunes of Elvis, the Beatles and the Ikettes -- oblivious to her surroundings and her less-than-harmonious voice.

“She couldn’t sing a lick,” Diamond said. Every year, she lighted candles to mourn the anniversaries of the deaths of Elvis and John Lennon.


Brown knew she was different, her sisters said. A medication side effect caused her to lose her hair as a teen, so she wore wigs. She had a seizure disorder and, as she got older, hypertension and diabetes.

She once told Diamond that after she died, she’d like to come back as “normal.” Perhaps to compensate, she’d sassily assert “I know that” to whatever anyone told her.

Brown was fortunate, her family believed, to have doctors at Brotman who knew of her limitations. Some had treated her for years.

Thelma Allen visited her sister July 1, the day after her admission. She said Brown’s longtime primary-care doctor, Daryl Houston, told her that Brown had a little fluid overload in her lungs from the blood transfusions she had received to combat her anemia. “I didn’t think anything of it, because I felt comfortable with Dr. Houston,” Allen said.


What she wasn’t told, Allen said, was that doctors had intended to perform an emergency hysterectomy that day, certain the anemia was caused by abnormal vaginal bleeding, which Brown had previously complained about. But an anesthesiologist canceled the surgery, saying Brown’s fluid-filled lungs made it too risky.

Brown had the hysterectomy the next day. Diamond and Allen said they assumed that their elder sister, Alice Brown, had approved the procedure. She hadn’t, they said.

They later discovered that Linda Brown had signed the consent herself, even though her mental limitations required an authorized surrogate to sign on her behalf, according to health inspectors. On other hospital consent forms, her signature appeared falsified, the inspectors found.

The morning after the surgery, Allen was assigned to care for Brown and five other post-surgical patients. Both she and Diamond noticed that Brown wasn’t her usual chatty self. “I said to her, ‘You’re going to have to perk up. You got to get out of the bed and move,’ ” Diamond said.


Despite all the intravenous fluids going in, there was scant urine coming out, a sign that her bladder and kidneys were not functioning properly, said Diamond, a post-delivery nurse at Harbor-UCLA Medical Center. Both sisters said Brown’s doctors did not seem overly concerned.

Brown’s condition deteriorated. She died the morning of July 5, while Allen was on her way to the hospital.

When Diamond arrived, she demanded that Dr. Norma Salceda, the gynecologist who performed Brown’s surgery, tell the family what went wrong.

“These things happen,” Diamond recalled Salceda saying, suggesting the probability of the embolism.


Diamond, whose pretty features turn fierce in the face of perceived wrongs, said her reply was loud and furious. “I said, ‘No, that is not what happened. You are going to tell me what happened.’ ”

No consolation

As the family waited in the hallway, no one offered explanations or even consolation.

“No supervisor approached us. No social worker. No charge nurse. No one. Ever,” Diamond said.


Allen felt she was no better off for being a hospital staffer, despite having been recognized in the past as a “Shining Star” who had made an “outstanding contribution to Brotman,” according to an internal newsletter.

A hospital official told the sisters that federal patient privacy laws prohibited the sisters from looking at Brown’s final medical charts, even though Allen had previously had access as one of Brown’s nurses.

Because no family member was Brown’s legal guardian, Diamond said, she was forced to hire a lawyer to subpoena the records.

“They were already circling the wagons,” she said.


But unlike the families of most patients, Diamond said, she knew how hospitals worked.

When Brotman called to ask permission to do an autopsy, Diamond said, she called the Los Angeles County coroner to request an independent autopsy.

She filed a complaint with the California health department, which oversees care in the state’s hospitals, and she called back again and again until an inspector was assigned and a probe completed.

Six months after Brown’s death, Diamond and Allen had their answers.


The health department report faulted nearly all of Brown’s caregivers, beginning soon after Brown arrived in the emergency room.

The report said doctors failed to investigate Brown’s enlarged heart and the fluid in her lungs as signs of congestive heart failure.

Transfusions ordered by Houston, who was not in the ER and was in contact by telephone, forced even more fluid into her lungs, the report said.

The coroner later found that an enlarged heart muscle, unable to pump effectively and stressed by an abnormal heart rhythm, led to Brown’s death.


Inspectors found that Houston, who did not examine Brown until 11 1/2 hours after her arrival in the ER, had “no current core privileges to practice in the facility,” the report said.

Later, gynecologist Salceda performed an emergency hysterectomy with no evidence that Brown was “suffering from acute, life-threatening vaginal bleeding at any time” before her surgery, inspectors said.

The only reports of bleeding, inspectors said, came from Brown, who was described in medical records as a “poor historian [with] poor cognition.”

Dr. Luis Torres-Garcia, the anesthesiologist who raised concerns, was “unable to explain” to inspectors why he ultimately agreed to go ahead with the surgery.


Houston and Torres-Garcia declined to comment. Salceda did not return calls for comment.

Finally, the inspectors said, as Brown’s condition worsened on the night of July 4, no doctors examined her.

Even as her vital signs plummeted in her final three hours, there was no evidence that her nurse alerted her superior or any physician, according to the report.

The nursing staff was cited for its repeated failure “to act as the patient’s advocate.”


A sense of betrayal

After they learned what happened, the sisters -- driven by anger and a sense of betrayal -- sought to hold the hospital and its caregivers accountable.

They sent portions of the inspection report in January to the Medical Board of California, which oversees the conduct of physicians, and to the state Board of Registered Nursing. Then they waited.

As the months passed, Diamond and Allen grew bitter.


Diamond angrily called the medical board, accusing officials of dragging their feet.

Allen sent pleading letters to everyone she could think of: local, state and federal lawmakers, the mayor, reporters.

“It’s like bumping your head up against a brick wall,” Allen said.

In April, Brown’s family sued the hospital, the doctors and other hospital staff for more than $30 million, alleging battery and abuse of a dependent adult. The suit is pending. Salceda denied the allegations. Houston, Torres-Garcia and Brotman filed motions to dismiss the suit, contesting the legal basis for the complaint.


As time passed, Allen kept replaying Brown’s final days in her head, searching for a moment she could have done something different.

Should she have pressed harder?

Knee surgery kept her out of work after Brown’s death, but later, after all that had happened, she couldn’t go back. She quit.

Most days she visits the vault where her sister’s ashes lie to play the oldies she loved. “She can hear it,” Allen said. “I know she can.”


Review promised

In June, more than 11 months after Brown’s death, Brotman promised the state that it would review or revamp almost every process and procedure identified by inspectors in the case, including such basics as when nurses should alert their bosses or doctors to a patient’s deteriorating condition.

After refusing for weeks to answer a Times reporter’s questions about the case, Brotman officials said in a long interview that the failures in Brown’s case were not as clear-cut as the state report portrayed.

Inspectors didn’t review outpatient records that might have provided justification for Brown’s emergency hysterectomy, including a prior history of vaginal bleeding and fibroids, the officials said. Nor did they consider nursing notes and other evidence suggesting that Brown’s final nurse did much more to aid her than was documented in the medical record.


As for the sisters’ complaints that the hospital shut them out, Brotman leaders said it was Brown’s primary doctor’s responsibility -- not theirs -- to explain what happened.

“The hospital,” Levine said, “does not have a lead person who is supposed to take care of this unfortunate job.”

In July, the sisters got a final shock: A three-page letter from the state medical board arrived, explaining that its investigation of Brotman physicians was closed. Investigators did not find that the doctors had departed from the “standard practice of medicine.”

Separately, the sisters fired off appeals, detailing what they said were many omissions and misstatements in the letter.


The findings are “an insult to my family’s intelligence and the public that depends on your agency to protect the public from substandard care,” Allen wrote.

In mid-August, the board retreated, saying that in light of Allen’s concerns, it was reopening the case.

Today, more than a year after Brown’s death, the two feel they have been robbed of more than a sister.

Diamond has lost trust that the medical system -- and her fellow nurses -- put patients first.


Her anger flares when she sees a colleague ignore a patient’s call light. “When the light goes on,” she says, “you go see what the patient wants.”

Allen has lost her passion for medicine altogether.

“I loved being a nurse,” she said. “I just don’t want to be a nurse anymore.”

tracy.weber@latimes.com