What struck a cord most with me from our first day was most definitely the comment made by Lewis’ mother that stated he “died because he was in the hospital.” There’s something truly gut wrenching about hearing a statement that strong but sadly, entirely true. I think at times people are slipping through the cracks right under our noses with absolutely no malicious intent. There was no one person causally responsible for Lewis’ death. His death was a failure of our system and an example of what can come of poor continuity of care. Moving forward in my own practice, I hope to be more aware that these events can happen if we aren’t constantly asking and preparing ourselves for the worst.