I was deeply touched by Helen’s story regarding the death of her son, Lewis Blackman, not only on a cognitive level of understanding but as if I had traveled back to 2010, when my family lost my maternal grandmother to patient safety errors. My grandmother lived with me and cared for me from the moment I was born until her dying day. She helped raise me, as both of my parents were busy physicians early in their medical careers when I was born. I was fascinated by Helen’s words in, “The Faces of Medical Errors… From Tears to Transparency, The Story of Lewis Blackman,” and I jotted down quotes of hers that were eerily similar to those of my mother regarding my grandmother’s case. Helen characterized the hospital as a “system that’s operating for its own benefit,” much as my mother had wondered aloud why everyone seems to be going through the motions of their duties without caring about the outcomes of each completed action. Helen commented, “They never led on to us,” with regards to the attitude kept by the medical staff caring for her son. Her opinions were disregarded, and her concern for her son when his condition deteriorated was swept under the rug.
By far the most angering to me is that last act, that Helen consistently went unheard each time she could see a decline in Lewis’ condition. The helplessness on Helen’s face and the exasperation in her tone when she stated, “I am the only person who knew everything that had happened to Lewis,” made me feel as though as I was looking in the mirror. Instead of seeing Helen, I could see my mother and me moping at the breakfast table on an otherwise ordinary Sunday morning, discussing my grandmother’s case. My mother was at my grandmother’s side all the time, in constant communication with anyone who would listen. Even in the aftermath of a preventable accident that isn’t your fault, there is still significant pain in knowing that you were aware of a problem in the first place, and that the problem may not have ended in death if only your voice had been heard.