A year ago, on the 18th of March 2003, I was on top of the world. Finally, after 3 months of being in and out of the hospital, Madeleine my wife, or as I called her Honey, would be healthy again and we could then get on with life. I couldn't wait to call her and say I was home like I did everyday. I said, "Hi Honey, I'm home." In a faint voice I heard her say, "Ah Eddie! You woke me up from a sleep." I chuckled a bit and said, "Oh I'm sorry Honey, just letting you know I'm home. Go back to sleep now. Everything's going to be just fine. Luv Ya!" Then in that same faint voice she said, "Love you too". At that moment, little did I realize her weak voice saying, "Love you too" would be the last three words I'd hear from her lips.

At around 7 o'clock in the morning I was startled out of a sleep by the ringing of the bedside phone. Someone said, "Mr. Mendoza." With a little fear creeping up on me I said, "Yes, what is it?" The person, a woman I believe, said, "We seem to be having some trouble with your wife's breathing." I screamed, "What? What's going on?" She said, "We are having a problem with your wife. We're trying to resuscitate her. Will you be coming to the hospital?" In sheer panic I yelled, "Of course I'm coming. I'll be right there. Where should I come?" She answered, "Just come up to her room." Frantically, I called my neighbour to drive me to the hospital. We got there in 20 minutes and I rushed up to her room on the fifth floor. The door was closed and there were some people standing around. I knew then what had happened and in a state of complete shock I shouted out the question anyway, "What happened?" One of her doctors came up to me and said, "I'm so sorry Mr. Mendoza, we tried our best, did everything we could, but couldn't resuscitate her. I'm really very sorry." I was totally stunned and in a horrified state pushed open the door and rushed to her prone lifeless body, screaming, "NO! NO! NO! This can't be happening." I was sobbing hysterically, cradling and hugging her face, repeating again and again, "Honey, Honey it's me Eddie!" Desperately, I was urging her to respond. Her face and hands felt cold and numb, and the stark reality of what had happened hit me like a bolt from the sky. The intense heartache and anguish simply overwhelmed me and the tears streamed out uncontrollably.

I finally got hold of myself and left the room. I blurted out, "What happened here? When did this happen?" and a nurse said, "It happened a short while ago when I walked in to give her morning medication and realized there was a problem with her breathing." "What do mean problem with her breathing?" I yelled and continued with, "Was she having difficulty breathing? Not breathing? What? And how do you know it happened just when you went in to awaken her for her morning medication and not during the night?" She replied, "Whenever I looked in on her during the night, from the heaving of her chest I could tell that she was just sleeping." I was totally amazed when she said that. I just didn't believe her. Why? First of all, having spent many a night in the hospital, pacing the halls to try and stay awake, I saw nurses go into rooms only when patients rang for them. Just a few nurses who felt the need to check up on their patients would, at the most, look into the rooms from the hallway. And another thing, Madeleine who was so weak, just skin and bones, always felt so cold and needed three or four blankets over her. So how could the nurse even dare to suggest she knew my wife was just sleeping because she saw her chest heaving? I tried to argue the point but got nowhere and in my distressed and highly emotional state simply dropped the matter. Then the doctor asked, "Mr. Mendoza would you like us to do an autopsy?" I said, "Yes! Yes! I want to have an autopsy done."

So, what went wrong? Why did Madeleine, my wife, die when she wasn't supposed to? In order for you to really understand what happened, let me take you back in time.

For many years, Madeleine suffered from diverticulitis a non-life-threatening but extremely painful bowel disease. Eventually, when medication and diet become less effective, surgery is generally needed. In October 2002, while visiting in Orangeville, Ontario, she had a severe attack of the illness and went into the hospital through Emergency. There they did thorough testing, including a CTScan. In a detailed report, they described the diverticulitis and also some other intestinal problems such as ulcers and different forms of colitis. They strongly recommended surgery for the diverticulitis and suggested that the other problems should also be checked out. Madeleine had suffered so much for so long. The attacks were happening more frequently and we wanted to spend the rest of our years living in ease and comfort. We felt that she needed to have the surgery.

And so when we returned to Ottawa, we went all out to pursue the matter. We got the reports and the CTScan pictures from the Orangeville hospital. One of her doctors recommended a highly respected surgeon who specialized in bowel surgery and arranged an appointment. On the 19th of December 2002 we went and saw the surgeon at his office in the hospital. He had the Orangeville hospital report with him and skimmed through it from time to time while he asked Madeleine to describe her bowel problems over the years. Then he leaned over, touched her hand and, in a tender voice said, "Mrs. Mendoza you've suffered for many, many years. You've endured a lot for so long. Now it's time for you to have a good life - you deserve it. I'll fix all your problems." Madeleine looked at me with tears in her eyes, then turned back to the surgeon and, in a whisper and all choked up, said, "Thank you doctor." He suggested that she check into the hospital right away in order to build up her strength for the surgery that he would perform in early January when he returned from vacation.

On the 19th of December 2002 Madeleine was admitted into the hospital. The surgeon came by the next day with a couple of other doctors. He introduced them to us. One, a fourth-year student, was his right hand man - whom I shall be referring to as "the doctor" - and the other was a second-year student. The surgeon said they'd prep her for the surgery by building up her strength with TPN (total nutrition through an artery) and a liquid diet. So, we were off to the races! Over the next few weeks, things couldn't have been better. Madeleine put on weight, gained strength, walked about and was a picture of health. "Eddie, I feel just great. I'm a little anxious about the surgery, but when that's over we'll be able to do all the things we've planned." I'd say: "Honey, it won't be long now. Just remember we're going to Vegas in the fall." On Christmas Day I surprised her. I got all dressed up in my best suit and, with two wine glasses and a small bottle of sparkling wine, walked into her room and said, "Tadaa, Merry Christmas Honey!" She laughed and was ever so thrilled.

On the 6th of January 2003 Madeleine had the surgery. The next day the surgeon came by. "How do you feel Mrs. Mendoza?" he proudly asked. Madeleine with a broad smile nodded her head. I asked, "Doctor, did you see anything else while you were in there, like ulcers and such?" He said, "No, I didn't see anything else."

It seemed that the surgery was a success. The worst was over, soon she would be up and about and we would now be able to live the lifestyle we had planned. We were in seventh heaven! Madeleine came home on the 15th of January 2003, ready for recovery from the operation even though it could be long and slow. But almost immediately after she got home, troubles began. She started having bouts of diarrhea, nausea, vomiting and pain so severe, she'd be crying, "Please Eddie, make the pain go away." The symptoms got worse and worse. I tried to reach the surgeon but he was unavailable due to his administrative duties as an executive in the hospital. I got hold of the doctor. He said to get her back into the hospital, which I'd have to do through Emergency. So three days after she came out, Madeleine went back into the hospital. It would be the first of three times.

Each time, she had to go through Emergency just to get admitted into the hospital. If she was bad going in, which she was, she was worse coming out of Emergency. Doctors, including students would come by in twos and threes to examine her and kept asking the same questions. Nurses and attendants didn't pay any attention. All I could do while Madeleine was crying in agony was to help her as best I could and comfort her. "Hang in there Honey. It won't be long." And it was the same for everyone else - total lack of care for the patients by the nurses. None of the patients who needed it, got any extra care and attention. Isn't it scary - you're in an emergency situation and your life is in the hands of student doctors and careless nurses?

After she'd come out of Emergency they would stabilize her condition with IV. Then after tests and CTScans, the surgeon and his team would tell us what they thought was causing the problems. The first time, the surgeon told us, "There's has an adhesion of the small intestine that sometimes happens after bowel surgery and with controlled diet, the condition corrects itself." We accepted his explanation and Madeleine came out of the hospital on the 26th of January 2003. But within three days it all started up again - heartburn, nausea, vomiting, severe pain which got worse and worse, and Madeleine was back in the hospital on the 3rd of February. This was the second time. The surgeon said, "The adhesion is gone but there's still an obstruction. We don't know what's causing it. Maybe your digestive system isn't functioning properly after abdominal surgery."

Or, he said it might be celiac disease (a lack of tolerance for gluten, a protein found in wheat, rye and barley). All this was just guesswork but we went along with it. Madeleine came home on the 6th of February. For two or three weeks, she showed some signs of improvement but it was slow and she was having great difficulty eating and digesting anything. I pleaded with her, "Honey please, you've got to try and eat." And she'd say, "Eddie I'm trying but I can't. I gag, I've got heartburn and I'm sick to my stomach." And one day when Madeleine got out of the bathtub she said, "Eddie just look at me. I'm just skin and bones" - which she was. With tears streaming down her face she added, "Eddie, I'm going to die. I don't want to die. Eddie, I'm scared!" She had me in tears then and I replied, "No Honey, no you're not going to die. We're going to lick this thing." And then, once again, the nausea and heartburn got worse, the vomiting started and the pain became more severe and more frequent. We kept hoping that it would subside but it didn't and we had to rush back into the hospital. Madeleine didn't want to go back. "Eddie, I don't want to go back to the hospital. Please don’t take me back." But there was no other choice. Very reluctantly she went back on the 5th of March 2003.

It was the third time and, turned out to be, the last time. This time, the doctors insisted on pursuing their theory that she had celiac disease. We tried to tell them she didn't because if she did, just eating a slice of bread would trigger a bad reaction. But they were determined to do a biopsy and see the results. Despite being fed nutrients through the carotid artery and through the nose, Madeleine just got weaker and weaker. She couldn't get out of bed and make the five steps to the bathroom without help. The TPN, which did wonders for her in December, wasn't helping at all. When I asked about this, I merely got a shrug and no satisfactory explanation. Madeleine was literally a skeleton - you could count every bone in her body - but they didn't take her weak condition seriously. The nurses knew about her bowel problems and her frequent attacks of severe pain but when she rang for help they only came when they chose to. It was generally left up to me to take care of her. At one time, the doctor had changed Madeleine's medication and noted it on her chart. Later in the day when I asked the nurse, her comment was, "Oh! Did he?" She went and looked at the chart but by this time the hospital pharmacy was closed - a clear case of neglect but it didn't bother anybody.

As the days went by, waiting for the biopsy results, Madeleine got weaker and weaker and the pain got worse. In agony and with tears she'd say, "Eddie, I feel so sick, please help me. Somebody please help me." "Eddie, I want to come home. Please, please take me home." All I could do was to caress and comfort her with, "It's going to be okay Honey, just hang in there. I know you can do it." But I began to get really worried. We knew that testing for celiac was just a waste of time. The surgeon and his team were just playing a guessing game. I asked why our family doctor wasn't consulted. They told me the hospital doesn't do that unless the doctor has "hospital privileges" (being a staff member of the hospital). Then I told them that at home I kept a log of her food intake and medication and how she reacted, and I'd like to show it to them. I asked to be kept in the loop. They replied, "Okay, you're in the loop." That's as far as it went. Never once did they ask for that information. In the hospital, only I monitored her diet and how she reacted from it. I told the nurses I was recording what she ate on her diet sheets. They said, "That's nice!" But they never looked at the sheets nor entered my notes on her chart. The doctors never asked for this information either. It made no sense. Nobody wanted help from others.

I started thinking about the Orangeville hospital report. Surely from their own CTScans they would have seen the same problems if they were there. But what if they only looked where they thought the problem was? So three days after Madeleine had checked into the hospital, I asked the main doctor on the team "Doctor…have you seen this report?" He replied, "No." After he went through it, I asked, "So what do you think, Doctor?" He shrugged and said, "Let's see what the celiac test results show." I was shocked that the surgeon hadn't shared the report with the rest of his team. I asked about the hospital gastroenterologist. He said they consulted her from time to time and she'd be coming up to see Madeleine. Of course, I couldn't confront the surgeon. They said he was busy with his other administrative duties. Two more days went by, the gastroenterologist hadn't shown up, there was no sign of the surgeon, we were still waiting for the biopsy results and I was starting to panic.

I went and saw the gastroenterologist with the Orangeville report in my hand and asked if she had seen it. I was stunned by her reply, "No. I've only been giving advice when asked." She then added, "By the way, the results are in. Your wife doesn't have celiac disease." Oh what a surprise!

We talked while she flipped through the report and she agreed to do a colonoscopy. I asked when she'd do it and she said, "Next week." It was Friday and I said, "When next week, Doctor?" She said, "Sometime next week." In a pleading voice, I said, "Doctor…she doesn't have time." "Okay, early next week" she replied. Saturday, Sunday and Monday went by. The doctors and nurses did nothing for Madeleine. So we waited and waited. The motto of the hospital is: "THE PATIENT HAS TO BE PATIENT" which means "It'll happen when it happens." It was the same for every other test she had - waiting to get the tests done and more waiting to get the results back. Finally, on Tuesday Madeleine had the colonoscopy. After it was over, Doctor…spoke to me. "We've found something. Take a look at these pictures. Those sores are highly inflamed ulcers in a colon." Well, that's what the Orangeville report showed - that was the cause of all the problems. And then it floored me when she said, "It's next to where the surgery was done." She said the ulcers could be treated with antibiotics. I went to the waiting room. Madeleine was heavily sedated. I said, "Honey, guess what! They found something. You're going to be okay" She managed to open her eyes and from the corners of her lips, gave me a faint smile. Back in her room we hugged each other with joy. Her troubles would soon be over and she was going to be well again.

But, as you know, the next morning Madeleine was gone. The surgeon came to offer me his sympathies. I stared at him and said, "Dr…you know that Dr…[the gastroenterologist] found ulcers in her colon" and his reply was, "I didn't see any of that when I did the surgery." I just shook my head, too distraught to say anything.

Months later I got the autopsy report. It showed that Madeleine died from, "Gastrointestinal Ulcer, Perforated." I was devastated. The autopsy revealed the other bowel problems that were in the Orangeville report. The surgeon had this report. Why didn't he check it out? I was out of Ottawa at the time but talked with the surgeon by phone. He said, "I know how you feel Mr. Mendoza, but as you can see from the autopsy report, your wife had many serious bowel problems and probably wouldn't have lived very much longer." Can you believe that!

Yes, Madeleine and I planned to take it easy and enjoy the rest of our years. We even bought a new car to travel around this great land of ours. And we would have done all that, because Madeleine wasn't supposed to die.