The Untimely Death of Madeleine Mendoza: A Husband’s Journey from Medical Tragedy to Patient Safety, Part I
“I’d like to tell you about Madeleine and who she was as a person. Can I do that?” asked widower Ed Mendoza.
“Yes, tell me about her. I’d like to hear more about her,” I said.
And so begins the story of Madeleine Mendoza’s untimely death.
She enjoyed talking to everyone she met and was genuinely interested in what others had to say. People were immediately drawn to Madeleine’s caring nature and her desire to listen intently to their spoken words. Complete strangers felt at ease enough to share many details of their lives with her.
A summer pool party held at the apartment complex in which both Ed and Madeleine lived was the setting for their first meeting. Ed recalls an immediate attraction to her beautiful smile. It provided the first hint to the vibrant personality that he would come to love. While they talked that day by the pool his excitement continued to build as he learned that they shared similar values and beliefs. They soon began dating and married a year later. Their marriage contained all of the essentials of a happy union as they were best friends, lovers, and husband and wife. Laughter was a big part of their lives and a natural complement to Madeleine’s wonderful sense of humour. She and Ed always had fun together. They were a great team, trusted confidants and each other’s biggest supporters.
Ed never learned to drive so he always assumed the role of navigator when he and Madeleine made trips in the car. On one of their trips they were forced to visit the local hospital in Orangeville, Ontario after Madeleine experienced a flare up of the painful bowel disease diverticulitis. The results of a CT scan and its accompanying report recommended that she undergo bowel surgery for her diverticulitis. It also identified some ulcers in her colon that should be monitored.
After they returned home to Ottawa, the Mendozas visited Madeleine’s family doctor who provided a referral to a surgeon. The recommended surgery offered a chance for Madeleine to regain some of the quality of life lost to the years spent suffering from her bowel disease.
On January 6, 2003, Madeleine undergoes surgery for a bowel resection at an Ottawa hospital. In the weeks that follow she experiences severe pain and discomfort prompting three separate visits to the emergency department resulting in intermittent hospital stays. Madeleine’s condition continues to deteriorate. Her final trip to the hospital occurs on March 5. Madeleine is afraid she is going to die. Ed tries to reassure her. He spends days and nights at her bedside and is shocked by what he observes on the frontlines. He sees poor quality bedside monitoring and care as well as a lack of communication between all health care providers. During this hospital stay Ed learns that Madeleine’s surgeon has not shared the Orangeville hospital’s report with any other health care providers. With this report in hand he approaches the gastroenterologist who, at Ed’s insistence, agrees to perform a colonoscopy. The test reveals highly inflamed ulcers in Madeleine’s colon which the gastroenterologist says can be treated with antibiotics.
In the early morning of March 18, Ed is awakened by an alarming sound. It is his home telephone ringing loudly. He picks up the receiver and hears a nurse’s voice inform him that they are trying to resuscitate his wife. A wave of panic surges through his body as he tries to comprehend the magnitude of her message. He rushes to the hospital and finds the door to Madeleine’s room closed. His mind tells him what his heart already knows. He frantically pushes through the door to get to her bedside where he begins to sob while cradling her lifeless body.
The autopsy report provided by the hospital’s pathologist states the cause of her death as “Gastrointestinal ulcer, perforated”. Ed attributes Madeleine’s untimely death to the failure to provide a proper standard of care or what he refers to as health care neglect.
Twice yearly, on the anniversary of her burial and their wedding anniversary, Ed takes the 12 hour bus trip from Ottawa to Madeleine’s grave site located in her birthplace of Cochrane, Ontario. The rest of his time is devoted to another journey – trying to improve the quality of patient care in Canada.
To be continued…