I knew that my patients were once without mental illness, just like my little sister Doris had been before her diagnosis 10 years before, and I always tried to picture them like that, each their own best version of themselves.

A sister’s preventable death.

In this month’s Reflections column, “No Room for Error: Reflections on My Sister,” family nurse practitioner Kelly Vaez shares the story of the unexpected death of her sister, who had been diagnosed with schizophrenia ten years earlier. It’s particularly heart-wrenching to be able to see clearly, in retrospect, the ways in which our rushed, fragmented, and mental-health-unfriendly health care system contributed to what was probably an easily preventable death.

A dentist prescribed an unusually long course of antibiotics after a routine tooth extraction. The primary care team seemed unaware of the antibiotic therapy. No one made the connection between Doris’ diarrhea and this antibiotic, a frequent cause of C.diff infection.

And finally, loperamide—a drug that should never, ever be given for diarrhea that might be caused by C. diff—was prescribed with what seems to have been minimal assessment for the cause of the diarrhea. Was this last because the patient was a young adult with schizophrenia, and often the physical complaints of people with serious mental health issues aren’t taken seriously?

Easy for the severely mentally ill to slip through the cracks.

The author recalls these events years later, while she is working on a lecture for nursing students about caring for people with mental illness in the primary care setting. She notes:

What could I say in this lecture to portray how easily we can lose these patients? How they can slip through the cracks of the system in an instant. No room for error or poor communication—these people are the epitome of vulnerable.

Doris had thrived until she slipped through those cracks in the system. You can read her story in the February issue. Let us know your thoughts on it.