The state review found no violation by any individual.

It made four recommendations.

The hospital adopted all four inside a year and the chief executive wrote to me, unprompted, and enclosed the new protocol.

That letter is the only apology I received from any institution in this entire matter, and it came from the only one that did nothing wrong.

I have thought about that a great deal.

Dr.

Prewitt-Osei has never written to me.