After hearing about a 90-year-old woman’s death at Summit Park Hospital, the county-run facility, left me upset and angry.

How could this happen? It seems that closets weren’t bolted to the wall, and this was the third time one had fallen on a patient. This woman, whose family entrusted the hospital to keep her safe, suffered from dementia. She couldn’t keep herself safe; that, no doubt, is why she was in a nursing home facility.

Like the horrific story of Jonathan Carey, it’s not only heartbreaking, but a condemnation of a system that seems to put those who need are care the most are thought of least. Jonathan, from upstate New York, was autistic with severe impairments. His parents had him in one residential setting, and believed he was being abused. He was removed, but they could not care for him at home; his needs were just too great. At another facility, he was improperly restrained in a van and left alone, where he suffocated.

There are wonderful people and terrific facilities who help support families dealing with these most needy and fragile children and elderly adults.

Yet there are cracks in the system. These senseless acts happen, and there is no going back.

How could these wardrobe closets fall not once, but twice, in a unit with people with Alzheimer’s and dementia who were unable to protect themselves, and no one took the time, took the right step, and simply bolted them to the wall? (Visit just about any hospital room and see that these closets are secured to the wall—now think about someone who has dementia wandering a room becoming agitated. The danger should be so obvious after two closets were already pulled down!)

What a shame, what a loss. How tragic for this woman’s family, loved ones and our county. The state has levied fines, but there are many many questions that need to be answered, and county government, which “manages” this facility, deserves to give its residents answers.