For the past year, police detective Tim Lillard has spent most of his waking hours unofficially investigating his wife's death.

The question was never exactly how Ann Picha-Lillard died on November 19, 2022: from respiratory failure, after an infection put too much strain on her weakened lungs. She was 65.

For Lillard, the question was why.

Lillard had been in the hospital with Ann every day for a month. ICU nurses had told him they were short-staffed, and were constantly rushing from one patient to the next.

Lillard tried to pitch in where he could: brushing Ann's shoulder-length blonde hair or flagging down help when her tracheostomy tube gurgled — a sign of possible respiratory distress.

So the day he walked into the ICU and saw five or six staff all huddled in Ann's room, he knew it was serious. He called their adult kids: it's mom, he told them. Come now.

All he could do then was sit on Ann's bed and hold her hand, watching helplessly as staff performed chest compressions and mouth-to-mouth resuscitation, desperately trying to save her life.

A minute ticked by. Then another. Lillard's not sure how long CPR continued — long enough for their son to arrive and take a seat on the other side of Ann's bed, holding her other hand.

Finally, the intensive care doctor called it. The team stopped CPR. Time of death: 12:37 pm.

Looking for medical answers

Lillard didn't know what to do in a world without Ann. They had been married almost 25 years. "We were best friends," he says.

Just days before her death, nurses told him Ann could be discharged to a rehab center as soon as the end of the week. Then suddenly, she was gone. Lillard didn't understand: what had happened?

Today, Lillard believes he has an answer: overwhelmed, understaffed nurses hadn't been able to respond in time as Ann's condition deteriorated. And he has made it his mission to fight for change, joining nurses' unions in their push for mandatory ratios that would limit the number of patients in a nurse's care.

"I without a doubt believe 100 percent Ann would still be here today if they had staffing levels, mandatory staffing levels, especially in ICU," Lillard says.

Last year, Oregon became the second state (after California) to pass hospital-wide nurse ratios that would limit the number of patients in a nurse's care, and states like Michigan, Maine, and Pennsylvania are now weighing similar legislation.

But supporters of mandatory ratios are going up against a powerful hospital industry spending millions of dollars to kill these efforts. And hospitals and health systems say any staffing ratio regulations, however well-intentioned, would only put patients in greater danger.

A crisis putting patients at risk

By next year, the US could have as many as 450,000 fewer nurses than it needs, according to one estimate. The hospital industry blames COVID burnout, an aging workforce and patient population, and an insufficient pipeline of new nurses entering the field.

But nurses unions say that's not the full story. There are now more actively registered nurses in the US (over 4.7 million) than ever before, with an estimated 130,000 new nurses entering the field between 2020 and 2022.

The problem, they say, is a hospital industry that's been intentionally understaffing their units for years, in order to cut costs and boost profits. This isn't, they say a shortage of nurses. It's a shortage of nurses willing to work in those conditions.

Whatever the causes, the nurse staffing crisis is now directly impacting patient care. The number of Michigan nurses who say they know of a patient who died because of understaffing has nearly doubled in recent years, according to a Michigan Nurses Association poll last year.

And just months before Ann Picha-Lillard's death, nurses and doctors at the health system where she died had asked the Michigan Attorney General to investigate staff cuts they believed were leading to dangerous conditions, including patient deaths, according to the Detroit News.

But Tim Lillard didn't know any of that when he drove Ann to the hospital on October 26, 2022. She was feeling short of breath a few weeks after she and Lillard had mild COVID infections.

They were both vaccinated, but Ann was immunocompromised: she had rheumatoid arthritis, a condition that also caused scarring in her lungs.

So just to be safe, doctors at DMC Huron Valley Sinai wanted to keep Ann for observation. But after a few days in the hospital, Ann developed pneumonia. Doctors told them she needed to be intubated. Ann was terrified. Lillard begged her: please, babe. Listen to them.

Tearfully, she agreed.

With Ann on a ventilator in the ICU, it seemed clear to Lillard that nurses were understaffed and overwhelmed. One of the nurses told him they were especially short lately, he says.

"The alarms would go off for the medications, they'd come into the room, shut off the alarm when they get low, run to the medication room, come back, set them down, go to the next room, shut off alarms," Lillard recalls. "And that was going on all the time."

Lillard felt bad for Ann's nurses, he says. "But obviously, also for my wife. That's why I tried doing as much as I could when I was there. I would comb her hair, clean her, just keep an eye on things. But I had no idea what was really going on."

Finally, Ann seemed to be stabilizing. A nurse told Lillard they'd be able to discharge Ann, possibly by the end of that week

On Thursday Nov. 17th, 2022 Ann was off sedation, and cried when she saw Lillard and her daughter. Still unable to speak, she tried to mouth words to Tim, "but we couldn't understand what she was saying."

On Friday, Nov. 18, 2022, Lillard went home feeling hopeful, counting down the days until Ann could leave the hospital.

Less than 24 hours later, Ann died.

Searching for answers

In a home that now felt unbearably empty and quiet, Lillard couldn't wrap his head around how things went downhill so fast.

Ann's underlying lung condition, infection, and her weakened state could have proven fatal in even the best circumstances. But Lillard wanted to understand: how had Ann gone from about to be discharged, to dying, seemingly overnight?

He turned his dining room table into a makeshift office, and started with what he knew. The day Ann died, he remembered the medical team telling him Ann's heart rate had spiked and she'd developed another infection the night before.

Lillard says he interviewed two DMC Huron Valley Sinai nurse administrators, and had his own doctor look through Ann's charts and test results from the hospital. "Everybody kept telling me: sepsis, sepsis, sepsis," he says.

Sepsis is when an infection triggers an extreme reaction in the body that can cause rapid organ failure. It's one of the leading causes of death in US hospitals.

Some experts say up to 80% of sepsis deaths are preventable (others say the real percentage of preventable sepsis deaths is far lower.)

Lives can be saved when sepsis is caught and treated fast, which requires careful attention to small changes in vital signs. One study found that for every additional patient a nurse had to care for, the mortality rate from sepsis increased by 12%.

Lillard became convinced that with more nurses on shift in the ICU, someone could have caught what was happening to Ann.

"They just didn't have the time to," he says.

A DMC spokesperson declined a request for comment about the 2022 staffing complaint to the Michigan Attorney General.

Looking at the role of ownership and revenue

When Lillard asked the hospital for copies of Ann's medical records, DMC Huron Valley Sinai told him he'd have to request them from their parent company in Texas.

Like so many hospitals in recent years, Lillard and Ann's local health system has been absorbed by a series of other corporations. In 2011, the Detroit-based Detroit Medical Center health system was bought for $1.5 billion by Vanguard Health Systems, backed by the private equity behemoth Blackstone Group.

Two years after that in 2013, Vanguard itself was acquired by Tenet Healthcare Corp, a for-profit company based in Dallas that operates "480 ambulatory surgery centers and surgical hospitals, 58 hospitals and approximately 160 additional outpatient centers," according to its website.

As healthcare executives face increased pressure from investors, nursing unions say hospitals have been intentionally understaffing nurses in an effort to reduce labor costs and increase revenue.

Insurance reimbursements incentivize keeping nurse staffing levels low.

"Hospitals are not directly reimbursed for nursing services in the same way that a physician bills for their services," says Karen Lassater, an associate professor of nursing in the Center for Health Outcomes and Policy Research at the University of Pennsylvania.

"And because hospitals don't perceive nursing as a service line, but rather a cost center, they think about nursing as: how can we reduce this to the lowest denominator possible?"

Lassater is a proponent of mandatory nurse ratios. "The nursing shortage is not a pipeline problem, but a leaky bucket problem. And the solutions to this crisis need to address the root cause of the issue, which is why nurses are saying they're leaving employment. And it's rooted in unsafe staffing. It's not safe for the patients, but it's also not safe for nurses."

A battle between hospitals, unions

Almost one year after Ann's death, Lillard told a room of lawmakers at the Michigan state capitol that he believes the Safe Patient Care Act could save lives.

It was Nov. 9, 2023, and the state's House health policy committee was holding a hearing on the bills, which would limit the amount of mandatory overtime a nurse can be forced to work, and require hospitals to make their staffing levels available to the public.

Most significantly, the bills would require hospitals to have mandatory, minimum nurse-to-patient ratios: one nurse for every patient in the ICU, one for every three patients in the ER, plus a nurse for triage; one nurse for every four post-partum birthing patients and well-baby care, and so on.

State efforts to pass mandatory ratio laws failed in Washington and Minnesota in 2023 after facing opposition from the hospital industry.

In Minnesota, the Minnesota Nurses Association accused the Mayo Clinic of issuing what was essentially "blackmail": Mayo told lawmakers it would pull billions of dollars in investment from the state if mandatory ratio legislation passed.

Lawmakers cut nurse ratios from the legislation soon after.

Speaking up at a state House hearing

While Lillard waited for his turn to speak to Michigan lawmakers considering the Safe Patient Care Act, members of the Michigan Nurses Association (which says it represents some 13,000 nurses in the state) told lawmakers that their units were dangerously understaffed — with critical care nurses sometimes caring for up to 11 patients at a time.

"'Last year I coded someone in an ICU for 10 minutes, all alone, because there was no one to help me,'" said MNA president and registered nurse Jamie Brown, reading from another nurse's letter.

"I have been left as the only specially-trained nurse to take care of eight babies on the unit: eight fragile newborns," said Carolyn Clemens, an RN from the Grand Blanc area.

Nikia Parker said she's left full-time ER nursing, a job she believes is her calling. After her friend died in the hospital where she worked, she was left wondering whether understaffing may have contributed to his death.

"If the Safe Patient Care act passed, and we have ratios, I'm one of those nurses who would return to the bedside full time," Parker told lawmakers. "And so many of my coworkers who have left would join me."

But not all nurses agree that mandatory ratios are a good idea.

While the American Nurses Association supports enforceable ratios as an "essential approach," the Michigan ANA chapter doesn't, saying there may not be enough nurses in Michigan to satisfy the requirements of the Safe Patient Care Act.

And for some lawmakers, the risk of collateral damage feels simply too high.

State Representative Graham Filler asked: what happens if we mandate ratios, but it backfires?

"We're going to severely hamper health care in the state of Michigan," Filler said. "I'm talking closed wards because you can't meet the ratio in a bill. The inability for a hospital to treat an emergent patient. So it feels kind of to me like a gamble we're taking."

Michigan hospitals are already struggling to fill some 8,400 open positions, according to the Michigan Health and Hospital Association (MHA).

The MHA says complying with the Safe Patient Care Act would require hiring 13,000 nurses.

Every hospital in the state signed a letter opposing mandatory ratios, saying it would force them to close up to 5,100 beds.

Lillard watched this debate play out in the hearing.

"That's a scare tactic, in my opinion — where the hospitals say we're going to have to start closing stuff down," he said.

He doesn't think mandatory ratios bills — which are still awaiting a vote in the Michigan House's health policy committee — are a "magic bullet" for such a complex, national problem. But he believes they could help.

"The only way these hospitals and the administrations are gonna make any changes, and even start moving towards making it better, is if they're forced to."

Seated in the center of the hearing room in Lansing, next to a framed photo of Ann, Lillard's hands shook as he recounted those final minutes in the ICU.

"Please take action so that no other person or other family endures this loss," he said. "You can make a difference in saving lives."

Grief is one thing, Lillard says. It's another thing to be haunted by doubts, to worry your loved one's care was compromised before they ever walked in the hospital doors. What he wants most, he says, is to prevent any other family from having to wonder: what if?

This story comes from NPR's health reporting partnership with Michigan Public and KFF Health News.