Chapter 12 - ST. CATHERINE'S REPORT
The hospital finished its preliminary review in three weeks.
I expected a lawyer-shaped document that admitted nothing.
It was more useful than that.
They found four concrete failures.
The electronic tracking outage lasted eleven minutes.
Downtime band printing used a shared unit session.
The wrong Bennett band was temporarily attached to my paper packet.
And disclosure to both mothers was delayed after they were medically alert.
That last one mattered most to me.
Dr. Walsh met me in person.
“Why?”
I asked.
She did not blame Ryan.
Not entirely.
After the discrepancy, the clinical team verified both babies through several matching processes.
A resident wanted immediate disclosure.
Risk management asked for fifteen minutes to confirm facts.
Then Claire was being monitored for blood loss.
Natalie was still unstable.
Fifteen minutes became forty.
Then spouses were told first because they were available.
Ryan and David both asked that the mothers be allowed to rest until more was known.
The staff agreed.
“The request should not have controlled our disclosure.”
Dr. Walsh said.
“No.”
“We should have told you as soon as you were capable of participating.”
“Yes.”
Not because every possible fear must be dumped on a patient immediately.
Because it involved my child.
The hospital implemented changes.
Individual downtime printer authentication.
Every reprint stamped automatically.
Wrong bands immediately cut and retained.
No spouse-only disclosure for infant identity incidents unless the mother is medically incapable and the delay is clinically justified.
Good.
Boring.
Important.
Then Dr. Walsh gave me the final pages.
One section concerned Ryan.
St. Catherine referred his removal of incident material to hospital legal and security.
No criminal complaint from the hospital.
The band had been recovered.
No patient information had been publicly disclosed.
But Ryan was barred from accessing risk-management areas and flagged for escorted contact if he returned during the current review.
He hated the wording.
That was not my problem.
Then Dr. Walsh pointed to one unresolved note.
At 4:26, when Jenna printed the reconstruction band, the printer produced two copies.
Jenna remembered one.
Where did the second go?
No one knew.
I stared.
“How many Bennett bands existed?”
“Original downtime band.”
“The reprint Ryan took.”
“Yes.”
“And another reprint.”
“According to the device count.”
“Where is it?”
“We do not know.”
May you like
One missing wristband had started the entire thing.
Another one was still missing.
