Chapter 4 - The hospital reviewed itself too
It would have been easy for the hospital to say:
A bad father did something criminal.
Not our fault.
They did not.
A hospital newborn unit is supposed to have layers of safeguards precisely because exhausted families cannot be the only protection.
An external patient-safety review later found several failures aligned at once.
A staffing handoff occurred during newborn hearing-screen returns.
Two bassinets were temporarily staged near the nursing station.
Aloysius was known to staff as my husband and had been seen accompanying our infant earlier.
A staff member incorrectly assumed he was authorized to remain near a returning bassinet.
Another nurse believed both babies had already been rematched with their rooms.
The electronic tags remained active, but the altered physical band was not scanned immediately when the bassinet returned.
None of those things meant switching babies was easy.
It meant several safeguards that should have stopped him sooner were used imperfectly.
The hospital suspended two staff members during review.
One later returned after retraining.
One supervisor received formal discipline.
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Policies changed.
The hospital did not pretend human systems cannot fail.
