Thanks.
The hospital staff let an ordinary but absolutely critical parameter get and stay out of bounds through last night. It's a devastating, devastating error.
We caught this same mistake previously & insisted it be correctly promptly to avoid exactly these consequences, staying into the wee hours of the night to be sure. But this time our guard was down, we weren't there, and they let it go.
They're good people, almost all of them good to excellent at their jobs. But it's a bureaucracy, where the doers follow unclear instructions issued by absent authorities. It's all open-loop. Errors fly through their net constantly, undetected, unchecked. And if unexpected things happen on a Saturday night, no one reacts until an authority takes notice the next day.
It has been a hard day, nearly as hard as they come.
James Arthur