A temporary record had gone into the system as an unknown patient, and the family-contact field remained blank.

No one at either hospital had intended to conceal her.

But different facilities had handled different pieces of the emergency, and nobody had had the information needed to connect her to the missing mother on Linden Street.

Investigators documented the communication gap and notified hospital administrators so it could be reviewed.

Lena did not minimize the mistake.

A child had been left alone for four days while his mother lay a short drive away.

The system had not created the crash, but it had allowed the separation to continue.