The Mother Who Slept in the Car Park

A well-run admission

A baby girl was born considerably before term and admitted to our NICU. Her course over the first fortnight was, by neonatal standards, good: respiratory support weaned steadily, one course of antibiotics for a suspected infection that did not materialise, feeds creeping up.

We were, genuinely, doing this well. Handovers were thorough. The parents were updated daily. If you had audited us on that admission we would have scored highly on every axis we measure.

On day eleven, a healthcare assistant mentioned to me, in passing, on her way somewhere else, that she thought the mother had been sleeping in her car.

What we had not asked

It was true. She had a forty-minute drive each way, another child at home being managed by an exhausted grandmother, no money for the hospital car park beyond what she was already spending, and a conviction — which she never articulated to any of us, because we never created a moment in which it could be articulated — that if she went home and something happened, it would be because she had gone home.

So she stayed. She dozed in a chair by the incubator until she was politely moved on at night, and then she slept in her car, and then she came back in at six.

For eleven days. In a unit where I could have told you her daughter's exact weight trajectory, her ventilation settings on any given shift, and the precise date we started fortifying feeds.

We had built an information system that tracked a two-kilogram patient in fifteen-minute detail and did not have a single field for the condition of the adult sitting beside her.

Why this is a clinical problem

I want to resist the framing that this is a story about compassion, because that framing lets us file it under "nice to have".

That woman was the person we were going to discharge a medically complex infant to. She was the one who would be reading feeding cues at three in the morning, spotting the difference between a sleepy baby and a septic baby, and administering medication accurately. Her capacity to do those things was, at that moment, a more important determinant of her daughter's outcome than anything I was adjusting on the ventilator.

And she was eleven days into severe sleep deprivation and we had not noticed, because nobody's job was to notice.

We also, I suspect, made it worse. We are so used to praising parental presence — "mum's been here every day, she's amazing" — that we had effectively built an incentive for her to destroy herself and then thanked her for it. Not one of us had ever said the words "you are allowed to go home".

What we changed

We did four things after that admission. None of them are expensive and I am mildly ashamed that they were not already in place.

• We ask, in the first forty-eight hours, where the parents are sleeping and how they are getting here. Plainly, as a question with an answer we write down, alongside feeding and respiratory support. The number of times the answer has been concerning is higher than I expected.
• We give explicit permission to leave. Someone says, out loud, early: your daughter is being watched continuously by people who are awake, you will be called if anything changes, and going home to sleep is part of looking after her, not a failure to.
• We stopped praising attendance. It sounds small. We used to congratulate parents for never leaving. We now try to congratulate them for pacing themselves, because the admission is going to be long and the marathon framing is the true one.
• We found out what the car park actually costs — which, over a three-month admission, was a sum that would make you put your coffee down — and we now flag concessions on day one instead of waiting for someone to admit they cannot afford it.

Afterwards

Her daughter went home. It was a long admission with the usual plateau in the middle, and the outcome was good.

What I think about is not the discharge. It is that the information reached me sideways, from a healthcare assistant who was not asked and had no formal route to tell me, eleven days in. Every formal channel we had was pointed at the infant. There was no channel at all pointed at the mother, and so for eleven days the most important thing happening on my unit was invisible to me.

I am reasonably confident we would catch it now. I am not at all confident we would have caught it then, and it had been going on for years.

Published with the family's written consent. Names, dates, gestational specifics, location, family structure and the details of the clinical course have been changed or removed.