SAN FRANCISCO – Sheriff Ross Mirkarimi has revealed preliminary findings of an investigation into the disappearance of a San Francisco General Hospital patient who was found dead in an exterior stairwell of the facility more than two weeks later.
While the investigation is not complete, the details Mirkarimi disclosed Wednesday reveal confusion over Lynne Spalding Ford's physical description, failure to properly search the stairwells, poorly functioning video equipment and other problems that could have contributed to her death.
Surrounded by a dozen members of his command staff at a City Hall news conference, Mirkarimi said Spalding Ford, a "loving mother of two," could have been "anyone's loved one, which is why the severity of the situation is not lost on any of us."
"What happened to Ms. Spalding Ford should never have happened to anyone," he said, vowing to make necessary changes to ensure that "it will never happen again."
The chronological account that Mirkarimi read aloud begins on Sept. 21, the day that Spalding Ford, who had been admitted for a
Spalding Ford, 57, is a native of England and is white. When she disappeared, it was unknown whether she was in a hospital gown or street clothes. However, Mirkarimi revealed that initial reports from a hospital staffer to sheriff's deputies at the "institutional patrol unit" charged with overseeing hospital security described her as "African American and wearing a hospital gown."
The assertion was repeated "twice" to the deputy during the conversation, which took place at 10:25 a.m.
Swing shift deputies who came on duty at 8 p.m. that night and conducted a routine meeting with hospital staff were unaware of the disappearance. A deputy who went to Spalding Ford's ward an hour later to gather further information was told only that she was "an older woman with black hair."
She was then described in the sheriff’s log as an “Asian female.”
Confusion also stemmed from mixed information on Spalding Ford's physical and mental state. Her physician had to clarify to deputies in two conversations that Spalding Ford had "AWOL'd." The doctor had initially reported that Spalding Ford was scheduled for release but was "confused and not safe to be on her own."
When it became clear that deputies were not considering her "missing," the doctor called back to stress that she may not have been discharged if the physician had in fact been able to exam and evaluate her that morning.
Nevertheless, because Spalding Ford was not on a psychiatric hold she was not formally considered a missing person by the institutional patrol unit. Spalding Ford's daughter separately contacted San Francisco police, and it was that department that launched a missing person case.
Police on Sept. 25 called a sheriff's supervisor at the hospital to request that deputies pull video for San Francisco police to review "to see if they could spot Ms. Ford leaving." But due to hardware issues, the video was not pulled from the system for viewing until Oct. 3.
Meanwhile, on Sept. 30, hospital officials asked the Sheriff's Department's institutional patrol unit to "search the entire campus." The campus covers 24 acres with multiple buildings and Mirkarimi said the search "did not include all stairwells." The search resumed the following day but "only about half the stairwells were searched."
Lastly, the report notes that at 7:15 a.m. on Oct. 4, a member of the hospital's medical staff called deputies, "saying that someone had told the staff person that there was somebody laying on the landing in the 3rd or 4th floor of stairwell 8."
"The Communications Center staff responded, 'We'll look into it,'" the chronology of investigative findings shared by Mirkarimi states. Yet it concludes: "There is no indication that anyone was dispatched to the stairwell."
Mirkarimi said the ongoing nature of the investigation required that he keep names and ranks of involved deputies confidential. But he said, "there will be staff changes."
He announced that he has assigned a captain to oversee the institutional patrol unit "with the mandate that he -- in concert with SFGH -- conduct a thorough security assessment of the unit itself as well as how IPU and hospital staff communicate and work together."
The captain will report directly to Mirkarimi, who said he has mandated daily patrols of the fire stairwells. The department is also now requiring that responses to "stand alone audible alarms" such as the one Spalding Ford apparently used to exit into the stairwell, be documented.
The Sheriff's Department has added a position for the stairwell checks and is exploring improvements to its dispatch system and its video system as well as broader staffing enhancements.
Spalding Ford's body was found Oct. 8. The San Francisco Police Department as well as the coroner and San Francisco General Hospital are conducting separate investigations. Her family has retained an attorney, who Mirkarimi said was briefed on his department's preliminary findings.