SAN FRANCISCO — Efforts to locate a patient found dead in a stairwell 17 days after she disappeared from her room at San Francisco General Hospital were stymied by confusion over her race, inadequate searches and malfunctioning technology, a preliminary sheriff's investigation showed Wednesday.
The inquiry is not yet complete. But San Francisco Sheriff Ross Mirkarimi, whose department is responsible for security at the 24-acre public hospital campus, held a City Hall news conference to share initial findings into what went wrong in the search for Lynne Spalding.
Mirkarimi, using the woman's legal name, said the "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 ensure that "it will never happen again."
Spalding, who had stopped using "Ford" after her divorce, lived in San Francisco's Mission District for years, working in jobs related to the travel industry. The 57-year-old British woman who charmed friends with her vivacious nature and heavy accent was admitted to the hospital with an infection.
The chronology that Mirkarimi read aloud begins a few days later, on Sept. 21, when Spalding walked out of her room on Ward 5D and failed to return.
Some miscommunication is attributed to hospital employees. Most of the mishaps, however, appear to be the fault of sheriff's deputies with the "institutional patrol unit," which oversees hospital security.
In an initial 10:25 a.m. call to the unit, a hospital staffer described Spalding as "African American and wearing a hospital gown." Spalding is white and it was not known at the time whether she was in a gown or street clothes.
Swing-shift deputies who came on duty at 8 that night were unaware of the disappearance, but after gathering information at her ward they described her in a log as an "Asian female."
Spalding's physician had to twice call deputies to clarify that Spalding had gone AWOL, was "confused and not safe to be on her own," and could be in danger.
Still, because Spalding was not on a psychiatric hold, she was not formally considered a missing person by deputies at the hospital, who were on the lookout and said that if they saw her they'd bring her back. But they weren't systematically searching for her. Spalding's daughter contacted the San Francisco Police Department, which launched the missing person case.
The search was further stymied by surveillance system hardware issues that prompted an eight-day delay in providing video to police that might have shown Spalding leaving the facility.
Meanwhile, a search of the "entire campus" by deputies, which hospital officials requested Sept. 30, "did not include all stairwells," Mirkarimi said. Although it resumed the following day, "only about half the stairwells were searched."
The last contact with deputies came on the morning of Oct. 4, when a member of the hospital's medical staff called to say "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 findings state. "There is no indication that anyone was dispatched to the exterior stairwell."
Spalding's body was found there four days later.
Mirkarimi said "there will be staff changes" at the unit. He has assigned a captain to oversee it and "conduct a thorough security assessment of the patrol unit itself as well as how [the unit] and hospital staff communicate and work together."
Mirkarimi has ordered daily patrols of the fire stairwells and required that responses to "stand-alone audible alarms" be documented, he added. Spalding is believed to have triggered such an alarm when she opened the door leading to the stairwell.
The San Francisco Police Department, San Francisco medical examiner and San Francisco General Hospital are conducting separate investigations, and an independent review by UC San Francisco that was requested by Mayor Ed Lee is underway.
Meanwhile, hospital officials disclosed Wednesday that a team of federal healthcare regulators are conducting an investigation.
"The federal investigation is helping us tremendously to learn more about what happened," San Francisco General Hospital Chief Executive Sue Currin said. "Our only focus is on having a safe and secure environment for our patients, staff and visitors. To do that, we need to get to the root causes of what happened in Lynne Spalding's death."