A woman found dead in a stairway on the grounds of Zuckerberg San Francisco General Hospital was identified by officials as a resident of a nearby care home who had been missing for 10 days.
The death of Ruby Anderson — who was discovered in a stairwell of the power plant building Wednesday afternoon — prompted swift changes on the sprawling campus as officials acknowledged gaps in security protocols.
“Something went wrong here because Mrs. Ruby Anderson died, and it’s a terrible thing that happened, and we’re looking into how it can be prevented in the future,” said Rachael Kagan, a spokeswoman for the San Francisco Department of Public Health. “We’ve seen a loophole now in the system, or a consequence that can happen that had never happened before.”
On Friday, Kagan said that preliminary coroner’s reports found no evidence of foul play. A cause of death has not been determined.
Anderson lived at the nearby Behavioral Health Center Residential Care Facility for the Elderly — which, like the hospital, is overseen by the public health department — and she regularly signed herself in and out. About 9 a.m. on May 19, Anderson checked out of the care home, which houses 50 people, and indicated she’d be back by 4 p.m., officials told reporters at a news conference.
The staff reported her missing to the San Francisco Sheriff’s Department the following afternoon. Deputies checked if she’d been admitted to the hospital, called her family and the medical examiner, and distributed missing person fliers around the hospital campus.
If Anderson had been a hospital patient, sheriff’s deputies would have searched the entire hospital campus, including the power plant stairwell. That security measure was implemented five years ago after a patient was found dead in an emergency stairwell 17 days after she vanished from her hospital room.
Lynne Spalding, 57, had arrived at the hospital with an infection and went missing from her bed two days later. Eventually, a worker discovered the woman’s body in an exterior stairwell enclosed by wire mesh on the hospital’s fourth floor.
San Francisco’s medical examiner determined that Spalding died from dehydration and complications from alcoholism. After her death, San Francisco General revamped security and implemented new procedures to prevent a similar incident, including daily inspections of all stairwells in the main hospital buildings.
A claim brought by her family was settled for $3 million in 2014, the San Francisco Chronicle reported.
Officials this week tightened security measures at the power plant building, which until Anderson’s death had been accessible to people without an a ID badge between 6 a.m. and 6 p.m. Now, access to the building requires an ID badge around the clock.
“We’re going to be reviewing everything to see where the holes are and where the gaps are because certainly it looks like we need to do better,” said Sheriff Vicki Hennessy.
1:15 p.m. June 1: This article has been updated to include the preliminary coroner’s report.
This article was originally published at 8:30 p.m. May 31.