The San Francisco hospital where a patient disappeared last year, only to be found dead 17 days later in a exterior stairwell, should share in the blame with the sheriff's department for "systemic" failures that led to the death, according to new report.
By the time her body was discovered Oct. 8 during a routine quarterly maintenance check of the stairwell, Spalding Ford's body had suffered "moderate decomposition," according to a medical examiner's report, which listed her cause of death as dehydration and complications from alcoholism.
The disturbing case led to changes in the way the San Francisco Sheriff's Department patrols the sprawling 24-acre public facility and spurred numerous internal and external investigations of hospital practices.
In the latest report obtained by the San Francisco Chronicle, state health inspectors working on behalf of the federal agency that decides whether hospitals are meeting standards for receiving Medicare payments found that a breakdown in planning and nursing care created the potential for a "chaotic and poorly coordinated" response that led to Spalding Ford's death.
The report for the Centers for Medicare and Medicaid Services was based on interviews with dozens of hospital staff members and San Francisco County sheriff's deputies, which provide security at the facility.
In addition to the botched search effort, the report found that nurses failed two days before she vanished to heed written orders to "NEVER leave patient unattended."
The medical examiner's report released in December did not pinpoint when Spalding Ford died -- something her surviving family members have been calling on officials to determine. Family spokesman David Perry told The Times that if Spalding Ford died "anything more than an hour or two after she went missing on that stairwell," the cause of death is "neglect and malfeasance" on the part of the hospital and sheriff's department.
Hospital and sheriff's officials have said they have taken steps to prevent similar incidents. In a statement to the Chronicle, the hospital sought to assure Spalding Ford's family "and all our patients, visitors and staff, that we are a safer organization today."
The sheriff's department did not comment.