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SF concedes gaps in protocol after woman dies in hospital stairway

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Sheriff Vicki Hennessy speaks during a news conference at Zuckerberg San Francisco General Hospital on Thursday, one day after 75-year-old Ruby Andersen was found dead in a hospital stairway (Michael Barba/S.F. Examiner)

A day after a missing elderly woman was found dead inside a stairwell at Zuckerberg San Francisco General Hospital, city officials on Thursday acknowledged gaps in protocol that thwarted attempts to find her.

Ruby Andersen, 75, was reported missing from an elderly residential care facility at the hospital on May 20, more than a week before engineering staff found her body in the power plant building on campus.

Sheriff Vicki Hennessy said deputies would have searched that building for Andersen had she been a patient of the hospital under procedures instituted after a missing patient was found dead in another hospital stairway in late 2013.

But Andersen was a resident of an elderly care center on campus, not a medical patient.

“We are going to be reviewing everything to see where the holes are, where the gaps are because certainly it looks like we need to do better,” Hennessy told reporters outside the hospital. “This is a process and we want to get it right.”

Ruby Andersen was reported missing on May 20, and found dead in a stairwell at San Francisco General Hospital on May 30. (Courtesy image)

The startling discovery Wednesday echoed the death of Lynne Spalding, a 57-year-old woman whose body was found in a stairway 17 days after she went missing from her hospital bed in September 2013.

San Francisco settled a lawsuit with her family for nearly $3 million a year later.

Rachael Kagan, a spokesperson for the Department of Public Health, said protocols for missing patients that the hospital and Sheriff’s Department strengthened after the death of Spalding had been working until this week.

“We’ve seen a loophole now in the system or a consequence that can happen that had never happened before, that had never been anticipated before,” Kagan told reporters. “We are taking immediate steps… to do what we can immediately and we will continue to go forward.”

Andersen went missing after checking herself out of the residential care facility at 20th Street and Potrero Avenue at 9 a.m. on May 19, according to Hennessy. Facility workers expected her back by 4 p.m., and reported her missing to the Sheriff’s Department the following afternoon when Andersen did not return.

Hennessy said a sheriff’s deputy made a series of attempts to find Andersen May 20 by reaching out to her family and checking to see if she was admitted to the hospital, booked into jail or at the Medical Examiner’s Office.

The deputy also reported Andersen as a missing person. The report was forwarded to the to the San Francisco Police Department May 21.

On May 22, Andersen’s family contacted authorities to confirm she was missing and deputies handed out missing persons flyers at the hospital, according to Hennessy.

Andersen was not found until engineering staff reported a possible dead body in the stairwell at the power plant building on campus, just two blocks away from the residential care center where she lived.

Hennessy said deputies are not responsible for regularly patrolling the building under the agreement reached with hospital officials after Spalding’s death. The Sheriff’s Department only patrols the hospital buildings with patients as well as the outside areas of the campus.

The Medical Examiner leaves the scene of an investigation after the body of a woman was found inside a stairwell of the power plant building at Zuckerberg San Francisco General Hospital on Wednesday, May 30, 2018. (Kevin N. Hume/S.F. Examiner)

Roland Pickens, director of the San Francisco Health Network, which oversees the facilities at hospital, said the power plant building is open for staff between 6 a.m. and 6 p.m. seven days a week without a security checkpoint.

“One of the immediate steps we took yesterday after finding this incident was to institute 24/7 security badge access into the power plant building,” Pickens told reporters. “That’s an immediate measure we are taking and we will obviously take more as we learn.”

Pickens said hospital officials and deputies have initiated a search of all of the buildings on campus in the wake of the discovery.

This story has been updated to include additional information.


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