Repeated incomplete search efforts, conflicting reports, miscommunication and a failure to follow orders describe events at San Francisco General Hospital in the days after a patient went missing in late September — a patient who was later found dead.
The Sheriff’s Department, which provides security at the hospital, released preliminary findings Wednesday in its investigation into the circumstances surrounding the disappearance and death of patient Lynne Spalding. Her body was discovered Oct. 8 in an emergency stairwell only yards from her hospital bed.
At a Wednesday news conference at City Hall, Sheriff Ross Mirkarimi did not explicitly say his department botched the search, but he offered condolences to the family and laid out steps being taken to prevent such events in the future.
“This should have never happened to anyone,” he said.
Mirkarimi did not take questions, but promised there would be additional units assigned to the hospital and a new commander who will report directly to him, among other efforts to improve security.
Haig Harris, who represents Spalding’s two children, said the findings did not go far enough and too many questions remain unanswered.
“It’s just the kind of rhetoric you expect to hear,” Harris said of Mirkarimi’s statement and the timeline. “‘We’re sorry. We’re looking into it so it doesn’t happen again.’ It doesn’t help the two kids that were left without a mother.”
The point-by-point findings did not include names, but did illustrate myriad failures by hospital security — from the day Spalding went missing to the day an unnamed person reported seeing a body in the stairwell where her body was eventually recovered.
On the morning of her disappearance, Spalding, a 57-year-old white woman from the U.K., was first reported as a missing black woman.
When the swing shift came on duty later that day, no one informed them a patient had gone missing.
That night, a deputy was told by staff that an “older woman with black hair” was the missing patient. But the sheriff’s unit log book recorded that an Asian woman had gone missing.
While hospital staff searched its unit the morning Spalding went missing, sheriff’s personnel did not search the 24-acre campus until Sept. 30, when the hospital asked them to. But “the search did not include all stairwells,” the timeline said.
On Oct. 1, an attempt to rectify the incomplete search was ordered. Still, only “about half the stairwells were searched.”
Spalding’s body appears to have been discovered for the first time Oct. 4 when hospital staff told a deputy that someone reported “there was somebody laying on the landing in the third or fourth floor of stairwell 8.” Sheriff’s personnel replied, “We’ll take care of it,” according to the timeline. “There is no indication that any one was dispatched to that stairwell.”
Despite Wednesday’s revelations, Harris said the events surrounding Spalding’s death remain unclear. The most disturbing thing about the case is “the conflict in the story that comes from each person that I talk to,” he said.
The report said hospital staff reported Spalding as “confused,” but Harris countered that hospital staff told him she was not on disorienting medication.
Hospital staff also told Harris that Spalding was found in street clothes with her purse beside her body. The timeline said she was last seen in a hospital gown.
“I don’t want to point the finger at one or the other,” Harris said. “There’s more than one wrongdoer here. Certainly the hospital has culpability and certainly the sheriff’s office has culpability.”
The Medical Examiner’s Office has yet to release a cause of death.