Memo to SF Health Commission Oct 14th


DATE: October 14, 2013

TO: San Francisco Health Commission

FROM: Barbara A. Garcia, MPA, Director of Health

RE: Disappearance and Death of Lynne Spalding Ford at San Francisco General Hospital and Trauma Center


Summary of Events

Last week, the City of San Francisco suffered a tragedy. On Tuesday, October 8th, a body soon identified as Lynne Spalding Ford was found in a fire stairwell on the San Francisco General Hospital and Trauma Center (SFGH) campus. Ms. Spalding Ford had been missing since she left her hospital room on September 21st.

Hospital leaders have been in touch with Ms. Spalding Ford’s family since the morning that she went missing. On October 8th, they informed the family when the body was found and notified the family again the next day when they concluded that the body was that of Ms. Spalding Ford. I join them in expressing our deepest sympathy to the family for their loss. We assure this family, and all families in our care, that we will find out what happened, and ensure that it never happens again. The hospital leadership and staff are devastated by this terrible event.

At this time, we do not know what happened. We are fully cooperating with investigations by the San Francisco Police Department, the San Francisco Sheriff’s Department, the California Department of Public Health, and the Joint Commission. We are awaiting the San Francisco Medical Examiner’s determination of cause and time of death.

We do know that Lynne Spalding Ford was admitted to the hospital on September 19th and her condition was improving two days later. On September 21st, she was in fair condition when she left her hospital room shortly after being checked on by a nurse at 10:15am. Fifteen minutes later, the nurse attempted to check on her again and, upon finding her room empty, initiated a search. When she was not found, she was considered to be absent without leave (AWOL).

Within an hour of her disappearance, SFGH staff notified the family and sheriff’s department on site. The sheriffs searched the campus, and did not find her. Until her body was discovered by a member of the hospital staff on October 8th, she had been considered a missing person, and the San Francisco Police Department was investigating her disappearance. The stairwell where  she was found is a fire exit that is not routinely used by staff, patients, or the public. It is alarmed and is unable to be opened from the outside without a key. The bottom of the stairway exits to the hospital grounds.

SFGH provides patient care and security to more than 100,000 patients and their families each year. Nothing like this has happened before – this event is without precedent.


What’s Been Done

On Thursday, October 10th, Mayor Ed Lee visited the hospital to express his support and sympathy to staff during this crisis. He also called for an independent review of the hospital’s safety and security systems. The review will not duplicate efforts of the ongoing investigations into Ms. Spalding Ford’s death. Rather, it will help ensure that we are doing everything we can to honor our pledge to Ms. Spalding Ford’s family that this tragedy will never be repeated, and to ensure that the SFGH campus is safe for all our current and future patients. On Friday, October 11th, the Mayor announced that UCSF agreed to conduct the review, bringing in appropriate hospital security and facilities experts as needed.

We are grateful for the support of the City that is bringing resources to bear to make sure that SFGH is completely safe and secure for our patients and families, as well as our staff. We want our patients to have full confidence that in addition to excellent health care services, we will also provide for their safety and security when they are on our campus. At the end of this process, SFGH will be a stronger organization.

While the terms of the independent review are still being defined, the hospital has already taken the following steps to improve security:

Introduced a policy of daily fire stairwell checks in the main hospital;

Initiated updates to all fire stairwell alarms in Building 5-Main Hospital that triggers automatic stairwell checks and deactivation by sheriff security staff; and

Introduced a policy to require that in the event a fire stairwell alarm near an inpatient unit is triggered, the charge nurse will immediately conduct a census check of the unit to ensure all patients are present.

What’s Next

There are several elements to the response to this tragedy that are still underway. We will provide you with regular updates on:

 The independent review by UCSF, including scope of work, schedule, expectations, and recommendations;

 Examination by SFGH’s regulatory bodies, including status and findings of investigations;

 The findings of the medical examiner, including the cause and time of death; and

 Facility, policy and operational solutions that will be implemented to prevent such a tragedy from occurring again.

I will keep the Health Commission updated as this situation unfolds. I know that you join me and everyone at DPH and SFGH in expressing our condolences to Lynne Spalding Ford’s family and friends and in our steadfast commitment to find answers and fix this problem.


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