Update November 14, 2013

Update November 14, 2013

The tragic death of patient Lynne Spalding Ford shook our hospital and the entire city. What happened to Ms. Spalding should never have happened. Our hearts go out to Ms. Spalding’s family and friends and we are keeping them foremost in our minds as we work to solve this problem. We are doing everything we can to learn the facts and to ensure that it never happens again.

Our only focus is on having a safe and secure environment for our patients, staff and visitors. To do that, we need to get to the root causes of what happened in Ms. Spalding’s death. We will do whatever it takes to make that happen, and make any and all required changes so that our hospital meets the highest standards.

Here is a round up of what has occurred since October 8.


  • We are seeking help from staff to identify a witness who saw a person lying in the stairwell on Oct 4. The UC Police Department is assisting the SF Police Department by circulating information to staff. Anyone with information should contact: SFPD Hot Line: 415/431-2127 or SFPD Inspector Dan Cunningham: 415/553-1109 or UCSF PD Hot Line: 1-800/403-4744 or UCSF PD Lieutenant Eric Partika: 415/571-4327
  • The SF Police Department is investigating the suspicious death of Ms. Spalding.
  • The SF Sheriff’s Department also is conducting an investigation, and released preliminary findings on November 6.
  • The CA Department of Public Health arrived on October 30 to conduct an investigation on behalf of the federal Centers for Medicare and Medicaid Services (CMS). They concluded November 8. We expect their formal findings in a few weeks, and we will provide a plan of correction for any deficiencies. An unannounced CMS validation survey with a full team of investigators is expected to follow to verify the implementation of the plan of correction.
  • We also expect a visit from the Joint Commission, the independent organization that accredits hospitals.  

Security – New Measures in Place:

  • Daily emergency stairwell checks by Sheriff deputies.
  • We have updated all emergency stairwell door alarms to require deactivation with a key.
  • When a stairwell alarm rings, it triggers a security check by Sheriff


  • When a stairwell alarm rings, and the stairwell is near a patient care unit, the charge nurse immediately checks the unit to ensure that all patients are accounted for.
  • We began a program November 8 to re-train and re-orient all Sheriff’s Department staff on the SFGH campus.

Security – Next Steps:

  • The independent review of our security and facilities systems by UCSF has begun, and its first priority is a review of security system controls for SFGH patient care buildings. The first recommendations are expected in 30 to 90 days. Contact UCSF News Office for more information.
  • Sheriff’s Captain Ken Ferrigno has been assigned to SFGH full time, and he will make personnel and procedural changes to address immediate security needs on campus. Contact the Sheriff’s Department for more information.
  • We are exploring expanding our existing private security contracts to make up for current shortfalls.
  • Barbara Garcia, Director of Health, is working with the Health Commission to seek near and long-term solutions to ensure patient and staff safety.

Ms. Spalding’s Family:

  • We have talked to her daughter and to the family’s lawyer on several occasions.
  • We have offered our condolences and any resources that we can provide.
  • We have shared information and updates as we learn them.

SFGH Staff:

  • Specially trained response teams have worked with several units affected by the tragedy and are still available to counsel individuals and groups.
  • Hospital chaplains held a service of healing for staff in the chapel.
  • The tragedy was discussed by hospital leadership and staff at an all-staff town hall and at a managers’ forum.

Regular updates are posted on our web site and on the hotline 206-3376.  


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