Statement on Patient Lynn Spalding Ford – Dec 13th

December 13, 2013


by Sue Currin, RN, MSN, CEO of San Francisco General Hospital and Trauma

SAN FRANCISCO — The tragic death of our patient, Lynne Spalding Ford, was a horrible event that 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 understand what went wrong. Everyone here at San Francisco GeneralHospital is shocked and saddened by Ms. Spalding’s loss.  We have been doing everything we can to learn the facts and to ensure that it never happens again.

With the Medical Examiner’s report complete, there is more information now available. We have not yet had a chance to review the report, but we hope that it can help the family and hospital better understand what happened. Although the picture is becoming more complete, we may never know everything about this tragedy, and questions may continue.  

 Nothing changes the fact that our only focus is on having a safe and secure environment for our patients, staff and visitors. 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.

 Our improvement work began immediately on October 8 and continues today.

 An independent review of the safety and security systems at SFGH has already begun. The review, by UCSF, is currently evaluating all hospital security policies and procedures, conducting staff interviews to identify needs and priorities, and soliciting proposals for outside experts to conduct a review of security systems controls, such as cameras and surveillance, entrance and exit access and alarms for SFGH patient care buildings. Next, the independent review will examine security staffing, including job classifications and assignments, hours, job duties, training and post areas.

 Other changes already in place at the hospital include:

  • 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.

 The San Francisco Sheriff’s Department, which provides security at the hospital, has instituted the following changes as well:

  • All 46 SFSD staff assigned to SFGH completed SFGH new employee orientation and training, include SMART training.
  • A full time SFSD Training Officer has been assigned to the SFGH campus
  • Captain Ken Ferrigno has been assigned to the SFGH campus full time. He  reports directly to the Sheriff as the Institutional Police Unit (IPU) Unit Commander.
  • Two full time Lieutenants have been assigned to act as SFGH Site Commanders
  • At each shift change (3 times a day, 24/7) the SFSD watch commander conducts a muster meeting – where information regarding current security issues in the hospital is passed along from shift to shift so there is continuity of services
  • The SFSD is developing a six week training course specific to working at Department of Public Health sites

 At the end of this process, SFGH will be a stronger organization. As the city’s only trauma center and care provider for more than 100,000 patients and their families each year, we want all our patients to have full confidence that in addition to excellent care, we will also provide superior safety and security systems. 


San Francisco GeneralHospital and TraumaCenter is the sole provider of trauma and psychiatric emergency services for the City and County of San Francisco. A comprehensive medical center, SFGH serves some 100,000 patients per year and provides 20 percent of the city’s inpatient care. In 2011, SFGH became the first hospital in the country to be certified for a Traumatic Brain Injury program. As San Francisco’s public hospital, SFGH’s mission is to provide quality health care and trauma services with compassion and respect to patients that include the city’s most vulnerable. GeneralHospital is also one of the nation’s top academic medical centers, partnering with the University of California, San Francisco School of Medicine on clinical training and research.


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