The tragic case of the death of Lynne Spalding, who was found in a locked stairwell at S.F. General Hospital on October 8 after disappearing from her hospital room 17 days earlier, reached another conclusion with the arrival of a report by state health inspectors on the incident. The report describes a chaotic hospital where orders to monitor patients around the clock are frequently disregarded, as was the case with Spalding. And it gives equal blame to Sheriff's deputies who all performed cursory, half-hearted searches of the grounds and the hospital building, allowing Spalding to die from neglect as a result.

The Chronicle provides details from the report, which has not been made public but which was performed on behalf of the Centers for Medicare and Medicaid Services, a federal agency that checks up on hospitals that receive Medicare payments. The report found that while it was clear Spalding needed 24-hour monitoring after being admitted for a bladder infection, sepsis, and severe disorientation on September 19, and a doctor had given written orders that she never be left unattended (she had a frequent habit of getting out of bed, so much so that nurses disabled her bed alarm because of the noise), nurses failed to record or fully heed that order. She wandered into a nursing station on September 20 at a time when she was not being monitored, and a nurse who was given the order by a doctor admitted she "did not get a chance" to record the order for round-the-clock monitoring on Spalding's chart during a change of shifts.

Instead, Spalding's nurses were given instructions that she be under "close observation," which amounts to checks every 15 minutes, and at the time she disappeared from her room, the monitor assigned to her had been called away. The duties to monitor Spalding fell to a patient care technician, not a nurse, and it seemed that the constant monitoring stopped after Spalding's roommate, who also required monitoring to keep her from falling, was discharged. The report suggests that patients requiring monitors are left unattended in at least a quarter of all cases at S.F. General.

The Sheriff's Department bears a lot of the blame for Spalding's ultimate death, however, and medical examiners were not even able to determine how many days she might have been alive in that stairwell before expiring. It sounds like not a single sheriff's deputy took his search duties seriously, and nor did they treat Spalding disappearance with the adequate amount of seriousness either.

Some blame is shifted to the Board of Supervisors as well, because the hospital says they have been asking for years to end their contract with the Sheriff's Department in order to hire private security, and the Supes have nixed this idea since 2009.

So, in short, the system failed Ms. Spalding, multiple nurses, patient care technicians, and sheriff's deputies dropped the ball, and everyone should feel ashamed.


Previously: Sheriff's Deputy In Lynne Spalding Case: 'No, I Didn't Smell Her...'