by Brianna Crandall — November 13, 2013—On November 6, San Francisco Sheriff Ross Mirkarimi released preliminary findings of his investigation into the tragic death of patient Lynne Spalding Ford at the San Francisco General Hospital and Trauma Center (SFGH). The 57-year-old Spalding was admitted to the hospital September 19 with a urinary tract infection, was reported missing from her room September 21, and 17 days later on October 8 was found dead in an emergency stairwell.
Along with the sorrow of the patient’s loved ones and concerned others, the tragedy shook the hospital staff and the Sheriff’s Department, which contracts with the Department of Public Health (DPH) to provide security services at SFGH and other DPH sites, and has caused facilities and security personnel at hospitals around the country to rethink their security measures. SFGH, a level-one trauma center, serves 100,000 patients a year and partners with the University of California, San Francisco, School of Medicine for research. The 598-bed public hospital is owned and operated by the City and County of San Francisco Department of Public Health.
According to a November 11 article in the Security Director News, Toronto-based security consultant David Hyde says a litany of security failures is to blame for Spalding’s death and the botched search that followed her disappearance. “This is a failure of procedures, of technology, cameras and alarms, of training and procedure,” said Hyde. “It’s a failure of all elements of security resulting in a tragic, avoidable death.”
Along with an ongoing investigation by law enforcement personnel and federal health care regulators, an independent review of the hospital’s security and facilities systems by the University of California, San Francisco (UCSF) is being conducted, with the first priority to review security system controls for SFGH patient care buildings.
The Sheriff’s Department is shifting personnel into and out of the hospital, with a new commander taking over the hospital security detail, the San Francisco Chronicle reports. No misconduct charges have been filed. All Sheriff’s Department staff on the SFGH campus are also being retrained and reoriented, and the hospital is exploring expanding its existing private security contracts. In addition, the Director of Health is working with the Health Commission to seek near and long-term solutions to ensure patient and staff safety.
The hospital already has taken several measures to tighten the security of its emergency exit stairwells, including:
- Sheriff deputies conduct daily emergency stairwell checks.
- All emergency stairwell door alarms have been updated to now require manual deactivation with a key.
- When a stairwell alarm rings, it triggers a security check by Sheriff deputies.
- When a stairwell alarm rings that is near a patient care unit, the charge nurse immediately checks the unit to ensure that all patients are accounted for.
A related SDN Editor’s Blog noted that major hospitals often “supplement or complement their security teams with off-duty law enforcement, but to solely rely on them and not have them trained properly is a different story.” The Editor contacted Bryan Warren, president of the International Association for Hospital Security and Safety, who made the point that “Administrators take it for granted that because you’re a deputy you can do hospital security. But it’s a very different role, and until we get that point across as a profession, we’re going to continue to have these challenges.”
The IAHSS has compiled a list of best practices and standards for emergency planning in its safety guidelines, but notes that members are under no obligation to follow them.
Brian Hyde agreed that following best practices is critical because of the special needs of the hospital environment. He feels that this type of security failure offers institutions of all types a chance to reexamine their security protocols and procedures. “Let’s not pile on to this hospital—that’s for the lawyers,” said Hyde. “Major failures are an opportunity for other facilities to look and say, ‘How are we doing on these things? What can we learn here?'”
