Gross Negligence in Bay Area Hospital


For five years now, I have worked as a nurse aide in a rural hospital setting. My mom worked in the same hospital for 15 years before moving on after obtaining her Masters degree in nursing science. Working in my hometown hospital with my mom’s old friends and coworkers has its perks, as does working in a rural setting.

I grew up in a rural setting, as well. In a town of 8,000 where my grandma has lived all her life, I’ve become accustomed to everyone knowing who I am and who I belong to. Whether good or bad, everything I do is practically public knowledge. Maybe that’s why I couldn’t fathom the circumstances when I read about Lynne Spalding, a 57-year-old British native who checked herself into San Francisco General Hospital only to be found dead in a stairwell after being reported missing for over two weeks.

Spalding, also known as Lynne Ford, had a urinary infection when she presented to the facility on Sept. 19 and was admitted to inpatient care. The infection caused confusion, which caused the doctor to order nurse checks every 15 minutes, although news reports vary from frequent checks to one-on-one care orders. According to an article updated on Feb. 1 by the San Francisco Gate, the nurse received the physician’s order to change from “close observation” to “never leave patient unattended,” after the patient had been observed wandering and disoriented on Sept. 20. The nurse who took the order stated she “did not get a chance” to change the order, so the order for continuous observation was not passed on.

Reports on timelines vary significantly, even within the SF Gate. The most recent article shows times as follows: On Sept. 21, the staff assigned to her observation was called away at 8:30 a.m. and was not replaced. At 9:55 a.m., the patient was reported missing and hospital staff proceeded to search the facility. The stairwell was not searched, as it is not their common practice and the one in question, “Stairwell 8,” is an alarmed fire exit, not typically utilized outside of an emergency. At 10:25 a.m., the Sherriff’s department was notified. The woman was apparently missing for nearly two hours before the authorities were notified. According to the initial report, deputies were told it was an African-American woman in a hospital gown, though Spalding is a Caucasian woman, found fully dressed in street clothes. This description was corrected.

According to the article from Nov. 7 on, the Sherriff’s department attempted to track her movements via surveillance cameras on Sept. 26. FIVE DAYS AFTER SHE VANISHED. The woman is ill, has documented confusion and is missing for five days before someone thought to check the cameras and see where she went after she left her room?! Not that it mattered, because the footage was unavailable due to “hardware problems,” at which point the facility notified the maintenance vendor responsible for the equipment.

On Oct. 4, four days prior to the discovery of her body, a hospital worker notified the authorities that there was a person laying in the stairwell, on the landing of the “third or fourth floor.” The communications center officer stated they would send someone over to check it out, however there is no indication that this occurred. On the same day, a hospital official contacted Haig Harris, the attorney for Spalding’s family, to say that an employee on the fifth floor reported a banging sound coming from Stairwell 8; a spokesperson for the facility confirmed this call was made but did not go into detail about the context.

Finally, on Oct. 8, an engineering worker for the facility stumbled upon her body during a routine quarterly check on the stairwell. Statements in several articles claim it is a locked area, so presumably it is accessible from the inside but locked from the outside, which would make sense in a hospital. I can see how a patient, in a UTI fog, could walk out the door on her floor, find it locked from the outside and be unable to find a way back in or even out of the building. However, I cannot see how two reports of activity in the stairwell were ignored.

Judging by the circumstances one can safely assume that:
-The stairwell alarm was either not functional or did not receive appropriate follow-up.
-The nursing staff were not well-acquainted with their patients.
-The Sherriff’s department did not conduct a thorough search of the facility and grounds.
-The facility does not routinely check hardware, including surveillance.
-The facility does not have, or did not implement, a protocol on a missing patient.
-Neither the facility nor the department took the report seriously, as follow-up was minimal at best.

I work in healthcare. I grew up in healthcare. I understand “short-staffed.” I even understand “shit happens.” But this is unacceptable. The overall dehumanization of this woman during the so-called search is appalling. The staff didn’t even know which patient was missing, let alone when she had actually eloped or where she might be. In an article from San Jose Mercury News, one deputy was quoted in a transcript from Oct. 8 as saying, “No, I didn’t smell her, but two of our other guys fucked up big time. They are both trying to blame the other one, but they didn’t do their job, nothing new. I’m just laughing.” Really?

It seems that no one cared at all about Spalding’s disappearance and little more empathy has been given over her discovery. The coroner’s report lists her death as resulting of “probable electrolyte imbalance,” possibly secondary to “chronic alcoholism.” The available information does not involve a physical description of her liver (i.e. “cirrhotic,” “hepatic,” fatty or scarred) which may confirm this claim. The substantiating facts for this involve unspecified lab work, which are said to reflect those of a person with chronic liver disease. At least one article stated her demise to be consistent with clinical sepsis.

We know that she was admitted on Sept. 19 for a UTI and confusion. Common side effects and comorbidities of a UTI can include but are not limited to dehydration; pain in the abdomen, bladder or urinary tract; confusion or delirium; and fever. For a UTI in which the patient is experiencing fever or pain, it is a reasonable assumption that she was receiving acetaminophen, the generic name for Tylenol. It is also reasonable to assume that she was receiving an antibiotic.

Ampicillin and tetracycline are two antibiotics potentially used to treat urinary infections. They are not the only ones used, and may not even be commonly used for UTI depending on the protocol of the facility and sensitivity of the infection. However, both of these antibiotics are shown to effect a common liver function test, the alanine aminotransferase, or ALT level. Acetaminophen can also have this effect. Antibiotics overall can affect the total billirubin level, another liver function lab.

Family states they have no records of Spalding being treated for chronic alcoholism. Because the Health Insurance Portability and Accountability Act (HIPAA) fortunately restricts the accessibility of medical records, the general public may never know if she had been treated for liver disease or alcoholism prior to her hospitalization at SF General. We may never know whether the hospital had records from any previous hospitalizations or doctor care, so it may never be conclusively shown whether or not she had a documented history of liver problems.

I wasn’t present at the autopsy. I don’t know exactly what the examination showed, or which labs they ran, or the accuracy of lab work days after the patient has expired. I certainly am not qualified to determine what killed Lynne Spalding. However, given the tremendous amount of evidence supporting gross negligence on the part of both the hospital and county law enforcement, it seems reasonable to question the findings of the coroner.

This woman—more than likely—sat in an unused staircase for two and a half weeks. We don’t know when she got there or when she died, because the coroner simply stated she had been dead for “some days,” but we know when she disappeared and when she was found. At best, she may have still been living on Oct. 4 when noise was reported in the stairs. Regardless, for an undetermined amount of time, probably over four days, Lynne Spalding was without food, water, or treatment for the infection that warranted her admission to the hospital. The adverse conditions, coupled with the treatment she did receive, may explain some findings of her autopsy. I simply find it very convenient that she was suffering from a previously-unmentioned chronic illness after expiring on hospital grounds, possibly days after a “search” of the area.

Aside from my disgust as a fellow healthcare worker, I find this to be an excellent example of the disregard we feel for other people. A lack of empathy has been progressively working its way into our demeanor. The two groups of people most inclined to show adequate concern for her disappearance shrugged it off, disregarding orders and even lying. The multiple issues with the facility itself (nonfunctional surveillance, an alarm that apparently didn’t sound) show that multiple people in a chain of checks-and-balances decided it “wasn’t their problem.” Why have we reached a place where public safety workers half-ass their duties?

More importantly, why does it take a 17-day disappearance resulting in a corpse to raise eyebrows? Why doesn’t it cause alarm until something this serious has occurred?

Please feel free to check out the links below, where I have tried to show any articles I read on the subject, as well as information I used to speculate about the lab work. I encourage you to do your own digging and correct me if I have made an error.


SF Gate:

CNN Timeline:

Mercury News:

CBS Global:

San Jose Mercury News:

Liver Function Tests:

Dehydration stats:


Modern-Day Suffragette?


I feel like this issue is covered in shades of grey, but it belongs in a world of black and white…

In my newspaper class, we are required to bring in two to three current-event stories per class period. When the bus rape in Delhi was causing an uproar in the media, we discussed it in class. In case you didn’t hear about it, or have forgotten what happened, here are the cliff notes:

On Dec. 16 2012, a 23-year old woman and her male friend were walking in Delhi around 9:30 p.m. IST. An off-duty bus carrying five men and one juvenile male stopped and allowed them to board, the driver claiming the bus was headed in the same direction they were. When the driver closed the doors and deviated from the route, the friend became suspicious. He voiced concern and was attacked by the men on the bus, being beaten with an iron rod. He was bound and gagged and lost consciousness for a period of time. The remaining men and the 17-year-old boy took turns raping the woman, as well as assaulting her with a foreign object, presumably the same rod they beat her friend with. Although she fought literally tooth-and-nail against her assault, she suffered detrimental wounds to her genitals, uterus and intestines. Afterward, the perpetrators threw her body and that of her friend from the moving bus. They were found and taken for medical treatment.

The woman maintained consciousness intermittently through her remaining days of life. She had multiple surgeries to remove damaged intestines, but her prognosis remained poor. Eleven days after the assault, the victim suffered a cardiac event in flight to Singapore, where she was to receive further medical attention for her deteriorating condition and damaged organs. The medical staff performed the appropriate cares, attempting to stabilize her vital signs. However, she was pronounced to be brain damaged upon arrival at the facility. Considering her abdominal trauma–resulting in sepsis–and accompanying pneumonia, any hopes for recovery were further diminished. The woman was pronounced dead at 4:45 a.m. on Dec. 29.

Since then, one of the men responsible has died in prison, presumably a suicide. Four more have been sentenced to death. The minor was sentenced to three years in a correctional facility. Three. Freaking. Years.

What?! “We’re gonna go ahead and kill these guys, but since he’s just a kid, we though three years oughta cover it.” What?!

I’m not saying that this 17-year-old kid should necessarily be killed. I’m not even saying that you should compare the moral judgment of a teenager to that of the adults present, but when the crime is so heinous you feel justified in lynching the grown-ups, maybe we should consider more than a couple years in the slammer. This kid isn’t even going to be the oldest guy in his JuCo classes when he gets out! He took part in beating a man until he was incapacitated, then raping and beating a woman until she DIED as a result of her injuries. For the love of God, put that boy away for a minimum of ten years. If you really think he can be rehabilitated, great. But he has barely more than a thousand days to think about the severity of what he participated in.

In addition to this case, there have been countless cases of suicides as a result of “slut-shaming,” which has taken the internet by storm over the last few years. There seem to be two main versions of this. Number one: Girl meets Boy. Girl gets dangerously drunk around Boy. Boy assaults Girl (Some variations include all of Boy’s friends assaulting Girl). Boy or his friends post pictures of said assault all over the internet, proclaiming Girl to be a whore, and proudly letting everyone know they’ve tapped that. Number two: Girl voluntarily sends risqué photos to Boy and/or performs various sexual acts, in which photos are taken. Again, photos and debauchery abound are laid out for the world to see.

Now, I’ve taken a somewhat weird stance on this whole phenomenon. First of all, I’d just like to point out that if Girl makes the appropriate decisions, Girl will never end up drunk and passed out at Boy’s house, etc. I will concede that there are cases where this occurs through no fault of Girl, but in almost every case I hear about, there has been some opportunity for the female in question to say to herself, “Whoa, maybe this is a bad plan.” Theoretically, we could almost eradicate this trend entirely–not by writing heartfelt news pieces about the effects of bullying, or looking down our noses at slut-shaming, but by taking our daughters, our little sisters, our nieces, hell, even our students aside and saying, “Please make the right decisions. If you are unsure whether it is the right decision, ask me.”

That being said, the cases where a girl is entirely taken advantage of do exist. So why is it that we, in a day and age we tout to be so forward-thinking, still have cases where a guy old enough to enlist in the American Army if he so chose is only sentenced to three years for the rape and murder of a woman? Why have we raised a generation of young men who find it not only acceptable, but commendable, to have sex with a girl who is passed-out-in-a-puddle-of-puke WASTED? And THEN, they are so proud of this that they take photos. Why is it that the girl is then the slut, while we pat the guy on the back for having “gotten laid?” Excuse me, but brother, if your claim to bedroom fame is that you can get off while I’m semi-conscious, I just don’t think I’m impressed. Even our music has taken us to that point. I heard “Caribou Lou,” the first time and I said, “Uhh, if you need that much alcohol to get me to do that, don’t be so proud of it.”

I would like to have thought that the great movement of my generation was not women’s lib. I would like to think that fight’s been fought. That’s a war that we won back before women wore pants on a regular basis. We’re fighting for men to marry men, right?? Surely we don’t have to put down our rainbow flags to burn our bras, right??

Am I out of line, here? I am I wrong? Have we really made it to the place where my daughters can truly be anything? Or do we live in a world where boys get their uncles to cover up the downright RAPE they committed, so that the entire town will turn on the victim? Because I thought my phone took pictures in color, these days.

*To read more about the cases I have referenced in this entry, here are a few articles to get you started. I strongly encourage you to read more than one on each case you’re interested in.
Delhi Bus Rape: Telegraph, Guardian, HuffPost
Slut-Shaming: HuffPost
Missouri Rape Cover-Up: Guardian, Fox News