Gross Negligence in Bay Area Hospital

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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 CNN.com, 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.

SOURCES: 

SF Gate: http://www.sfgate.com/bayarea/article/S-F-General-Sheriff-s-Dept-blamed-in-Lynne-5197170.php#page-1

http://www.sfgate.com/bayarea/article/How-S-F-General-lost-track-of-Lynne-Spalding-5122645.php

CNN Timeline: http://www.cnn.com/2013/11/07/us/california-body-in-stairwell/

Mercury News: http://www.mercurynews.com/california/ci_24872483/san-francisco-sheriffs-documents-prompt-outrage-case-woman

CBS Global: http://sanfrancisco.cbslocal.com/2013/12/13/coroner-ties-alcoholism-to-death-of-woman-found-in-sf-hospital-stairwell/

San Jose Mercury News: http://www.mercurynews.com/california/ci_24872483/san-francisco-sheriffs-documents-prompt-outrage-case-woman

Liver Function Tests: http://www.beatlivertumors.org/Liver_Function_Tests.html

Dehydration stats: http://adventure.howstuffworks.com/survival/wilderness/live-without-food-and-water2.htm

Antibiotics: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682098.html

http://www.nlm.nih.gov/medlineplus/druginfo/meds/a685002.html

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