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Into the Void: The Tragedy of Lynne Spalding's Disappearance Is How Close at Hand She Was Lost 

Tuesday, Nov 4 2014
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She was sick and confused.

She was brought to the hospital. She ended up stuck in a gray concrete stairwell filled with white noise. It was like being underwater.

On the other side of the locked door was the muted business of a hospital, the busy white coats deceptively near. Looking through the tiny window cut into the blue emergency exit door was like being a submerged swimmer gazing at beachgoers through watery goggles.

Outside, where she was trapped, there was the rhythmic din of an HVAC somewhere below and a freeway nearby.

Did she slam her fist against the locked door? Did she yell for help at the nurses and doctors inside the hospital?

Maybe. But no one came for Lynne Spalding.

Spalding — a white, 57-year-old mother of two with shoulder-length brown hair and a broad grin — wandered into a little-used emergency stairwell of San Francisco General Hospital one day in September 2013.

And, though only a few feet from help, it was as though she disappeared completely.

San Francisco General Hospital, wedged between Highway 101 and Potrero Avenue in the Mission District, is the city's trauma center and the last line of defense for much of the city's poor and homeless.

Consequently, on most days people come through the door like unwinding spools — some in cars, some walking from the bus lines running up and down Potrero Avenue. Nurses and doctors getting off long shifts or just starting new ones pass wheelchair-bound patients, families, and the limping wounded. Delirious patients rant and mumble not far from ambulance crews waiting for their next call. Gunshot victims often drive themselves to the front doors.

Somewhere in that busy world, Spalding turned a corner and vanished.

A lot had to go wrong for San Francisco's premier public hospital to lose a patient. Human error, institutional failings, and sheer bad luck contributed to Spalding's ordeal. When hospitals fail in such ways, they become, however fairly or unfairly, symbols for society's disregard for its weakest and neediest.

But they remain the only health care option for many people. They cannot turn away patients, so those most in need flock to their doors, making already busy and chaotic places more so. Like the DMV, they draw in all sorts, and like any system, they occasionally break down.

There is much we don't know about what happened to Spalding. Even with federal, state, and local investigations, many details are missing and may remain so. Trying to tell her story is akin to reconstructing the story of someone lost at sea.

In the fall of 2013, Spalding had been complaining for weeks about stomach pain, and over-the-counter medicine had done little, her then-boyfriend Mark Casey tells me recently. On Sept. 18, he got a text at work from Spalding's 19-year-old daughter: "My moms not feeling well." They took her to the hospital the next day, despite Spalding's protests.

She was given a bed on the fifth floor, and doctors tried to determine what had caused her recent weight loss and confusion. "She was a little confused when we brought her in," says Casey. He still isn't sure what was wrong with her. His only theory is that she had a bad reaction to the antibiotics they were giving her for a urinary tract infection.

The next day, Casey came to visit and Spalding seemed better. She wanted to leave.

But her doctors noted that her confusion didn't dissipate in the hospital. At times she didn't know why she was there or what day it was. She kept wandering away from her room. An alarm was attached to her, meant to notify the staff when she left her bed. But she wandered off so many times that it was turned off.

Increasingly concerned about her walkabouts, her doctors sent a note to the nursing staff to keep an eye on her at all times. The note never made it to anyone on the fifth floor.

When Spalding was left without supervision after 9 a.m. on the morning of Sept. 21, two days after she was checked in, the nursing staff returned to find her gone. She had taken all of her belongings, as if she meant to go home. Nearly everything — her clothes and purse and the $20 inside — was gone. The only thing she'd left in her room was her cellphone.

Forty minutes later, at 10:25 a.m., the staff reported her disappearance to the hospital's security staff, run by the Sheriff's Department out of an office inside the hospital. A perimeter search was conducted soon thereafter, which turned up nothing.

Spalding hadn't gone far. She ended up in the nearby emergency stairwell, only yards from her room.

The low-ceilinged hallway leading to the stairwell door is lit from above, and trafficked by orderlies, doctors, and nurses. At the hall's end, an exit sign glows like a beacon. Signs warn that an alarm will sound when the door is opened. But if the alarm went off, no one heard it or, if they did, didn't pay much attention.

It was one more noise in a noisy hospital.

When Casey came to the hospital around 11 a.m. with one of Spalding's friends, they found an empty room. "They were like, 'She got up and left,'" he recalls the nurses telling him. "We said, 'How does that happen?' They said, 'We're looking for her.'"

Even her doctor was surprised she'd gone. "I came into the room to discharge her and she was already gone... But she's very confused and not safe out on her own," Spalding's doctor, whose name has not been released, told a sheriff's deputy at 11:12 a.m.

The fifth-floor staff told security about a missing patient that morning, but they incorrectly described her. In the first call at 10:25 a.m., an unnamed medical staff member said, "I sent a CNA [Certified Nurse's Assistant] to look all over the place but we could not find her. She's [an] African-American lady, 57 years old. Female. She's wearing a hospital gown."

At 9 p.m., a note of a disappeared patient was logged for the next security shift. Spalding had been transformed again: This time, she was described as Asian. (Spalding was, again, white.)

But that message never got through, either.

The hospital is no stranger to what are known as AWOL patients — Away Without Leave. From January to October 2013, 96 patients had gone missing. As for deaths and serious injuries resulting from these disappearances, no such cases had officially occurred there during the previous decade. (In 2012, there were 16 such cases statewide.)

San Francisco General Hospital is not unique in dealing with AWOLs. According to 2011 data from the state, 38,333 patients in California either left a hospital without informing the staff or signed a statement to leave despite medical advice to the contrary. Hospitals are not legally able to make patients stay in their care except in certain extreme cases, so when patients walk away, they can't be stopped. This bit of chaos is baked into a modern hospital's programming and nearly impossible to change. Spalding's disappearance was one more noise in a noisy system.

The stairwell Spalding walked into is a tall square tower attached to the outside of the hospital. Each floor's blue exit door opens onto an outdoor landing where another door leads down into the stairwell. At the bottom of the shaft, five stories below, an unlocked door opens onto the street.

From the fifth-floor landing, past the netting strung up to stop pigeons roosting, a courtyard can be seen. Red brick hospital buildings — older than the main facility — enclose two patches of grass and a couple of benches. Trees grow along the brick buildings' edges and cast their shade on bright flower beds below.

This is where Spalding found herself on the morning of Sept. 21. She may have been confused and delirious. That delirium — and the fact that the doors into the hospital on the floors below her were all locked — may have been what kept her from walking to the bottom of the stairwell. If she had, she'd have found her salvation: an unlocked exit door opening to the outside.

Delirium or no, Spalding was not the first person who failed to find that exit door.

A woman visiting her son in the hospital in June 2013 had inadvertently walked out of a similar emergency exit only to find the door locked behind her.

She banged on the door but no one came to help. She walked a flight down to the next floor, tried to open a locked door, and then did the same several stories below. Both doors were locked. She started to get frantic. Fifteen minutes passed before a nurse finally heard the banging and opened the door.

Unlike Spalding, this woman wasn't sick. She wasn't confused about where she was. Still, she'd been frightened about not being able to get out.

"No one heard me," she wrote in an email to the hospital after hearing about Spalding's case. "I was fearful of going through another door [at the bottom of the stairwell] in case it also locked behind me and I became trapped further."

The day of her disappearance, hospital security told Spalding's daughter she should call the police and report her mother as a missing person. She did.

Soon after the call, a sheriff's deputy told another security staffer that "the person was going to be discharged anyway and she decided to take off and then her daughter made a stink about it. That's all that was."

The first campus-wide search wasn't conducted until the afternoon of Sept. 30, nearly 10 days after she'd gone missing. But the Sheriff's Department's search did not include all stairwells. It missed the stairwell she was trapped in. A second search on Oct. 1, meant to fix the oversight, repeated the mistake.

In the meantime, Casey and Spalding's family organized their own search. "We put up fliers all over the city," he says.

Images of Spalding's face were stapled to neighborhood light poles and passed out to the hospital staff.

A Facebook page was started for her. In the About section it read, "My lovely friend Lynne Spalding has been missing for three days now, have you seen her?"

Everyone thought she had wandered off the hospital grounds.

The fliers and Facebook page sent them on wild goose chases, says Casey. They'd get calls about sightings in the Tenderloin or other areas and they'd rush to the neighborhood and find no one.

"If we had known she might still be in the hospital, we would never be out canvassing the whole city. We would be searching the hospital," a spokesman for her family later told the San Jose Mercury News.

Spalding was actually found twice.

The first time was on Oct. 4, when a UCSF researcher came upon her just after 7 a.m. She was lying on the concrete floor of the stairwell in her street clothes: a black-and-white jacket, black jeans, black boots.

A call was made to the hospital's security, notifying them that someone was lying in the stairwell on the third or fourth floor. "We'll take care of it," the caller was told by security.

No one came.

Spalding was discovered the second and final time by a maintenance man. He was doing a routine check of the emergency stairwell and found her at about 10 a.m. on Oct. 8.

This time around, she made it out of the hospital. Spalding left through the unlocked door at the bottom of the stairwell. She was carried out on a gurney, swaddled in white sheets. The IV insertion tubes from her treatment were still in her arms.

Seventeen days had passed since she'd gone missing.

The long ordeal had been fatal. Spalding's delirium was caused by clinical sepsis, a condition brought on by infection that can cause organ failure. But she died of an electrolyte imbalance complicated by alcoholism. It's hard to know exactly when she died and how lucid she was in her final days. Even the medical examiner's report has few details to fill in the blanks. It didn't even list a date of death. It only said she had been dead for "some" days before she was found.

Did her dehydration cause cramping in her legs? Did her head ache? Did she know where she was? Was she, finally, trapped by her mind or her body?

Reactions to her discovery varied.

Hospital security, who had failed to property search for her, were cavalier about it, as a transcript of a phone call between two sheriff's deputies that day reveals:

"Well, they found her today."

"Oh they did?"

"Yeah, she was in one of the stairwells... four flights up."

"No kidding? They didn't smell her, huh?"

"No, I didn't smell her, but two of our 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."

Casey, like Spalding's twin brother Bill, learned she'd been found from the media. Casey got a phone call that day. "I found out, a TV reporter... called me," he says now. Bill saw it on television.

"Her family and friends are just devastated... They're frustrated and apprehensive," a family spokesman told the Mercury News on the day she was found.

Since then, Spalding's family in San Francisco, communicating mostly through spokespeople and lawyers, has stayed quiet on the matter.

But her brother has not.

The Spaldings grew up in the Village of Haswell in the north of England. It was the kind of place that held weekend livestock auctions. Most people farmed or worked in the coal mines, like her father. It was a small-town existence.

"We looked at pizza and we knew it was good, but we didn't know what it tasted like," says Bill Spalding now, who still lives in County Durham, near Haswell.

Bill says his sister grew up bold. Once, her father offered to take her down into the mine on a day when it was not running. She leaped at the prospect.

"Hours later she emerged, her face covered in coal dust, sporting a gigantic smile, and carrying in her arms a giant lump of coal. She'd taken a pick to the coal face and hewn it from the rock herself. She was 8 years old," Bill wrote soon after her death.

Spalding left England for Belgium and then Greece soon after she got out of school. In Greece she met an American serviceman and they moved to the States. Here, the relationship collapsed and she moved to San Francisco. Eventually she married and raised two children, working in the city's tourism industry.

A snapshot of her on the "Find Lynne" Facebook page shows her standing above a Pacific Coast beach. Her expression conveys the happiness of someone having arrived.

Bill has a strong regional accent, known as a Geordie, and parses no words when it comes to his sister's death. "Lynne's dead and that's the end of it. I would like to know how she personally was, if it's possible, in her last moments, in her last hours. Her last days," he says now. "It's possible in this day and age to get a better result than [de]hydration, sepsis, and chronic alcoholism."

He got his wish. A few weeks after her death, he was led up to the fifth floor of San Francisco General Hospital by the staff, which took him to the spot where his sister died.

After walking him down the hallway, where his sister presumably walked, they came to the exit door. "'I'm awful sorry I have to come with you,'" Bill recalls a hospital official saying as the deputy opened the door. In the stairwell, Bill asked where she had been found exactly, but they didn't want to say. "I looked and it was obvious where she'd been," he says. The security left him alone. "So I said a couple of words to my sister.

"She was just so confused, she didn't know where she was, she just wandered off," he says. "I went to the spot where she'd been. It was a blessed relief to go there... You could tell Lynne had been dead a long time."

On the first anniversary of her discovery, Oct. 8, 2014, Bill was on a bus in London emblazoned with images of his sister and full of people whose family members had, like Spalding, died abroad. They drove through the city lambasting the Foreign Office's failure to help them find out what happened to their kin.

Some protesters wore T-shirts with Lynne Spalding's face on them. "Shame on you" was written below, a dig at the Foreign Office.

Back in San Francisco, the family has sued the city.

Until recently, little had been said about who, if anyone, had faced consequences for the botched search for Spalding.

A federal investigation eventually found fault with almost everyone involved, including the hospital and the Sheriff's Department. In October, the Sheriff's Department, which after Spalding's death implemented a series of changes to hospital security, revealed that so far, several department employees who worked security when Spalding went missing have been punished. One was fired, two were suspended, and another five still face discipline.

The day her body was wheeled from a dark side-exit of the hospital, city officials stood in front of their hospital and promised that nothing like this would happen again. They called her death an anomaly, an unfortunate tragedy they would do all they could to prevent in the future.

But when the corona of media queried Mayor Ed Lee and health officials on Oct. 11, 2013, at a news conference in front of the hospital, a lost and delirious-looking young man wobbled barefoot not 20 feet away. He was in a hospital robe opened at the back, his ass exposed to the world.

Several months later, after the hospital put into place new protocols (more have been introduced since) to prevent disappearances, a patient wandered out of the hospital again.

She was discovered the next day, blocks away, alive.

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Jonah Owen Lamb

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