57 Year Old Lynne Spalding Missing Since 9/21/13 in San Francisco, CA

[grace-land]

http://www.ktvu.com/news/news/local/2-investigates-records-show-mistakes-during-search/ncfpf/

Posted: 10:54 a.m. Wednesday, Jan. 8, 2014
2 Investigates: Records show mistakes during search for SFGH patient

 
In hospital phone call transcripts and San Francisco Sheriff's Deputy log notes obtained by KTVU Monday afternoon, Spalding -- a 57 year-old Caucasian woman -- was described twice as an “African American lady” and once as an “Asian female.”

Names are redacted from the documents, but they raise new questions about the thoroughness and the attitude of those involved in the hospital search. In one transcript of a call between Sheriff's Department deputies staffing the hospital, one staffer says “... 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 daughter making ‘a stink’ is their interpretation of their daughter frantically trying to find out 'What happened to my mother?'“ Spalding family attorney Haig Harris told KTVU. “To refer to a daughter frantic about the disappearance of her mother, and to refer to it as 'a stink' is, it's just disrespectful.”
 
The transcript of an Oct. 4 call between hospital and Sheriff's Department staffers details the first time Spalding was apparently spotted:

“Um, there is somebody who got lost in the stairwell, stairwell 8, on the fifth floor. He said there was somebody lying on the landing on the third or fourth floor.”

“Okay, we'll take care of it, thank you, bye.”

But it wasn’t until four days later that Spalding was found, prompting this Oct. 8 call between Sheriff's Deputies:

“Well, they found her today.”

“Oh they did?”

“Yeah, she was in one of the stairwells right above the, four flights up.”

“No kidding? They didn't smell her huh?”

“No, I didn't smell her, but two of our guys f---ed 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.”

“Certainly there is concern when some of the language is not professional,” Horne told KTVU.

Harris said the call is appalling.

“They lost a person, didn't search to find her, and when they find her dead, they're laughing about it,” said Harris. “It's outrageous.”

[grace-land]

"no one at SF General or the SF Sheriff's Department took this case seriously."  How true and so sad. 

https://www.facebook.com/pages/FIND-LYNNE/370247543108609

FIND LYNNE shared a link.
6 hours ago

The cycle of callous incompetency at SF General and with the SF Sheriff's Department is fully on display in this latest report. The recordings obtained by the media reveal a dehumanizing lack of compassion and a disregard of minimum professionalism that are shameful. No one has yet to answer for or suffer meaningful consequences following the death of Lynne Spalding. Lynne's family and friends demand justice and full accountability. These recordings prove what we have been saying since September 21, 2013 when Lynne went missing: no one at SF General or the SF Sheriff's Department took this case seriously.
 -- David Perry, spokesman for the family & friends of Lynne Spalding.

[yuknomenot]

  This is so atrociously preposterous and it happened in the U.S.  Why isn't it all over the news.  The names of those involved should not have been redacted, they are all to blame and I still believe there should be murder charges.  This goes way beyond negligence imo.

[grace-land]

This is so atrociously preposterous and it happened in the U.S.  Why isn't it all over the news.  The names of those involved should not have been redacted, they are all to blame and I still believe there should be murder charges.  This goes way beyond negligence imo.

bbm  ^^^  

[grace-land]

Video at the link

http://www.bbc.co.uk/news/uk-england-25655405

9 January 2014 Last updated at 07:12 ET
Lynne Spalding death: Consular 'snub' claim by twin brother

 
Her brother Bill said he was treated "like a pariah" by UK consular staff when he visited the city.

The Foreign Office said it would not comment on individual cases, but said Mr Spalding could complain in writing about any perceived failings.
 
Mr Spalding, from Easington Lane, near Sunderland, has criticised delays in the ongoing US investigation into his sister's death, including a medical examiner's report, which suggested she was an alcoholic.

He said when he arrived in San Francisco for his sister's memorial service, he asked consular staff if they would help arrange a visit to the hospital so he could "spend a quiet moment" where she died.

But he said he was instead referred to a public relations executive acting for Ms Spalding's two American-born children.

Mr Spalding eventually persuaded hospital officials to allow him access to the stairwell.

The 57-year-old, who works as a carer for adults with autism, said: "I just want to find out if Lynne suffered and if so for how long.

'Inside information'
 
"I'm a British citizen seeking help from the British government about how my sister died and I've been offered no help or advice or assistance. It's disgraceful.

"I have no interest in any litigation, which I know has been talked about in America. I just want the truth about my sister's last days and hours.

"When I arrived at the consular office in San Francisco they initially claimed not to know who I was and thought I was a reporter trying to get inside information about Lynne's death. How ridiculous is that?"

Mr Spalding said he would be making a fresh appeal to the Foreign Office to speed up the investigation into his sister's death.
 

[Sister]

This is so atrociously preposterous and it happened in the U.S.  Why isn't it all over the news.  The names of those involved should not have been redacted, they are all to blame and I still believe there should be murder charges.  This goes way beyond negligence imo.

It makes me sick to my stomach!

[grace-land]

http://sanfrancisco.cbslocal.com/2014/01/09/sheriff-mirkarimi-wants-department-to-remain-in-charge-of-sf-general-hospital-security/#.Us9peO3NdJ4.facebook

Sheriff Mirkarimi Wants Department To Remain In Charge Of SF General Hospital Security
January 9, 2014 12:18 PM

SAN FRANCISCO (KCBS) — San Francisco Sheriff Ross Mirkarimi said he wants the sheriff’s department to remain in charge of security at San Francisco General but that he is also vowing changes after a missing patient was found dead.
 
“The budget for security services is not our budget; it’s the Department of Public Health. So what they pay for is essentially four deputies at a fixed sentry post,” Mirkarimi told KCBS.

He said the hospital, which occupies a 24-acre campus, is 30 percent understaffed.

“If we are going to fulfill the expectation of being the second largest law enforcement agency, then I insist on the proper resources of staffing and assets that help us do our job properly,” Mirkarimi said.

He thinks contracting hospital security is not a good option; they would not have the training or expertise to patrol the interior and exterior of the hospital which is located in a challenged community.

While the contracting out security services for San Francisco General is an idea that has been floated around for some time, Mirkarimi opposed the move when he was city supervisor.
 

[Sister]

http://sanfrancisco.cbslocal.com/2014/01/09/sheriff-mirkarimi-wants-department-to-remain-in-charge-of-sf-general-hospital-security/#.Us9peO3NdJ4.facebook

Sheriff Mirkarimi Wants Department To Remain In Charge Of SF General Hospital Security
January 9, 2014 12:18 PM

SAN FRANCISCO (KCBS) — San Francisco Sheriff Ross Mirkarimi said he wants the sheriff’s department to remain in charge of security at San Francisco General but that he is also vowing changes after a missing patient was found dead.
 
“The budget for security services is not our budget; it’s the Department of Public Health. So what they pay for is essentially four deputies at a fixed sentry post,” Mirkarimi told KCBS.

He said the hospital, which occupies a 24-acre campus, is 30 percent understaffed.

“If we are going to fulfill the expectation of being the second largest law enforcement agency, then I insist on the proper resources of staffing and assets that help us do our job properly,” Mirkarimi said.

He thinks contracting hospital security is not a good option; they would not have the training or expertise to patrol the interior and exterior of the hospital which is located in a challenged community.

While the contracting out security services for San Francisco General is an idea that has been floated around for some time, Mirkarimi opposed the move when he was city supervisor.
 

BBM

what an ironic statement . . .

[grace-land]

http://www.bbc.co.uk/news/uk-england-tyne-25757623

16 January 2014 Last updated at 06:49 ET
Lynne Spalding death: Minister promises consular 'snub' probe

A government minister has promised an investigation into how consular staff treated the brother of a British woman found dead in a US hospital stairwell.

Lynne Spalding, from Haswell in County Durham, was found yards from her bed 17 days after going missing from San Francisco General on 21 September.

Her twin brother Bill said consular staff in the city refused to help him when he attended her memorial service.

Home Office Minister Hugh Robertson has admitted staff should have done more.
 
After complaining to the Home Office, Mr Robertson pledged an independent investigation.

He said: "On this occasion our support to Mr Spalding fell short of our exacting standards.

"We informed Mr Spalding that our consulate would call him. Unfortunately, we did not deliver on this commitment as officials had not recorded Mr Spalding's number.

"Officials should have been more helpful, including keeping in regular contact with Mr Spalding. I will make sure we learn valuable lessons from this.

"I will arrange for the Director of Consular Services to conduct an independent investigation by an officer not directly connected to the case."

But Mr Spalding said: "I cannot believe my treatment merely fell below expectations - it was perverse and inhuman."
 

[grace-land]

http://www.sunderlandecho.com/news/twin-of-woman-found-dead-in-san-fransisco-hospital-stairwell-says-government-failed-his-sister-1-6384608

Twin of woman found dead in San Fransisco hospital stairwell says Government ‘failed’ his sister
(20 January 2014)

 
Arriving there on October 19, Bill and wife Gill, 53, of Easington Lane, headed for the British Consulate, thinking help and advice would be forthcoming. Bill went to visit the hospital where Lynne was found, but says consular staff told him he could not go, claiming it would be a conflict of interest.

Bill and Gill visited the hospital regardless.

“It was a case of humanity. It wasn’t complicated at all, it was simple,” Bill said. “The door to the stairwell, as we got out of the lift, is right in the front of you. It wasn’t some back stairwell that was hidden away, it’s right in the middle of the hospital overlooking a communal seating area.

“It was a concrete stairwell, similar to one in a car park. There was this mark on the concrete, this distortion. She had been lying there three weeks. It wasn’t pretty.

“It was rippled and discoloured, in the shape of a body. I could see where her head had been. I put my hand on it. My wife was with me and I said a few words. It was a little personal conversation with my sister. It was peaceful and there was light from the door.” Bill said the visit offered him much-needed reassurance that his sister had been dead for some time when she was found.

“It gave me a better idea than the medical examiner’s report,” he said. “All it said was that she died some days earlier.

“I wanted to be where she had been for 17 days. She detested being on her own, so if Lynne had a moment of lucidity, I just wanted to go there to look at the wall she looked at and just be there.”

Three months on, Foreign Office minister Hugh Robertson has apologised for the way he was treated.

But Bill, who works as a carer for adults with autism at a centre in Durham, is still fighting for answers.

“It’s my twin sister. I want the British Government to step forward and support my sister. It’s three months now, I can’t even grieve.

[Sister]

http://www.sunderlandecho.com/news/twin-of-woman-found-dead-in-san-fransisco-hospital-stairwell-says-government-failed-his-sister-1-6384608

Twin of woman found dead in San Fransisco hospital stairwell says Government ‘failed’ his sister
(20 January 2014)

 
Arriving there on October 19, Bill and wife Gill, 53, of Easington Lane, headed for the British Consulate, thinking help and advice would be forthcoming. Bill went to visit the hospital where Lynne was found, but says consular staff told him he could not go, claiming it would be a conflict of interest.

Bill and Gill visited the hospital regardless.

“It was a case of humanity. It wasn’t complicated at all, it was simple,” Bill said. “The door to the stairwell, as we got out of the lift, is right in the front of you. It wasn’t some back stairwell that was hidden away, it’s right in the middle of the hospital overlooking a communal seating area.

“It was a concrete stairwell, similar to one in a car park. There was this mark on the concrete, this distortion. She had been lying there three weeks. It wasn’t pretty.

“It was rippled and discoloured, in the shape of a body. I could see where her head had been. I put my hand on it. My wife was with me and I said a few words. It was a little personal conversation with my sister. It was peaceful and there was light from the door.” Bill said the visit offered him much-needed reassurance that his sister had been dead for some time when she was found.

“It gave me a better idea than the medical examiner’s report,” he said. “All it said was that she died some days earlier.

“I wanted to be where she had been for 17 days. She detested being on her own, so if Lynne had a moment of lucidity, I just wanted to go there to look at the wall she looked at and just be there.”

Three months on, Foreign Office minister Hugh Robertson has apologised for the way he was treated.

But Bill, who works as a carer for adults with autism at a centre in Durham, is still fighting for answers.

“It’s my twin sister. I want the British Government to step forward and support my sister. It’s three months now, I can’t even grieve.

This is so sad.  Thank you for the updates grace-land.

[grace-land]

http://www.utsandiego.com/news/2014/jan/24/feds-sign-off-on-san-francisco-hospitals-reforms/

Feds sign off on San Francisco hospital's reforms
4:27 p.m.Jan. 24, 2014

SAN FRANCISCO (AP) — Federal regulators have approved a San Francisco hospital's plans to beef up its security procedures after the a patient was found dead in a locked stairwell more than two weeks after she went missing from her room, hospital officials said Friday.

San Francisco General Hospital said inspectors from the Centers for Medicare and Medicaid Services signed off this week on a series of corrective actions the hospital took after Lynne Spalding's disappearance and death.

The reforms include equipping stairwell doors with alarms that can only be shut off with a key, having nurses account for all their patients when the alarms sound, and arranging for sheriff's deputies who provide security at the hospital to search the stairwells daily.
 
Along with instituting daily stairwell checks, Sheriff Ross Mirkarimi has agreed to assign deputies to look for patients who, like Spalding, had shown signs of being disoriented or confused before they disappeared. Previously, the sheriff's department only searched for patients who were on involuntary legal holds or who had another person with legal authority to make medical decisions for them, hospital spokeswoman Rachael Kagan said.

The hospital revealed for the first time Friday that four curious employees looked at Spalding's medical records without authorization after her body was found. Chief Executive Officer Susan Currin said the patient privacy breaches were revealed during an audit routinely performed for high-profile patients. All four staff members were put on administrative leave for violating patient privacy rules, and two were fired.
 

[grace-land]

https://www.facebook.com/pages/FIND-LYNNE/370247543108609

FIND LYNNE
16 hours ago

Statement from the Family & Friends of Lynne Spalding:

Today's report on new safety and security measures to be instituted at SF General in the wake of Lynne Spalding's needless death are above all, too little, too late for Lynne or her family.

Also, buried within the report is the first public mention of two violations of Lynne's privacy by both SF General and SF Sheriff's Department staff. According to the report, the people responsible are no longer employed there. That is, as it should be.

However, while this report is welcome, it still does not address the four sheriff's deputies who were assigned to search for Lynne, said they did, and then, did not. We have been told they have been re-assigned. That is not enough. We cannot re-assign Lynne to her life.

Additionally, although a preliminary report was issued by the San Francisco Medical Examiner on December 13 no exact time or date of death has yet been released. It is well past time for that information to be released to the public.

If today's announced new security measures prevent such a tragedy from taking place to another person and if they prevent the type of callous indifference and disrespect shown by SF General and SF Sheriff's Department Staff to Lynne's family and friends during the weeks after she went missing, only to be discovered dead on a hospital stairwell, then they are all to the good. But, as of right now, the statement is words on paper / on a screen. We will be watching, waiting and observing in Lynne's memory and in the name of all patients at SF General.
 -- David Perry, spokesman for Lynne Spalding's Family & Friends

[grace-land]

https://www.facebook.com/pages/FIND-LYNNE/370247543108609

FIND LYNNE
January 24

San Francisco General Hospital and Trauma Center
 Statement on Improved Safety and Security
 by Sue Currin, RN, MSN, CEO

 Changes Validated by Federal Inspection
 January 24, 2014

San Francisco General Hospital and Trauma Center reports that the federal Centers for Medicare and Medicaid Services (CMS) has verified our compliance with our Plan of Correction (POC) to fix the problems that contributed to the tragic death of patient Lynne Spalding Ford, and that we have made significant progress toward a safer and more secure hospital. Her family is in the forefront of our minds as we continue to work to improve safety and security for all our patients.

CMS conducted a thorough investigation from October 30 to November 8 2013, following the hospital’s self-reporting of Ms. Spalding’s death. The survey covered general security, patient safety/security and privacy. The federal investigators returned this week to re-survey the hospital. The surveyors completed staff interviews, observed practice in the patient care areas, and reviewed documents before concluding that SFGH is in compliance with all requirements.

 Many of the changes outlined in the POC already have been implemented and we can assure Ms. Spalding’s family, and all our patients, visitors and staff, that we are a safer organization today.
 Working in collaboration with the San Francisco Sheriff’s Department, which provides security on the San Francisco General Hospital (SFGH) campus, we have made significant improvements in the key problem areas identified during the investigations: general security, patient safety/security and privacy.
 General Security Improvements:
 Safer stairwells:
 o Security checks of all emergency stairwells are completed daily by Sheriff’s staff.
 o Emergency stairwell door alarms were converted to continuous audible alarms requiring deactivation with a key.
 o Security checks by Sheriff Deputies are triggered when a stairwell alarm rings.
 o Charge nurses check to ensure all patients are accounted for when a stairwell alarm rings near a patient care unit.

 Monthly meetings between the Sheriff and Department of Public Health Director.

 Weekly meetings between San Francisco Sheriff Department (SFSD) leadership and SFGH CEO are held to review ongoing security measures and the status of the POC.

 Sheriff’s Captain Kenneth Ferrigno assigned to SFGH as the on-site Institutional Police Unit (IPU) Unit Commander.

 Two SFSD Lieutenants assigned as SFGH Site Commanders providing 7-day per week supervision.

 SFSD Training Officer assigned to SFGH.

 All 46 SFSD staff at SFGH completed SFGH orientation and training on new security and safety procedures.

 SFSD developed a six-week training course for Department of Public Health sites that is being implemented.

 SFSD policies and procedures for IPU operations at SFGH were reviewed and revised.

 Patient Safety/Security Improvements:
 The hospital’s policy on AWOL and AWOL At-Risk Patients was strengthened when the Sheriff agreed to include in searches patients who exhibit behavior that concerns the clinical staff as to their state of mind. The policy includes a script for staff to follow to ensure accuracy when reporting an at-risk patient leaving the hospital before their treatment is completed. The Sheriff also developed consistent and comprehensive search procedures for missing at-risk patients on our hospital campus.

 The hospital developed, implemented and trained all staff on an organizational response called Code Green when a hospital-wide search is needed to locate an at-risk patient. Sheriff and hospital staffs work collaboratively when campus wide searches are needed.

 The hospital has created a new Patient Tracking System policy and procedure for patients who are at-risk of leaving their units. The hospital has purchased a tracking system that we plan to begin using next month for patients who meet the criteria.

 The policy on the Close Observation of the Hospitalized Patient was revised to clarify required nurse and physician communication, triggers for patient evaluation, and documentation of physician orders and actions instituted to keep patients safe. We learned that for these patients, whose status can vary multiple times during their hospitalization, we had weaknesses in the areas of consistent documentation and communication of these changes and revisions to their care plan. Staff are being retrained and audited to ensure that these vulnerable patients get the care they need.

 Privacy policies were effective and enforced:
 SFGH takes patient privacy extremely seriously and as such we conduct routine audits of medical records of high profile patients. During such an audit on October 21, we discovered four instances when hospital staff accessed Ms. Spalding’s medical record without authorization. This is unacceptable.

 We fully enforced our privacy policies to discipline the staff involved. All were placed on administrative leave immediately while an investigation took place. Since then, one has resigned, two have been terminated and one has returned to work.

 We reported these privacy breaches to the CA Department of Health and to Ms. Spalding’s family.

 There was an additional privacy violation by a member of the Sheriff’s Department staff at SFGH, who spoke on a recorded phone line about Ms. Spalding on the day she was found. Out of respect for Ms. Spalding’s family, we must clarify that the information given was not true. Even so, it still violated her privacy. We apologize for any additional hardship this may cause. That employee no longer works at SFGH or at any Department of Public Health site.

 Ongoing independent review of SFGH security systems by UCSF continues. It includes:
 o Evaluation of SFGH security system controls (e.g. cameras, alarms, panic buttons, exits).
 o Review of policies and procedures related to patient, staff and visitor safety and security.
 o Evaluation of SFGH campus security resources (staffing model, hours of service, post and patrol areas, job duties, training and job classifications assigned).

 What happened to Ms. Spalding was horrible and never should have happened. We have worked diligently to fact find, cooperated with multiple investigations and developed a plan to become a safer, more secure organization. This is not simply about passing inspection. It is about the memory of Lynne Spalding Ford, our patient, and the tragedy that occurred on our campus.

 We want everyone in San Francisco to be assured that we take this very seriously and have taken significant steps to improve. Patient safety is our top priority.

 With the support of Mayor Ed Lee, Director of Health Barbara Garcia and Sheriff Ross Mirkarimi, SFGH is a stronger organization. As the city’s only trauma center and care provider for more than 100,000 patients and their families each year, we want all our patients to have full confidence that in addition to excellent care, we will also provide a safe and secure environment.

 San Francisco General Hospital and Trauma Center (SFGH)
 San Francisco General Hospital and Trauma Center is the sole provider of trauma and psychiatric emergency services for the City and County of San Francisco. A comprehensive medical center, SFGH serves some 100,000 patients per year and provides 20 percent of the city’s inpatient care. In 2011, SFGH became the first hospital in the country to be certified for a Traumatic Brain Injury program. As San Francisco’s public hospital, SFGH’s mission is to provide quality health care and trauma services with compassion and respect to patients that include the city’s most vulnerable. General Hospital is also one of the nation’s top academic medical centers, partnering with the University of California, San Francisco School of Medicine on clinical training and research.
 

[Sister]

Well as David Parry wrote, we shall wait and see.
Only time will tell if lessons have been learned  -- regrettable they are learned by death.
 

[grace-land]

Well as David Parry wrote, we shall wait and see.
Only time will tell if lessons have been learned  -- regrettable they are learned by death.
 

Agree. 

[grace-land]

http://www.sunderlandecho.com/news/local/all-news/brother-demands-investigation-after-twin-found-dead-in-locked-hospital-stairwell-1-6398173

Brother demands investigation after twin found dead in locked hospital stairwell
Published on the 27  January 2014 06:00

THE twin brother of a woman found dead in a US hospital today called for an independent investigation into the circumstances surrounding her death.

Bill Spalding, from Easington Lane, says he wants an independent inquiry carried out as to how the body of his sister Lynne, 57, was found more than two and a half weeks after going missing.
 
Health inspectors have now carried out an investigation into patient safety, privacy and security at the hospital and claim a number of improvements have been made.

“We have made significant progress toward a safer and more secure hospital,” said a statement.

“We can assure Ms Spalding’s family, and all our patients, visitors and staff, that we are a safer organisation today.

“Her family is in the forefront of our minds as we continue to work to improve safety and security for all our patients.”

But grieving Bill, a carer, said the statement does not begin to satisfy his or the rest of Lynne’s family’s search for answers.

“This is just putting a gloss on the total disregard for the norms of procedure that any hospital in the first world should have,” he said.

“I think it’s about time there was an independent investigation carried out by people who don’t have a vested interest in the hospital.

“We were told that Lynne was found in a ‘remote stairwell’, but it was actually just feet away from her hospital bed, so that doesn’t add up.”
 
 

[Sister]

I don't blame the family one little bit!
 

[grace-land]

I don't blame the family one little bit!
 

I don't blame the family either.  Both the hospital and the Sheriff Department failed to provide her the care and safety that Lynne needed.  imo

[grace-land]

Finally, the truth is coming out.   

Two-page article

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

S.F. General, Sheriff's Dept. blamed in Lynne Spalding death
Updated 8:04 pm, Saturday, February 1, 2014

San Francisco General Hospital nurses failed to act on a doctor's order that Lynne Spalding be watched around the clock before she walked away from her room last fall, and at least one sheriff's deputy who was told to search the hospital stairwells said he understood it to be something he could do if he had "free time," according to a federal agency's investigation into her death.

Both the hospital and the Sheriff's Department share in the blame for the death of Spalding, whose body was found in a stairwell more than two weeks after she vanished from her room Sept. 21, investigators concluded. The stairwell where she was found was never searched before a worker stumbled onto her body during a routine check.

No emergency plan

The probe was conducted by state health inspectors on behalf of the Centers for Medicare and Medicaid Services - the federal agency that decides whether hospitals meet minimum standards to be eligible for Medicare payments - and involved interviews of dozens of hospital staffers and sheriff's deputies. The report has not been publicly released but was obtained by The Chronicle.

It found "systemic" failures at the hospital and said officials there never worked out an emergency plan with the Sheriff's Department. That created the risk of a "chaotic and poorly coordinated" response such as the one that led to Spalding's death, the report said.
 
'Nobody did anything right'

Spalding had been dead for several days by the time she was finally found Oct. 8, an autopsy concluded. The San Francisco medical examiner could not say exactly when she died.

"Nobody did anything right - that is exactly what happened here," said Harris, the Spalding family's attorney. "That is why we have a dead woman and a grieving family that will never understand how they lost their mother."