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It was revealed during a hearing Wednesday that the scope of the Laguna Honda Hospital patient abuse scandal has grown significantly since the stunning news was announced in June.

It was first reported that 23 patients had been victimized by six staff members, but the investigation has since uncovered a total of 130 incidents. Brent Andrew, Zuckerberg San Francisco General Hospital chief communications officer, said in an email that the incidents did not involve “many more patients” than what was originally reported, but he did not specify how many.

The six staff members are accused of photographing and recording victims while naked, sharing the images and videos with each other through text message and administering drugs as a method of restraint.

Public health officials Wednesday updated the San Francisco Board of Supervisors Government and Audits Committee on the investigation status and corrective measures being implemented at the facility.

Daderot/Wikimedia A patient abuse scandal at Laguna Honda Hospital in San Francisco, Calif. was announced June 2019. The investigation found six former staff members abused a total of 130 patients.

Officials said all six have since been fired and are prohibited from working for The City in any capacity. Troy Williams, Zuckerberg San Francisco General Hospital chief quality manager, said steps are being taken to guarantee they never again work in the health care industry.

Williams was brought in to assist the investigation and provide corrective guidance to ensure future patient safety. Laguna Honda Hospital CEO Mivic Hiros stepped down when the scandal was made public.

The hospital was initially fined $780,000, but the state is expected to tack on more in light of the additional cases discovered.

The City is exploring criminal charges against the former staff members is working with the San Francisco Police Department to conduct an investigation, Williams said.

The investigation was triggered in February when another Laguna Honda employee filed an internal complaint, prompting the City Attorney’s Office to get involved.

Following the June announcement, Williams said further forensic analysis of the former staff members’ cell phones revealed additional photos and recordings that reflected “physical, sexual and psychological abuse.” However, he said a majority of images were privacy breaches, such as patients captured in backgrounds.

The hospital sent the California Public Health Department newly discovered photos and recordings on a “rolling basis” until about mid-August, Williams said.

Williams noted that the nude photos and videos, and sharing of the images, was the extent of sexual abuse that took place at the hospital. They have not found evidence of further sexual assault.

Scott RIchard/Flickr A patient abuse scandal at Laguna Honda Hospital in San Francisco, Calif. was announced June 2019. The investigation found six former staff members abused a total of 130 patients.

Williams told supervisors that the hospital’s employee culture contributed to the scandal and its concealment.

Williams said:

“One of the things that we’ve learned as a part of our investigation is there was a culture of silence. These things were able to go on undetected for years. What we’ve learned is that people were afraid to report.”

The staff’s use of pharmaceuticals to restrain patients was another important issued raised at Wednesday’s meeting. Williams said the hospital is establishing regular medication audits designed to monitor what staff administers and identify trends.

A protocol is already in place that calls for a urine toxicology sample if a patient demonstrates behavioral changes or altered mental state.

The hospital quickly enacted several corrective actions in order to remain in compliance with the state. Margaret Rykowski, Laguna Honda acting chief executive officer, said the facility was certified in compliance Oct. 15.

Board President Norman Yee said at the hearing that transparency was necessary to assure the public that The City is acting to protect patients from abuse going forward.

Yee said:

“The public needs to know exactly what the hospital has done to turn itself around and to ensure that patients are receiving the highest quality of care without any risk of exploitation or abuse.”

He added:

“We cannot ask our residents to entrust the care of our loved ones to any entity that cannot prove that they have an effective system that guarantees the safety and well-being of any patient.”

There are two pending abuse-related claims against The City, according to Williams. The City Attorney’s Office has to yet to elaborate with details of those claims.


CORRECTION: A previous version of this article stated that 130 cases had been discovered in the course of the investigation, as cited by Tony Williams. Brent Andrew, Zuckerberg San Francisco General Hospital chief communications officer, since reached out to clarify that there have been 130 incidents that did not involve “many more” than the original 23 patients reported. He did not provide the exact number of impacted patients.

Jerold Chinn
Jerold Chinn covers transportation and City Hall in San Francisco for SF Bay. Email: jerold@sfbay.ca. Twitter: @Jerold_Chinn. Instagram: jeroldwashere.

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