Adrianna Roome was watering flowers in a community garden near her home when she noticed a man lying motionless, clutching a suitcase filled with his belongings.

The body of 30-year-old Greg Spruell lay stiff in the wooded hideout leading to Coit Tower, a popular San Francisco tourist destination and home to the city’s famous wild parrots. His bare feet were swollen and covered in scabs. A pipe he had used to smoke fentanyl and methamphetamine lay beside him. 

Roome alerted neighbors, some of whom fled in horror, before spending hours with the body while authorities investigated, she said. It’s not uncommon to see homeless people use the garden for shelter, she explained, but the discovery of Spruell’s body three years ago haunts her to this day.

“He was just so alone,” she said. “He had nobody.” 

While the overdose crisis isn’t unique to San Francisco, the city’s density and unaffordability create a stage for this misery that is distinctly horrifying.

Empty office towers and luxury condos cast long shadows over bodies sprawled on sidewalks downtown. The pastel hues of the city’s houses glow behind the silhouettes of tents and RVs. Parks, buses, restaurants, bars, grocery stores, and historic landmarks have become grave sites.

New data from the chief medical examiner’s office, analyzed by The Standard, show that at least 730 people fatally overdosed in public places over the past four years, accounting for 26% of the city’s drug deaths during that period. 

Some bodies went unnoticed for days or weeks, tucked away in alleys, inside tents, vehicles, or under freeways. Others who died struggled publicly, foam and blood bubbling at their lips, as bystanders tried to revive them or call paramedics. 

Many were discovered by more than one person, making it likely that hundreds, possibly more than 1,000 San Franciscans, have encountered overdose deaths on the city’s streets in the past four years.

In the wake of this unprecedented loss of life — more than 3,000 drug fatalities since January 2020, enough to fill all the event space at City Hall — some say they’ve become desensitized to finding death on their doorsteps. Others say they’ll be forever haunted by memories of the strangers whom they watched die, mortified by their inability to save them.

In Spruell’s case, the city was unable to locate living relatives. A funeral home in Colma spread his ashes in the bay, and Roome said she arranged candles where he died. Another neighbor planted flowers near where his body was found.

The Standard analyzed death reports for 700 people who fatally overdosed in public between Jan. 1, 2020, and Dec. 31, 2023. When we initially requested these documents, the city’s chief medical examiner’s office attempted to charge its usual price of $49 per report, meaning the full data set would have cost more than $35,000.

After an attorney representing The Standard argued that this was a violation of public record laws, the agency agreed to change its policy to charge just 10 cents per page — the price of printer ink and paper.

The data reveal the extent to which San Francisco’s public overdose crisis is also a mental health crisis. The reports — which pull information from family members and medical records — indicate that at least 22% of public overdose victims had been diagnosed with severe mental illness, such as schizophrenia, PTSD, depression, or bipolar disorder, according to The Standard’s analysis. Roughly 68% of the victims were homeless. 

As many as 26 bodies were found on trains and buses or inside train stations and at bus stops. Among them was James Isham, a 44-year-old homeless man who fatally overdosed while riding the 6 bus through the Haight in February 2023. Passengers screamed as the driver pulled over and someone attempted to resuscitate him. 

“Stop the bus,” a passenger yelled, according to the death report. “This guy is overdosing, he’s turning blue.”

Isham grew up a devout Christian in St. Lucie, Fla., and once had aspirations of becoming a preacher, according to an aunt, who asked not to be named. She said it’s unclear what led her nephew to do drugs or move to San Francisco, and he hadn’t been diagnosed with mental illness.

“When I found out, it pierced my heart,” she said. “When I used to take him to church, he used to always sit in the front because he wanted to listen.” 

When he died, his only possessions were a broken glass pipe and an ID tag from the city’s jail.

At least a dozen bodies were discovered in city parks over the four-year span. In September 2020, a Golden Gate Park hiker found the body of Andrew Houston, who died from a fentanyl and methamphetamine overdose, in a ramshackle tent made of tree branches near the Bercut Equitation Field.

Houston’s mother, Bennie Williams, said she tried repeatedly to have him diagnosed with mental illness from the time he was 11. She believed he eventually developed schizophrenia, but no doctor would offer a treatment plan, and his schools turned a blind eye. 

“There’s a great fear of them diagnosing it,” Williams said. “But you know how positive it could’ve been if he was diagnosed? He could’ve got services.”

Houston’s mental health deteriorated over several months in 2020, when he was 28, his brother Eugene Houston said. He barricaded himself in his room, believed people were spying on him, and got into fights with neighbors, which led to the family’s eviction. 

During this time, he was admitted and released from a psychiatric hospital in Oakland on several occasions, Eugene said, but never received a diagnosis. Experts who spoke to The Standard speculated that his symptoms fell into a gray area between mental illness and drug addiction, leaving him inadequately treated for either.

“They just threw him back to the wolves,” Eugene said. “There’s no way, with the things he was doing, he should’ve been back in public to just do the same thing.”

The hiker who found Andrew’s body was gone by the time the investigator arrived. 

To meet the magnitude of the epidemic in San Francisco, the Department of Public Health says it has trained every city employee on how to reverse an overdose. That’s every street sweeper, cop, firefighter, and librarian. Still, the city admits that is not enough to meet the fatal demands of the crisis, forcing bystanders who happen to be in the right place, at the right time, armed with the overdose reversal drug Narcan, to become heroes. 

The department said that in the last two years, it has more than doubled the number of specialists working with homeless people who suffer from addiction, counting more than 23,000 interactions with people in crisis. Street teams connected homeless people to services more than 1,100 times in the year following March 2023, including more than 130 connections to addiction treatment. In the spring, the city launched a nighttime outreach program, which connected more than 50 people to medically assisted drug treatment in its first four weeks.

The department’s annual budget for behavioral health services is $687.7 million, according to a January 2024 ledger.

But even experts who’ve made a career in mental health say they have trouble navigating the systems in place to help people. Local treatment programs lack coordination, they say, and hospitals aren’t equipped to discharge mentally ill patients into further treatment.

In September 2021, a city gardener found the body of 22-year-old Anthony Hearne in a grass field near JFK Drive, clutching a rolled-up dollar bill coated in pink fentanyl powder. He was released from a psychiatric hold at San Francisco General Hospital just two days prior, his mother, Deborah Hearne, told The Standard.

“The hospitals are all about discharging, not setting you up for more care,” Hearne said. “There’s not enough resources, and you don’t know where to go to find resources. It’s like finding your way in the dark.”

Mayor London Breed has repeatedly called for changes to local, state, and federal laws to allow the city to more forcibly compel people into long-term treatment. She’s joined by a growing chorus of residents and lawmakers who argue that allowing people to suffer on the streets is more cruel than forcing them into mental health facilities or jail. 

However, there remains a shortage of treatment beds across the city and the state, particularly for people suffering from both addiction and mental illness. 

Some experts and local politicians have lobbied the state to allow facilities where people can use drugs under the supervision of staff trained to reverse overdoses. They argue that forced treatment is ineffective for large swaths of people, and without controlled spaces to use drugs, those with addiction are bound to die while being persecuted for their illness.

The city tried opening one such site at the end of 2021, the Tenderloin Center. It closed after 11 months. 

In the Tenderloin and SoMa neighborhoods, which account for the largest share of the city’s public overdoses, many residents say they’ve grown numb to the horrors they witness. They’re faced daily with the choice of looking away or bearing the responsibility for someone’s life. 

Kate Robinson, executive director of the Tenderloin Community Benefit District, said residents of the neighborhood suffer from a condition she calls “ever-present stress disorder” due to the constant trauma. 

Robinson said she’s seen two people die from overdoses in her walks around the neighborhood, and most people on her staff have witnessed at least one.

“You go from one second experiencing something very, very traumatic,” Robinson said, “and then you have to continue on your day.”

In November 2020, Steve Trexler watched from his Tenderloin apartment window as a suspected drug dealer made a sale before walking away as the user crumpled and died, the victim’s death report states. 

In February 2021, roughly 15 people surrounded a 39-year-old woman as she fatally overdosed on cocaine near the corner of Turk and Hyde streets.

In October 2020, below a SoMa apartment building on Minna Street, a man burned alive while he fatally overdosed just after 4 a.m. A passerby lingered just long enough to flag down police officers before leaving the scene, the death report states.

“It’s just normal,” said Alfredo Oliver Vega, an immigrant from Peru who’s raising a 5-year-old daughter in the heart of the Tenderloin. “I go to my job, and I go home. I don’t want to worry about it.” 

The toll of public deaths would be higher if not for the efforts of normal people who have saved countless lives with Narcan or quick thinking. A mall security guard, a gardener, or a public bathroom attendant with an hourly wage of $18.07 is often the city’s last line of defense against this deadly epidemic. 

“Bystanders are often the most effective responders during a medical emergency, like an overdose, because seconds and minutes are the difference between life or death,” the Public Health Department said in an emailed statement. “Despite the stigma around drug use, people who use drugs have lives worth saving just as someone with diabetes or a heart condition.”

The city distributed more than 423,000 doses of Narcan since January 2020. But at times, bystanders weren’t carrying the medication — or they acted too late. 

At Chava’s Mexican Restaurant in the Mission, owner Marcello Rodriguez watched a longtime customer, Rafael Cruz, die from a fentanyl overdose while eating lunch in August 2023. 

Rodriguez said the 911 operator instructed him to perform CPR, but he was untrained. He pounded on Cruz’s chest as his face turned purple and green.

“They were telling me on the phone, ‘Do this, do that.’ But I don’t have any experience,” Rodriguez said. “I tried my best, but I couldn’t do anything.” 

Cruz remained on life support at San Francisco General Hospital for five days before dying, his death report states. Rodriguez said he now keeps Narcan in the restaurant’s medicine cabinet. 

“He was always the No. 1 customer, waiting for us to open the door,” Jovan Irigoan, a server at Chava’s, said of Cruz. “We appreciated him so much.” 

Roughly three years after her son John Fuller was found dead near the entrance of Alamo Square Park, Patty Fuller struggles to recall memories of his life. She fought back tears this summer as she thumbed through childhood photos at the Mexican restaurant in San Diego where his funeral was held.

She remembered how his friends adored him, how he nailed the lead role in his elementary school play, and how he aced his SATs. But other aspects of his life, and his tragic demise, live in a fog of unprocessed trauma, she said. 

“I was most proud of him just because of his personality,” she said. “He was loads of fun until addiction hit.”

Fuller was 14 when he started using drugs, she recalled. He joined the army at 19 in an attempt to get his life on track but returned home with PTSD after stints as a drone pilot in Iraq and Afghanistan.

“He killed so many people,” she said. “He couldn’t live with what he had done.”

Despite her best efforts, Fuller fell into homelessness, and the two eventually lost contact. Like other parents The Standard spoke to for this report, Patty said the options for her sick son were unclear, and she was mostly alone in trying to help him.

“He was hanging around homeless and a mess here for a while, and then he disappeared,” she said. “I couldn’t ever figure out why he ended up in San Francisco. It wasn’t like he had anybody there.” 

Liz Breuilly, a volunteer detective who locates missing people, said she repeatedly encountered Fuller living in Golden Gate Park. She could tell he was intelligent but was unaware that anyone was looking for him, she said, in part because SFPD has declined to release its full list of missing persons.  

“He was very, very, very smart,” Breuilly said. “But he was also delusional. There were times he was very sick, with psychosis. But he was never dangerous.” 

When Fuller died of a methamphetamine overdose in an Alamo Square bush in September 2021, the smell of his corpse lingered for several days before someone built up the courage to investigate. 

Flies swarmed and dogs yanked on their leashes to sniff as park-goers unknowingly walked past his body.

John Dallas, who lives across the street from the park, said neighbors knew from the smell that something had died. But for days, nobody did anything about it. 

“You’re walking the dog in the middle of a work day,” Dallas said. “You don’t really want to find a dead body.”