California has assembled a unique police force to protect about 1,800 of its most vulnerable patients men and women with cerebral palsy, severe autism and other mental disabilities who live in state institutions and require round-the-clock monitoring and protection from abuse.
But an investigation by California Watch has found that detectives and patrol officers at the state's five board-and-care institutions routinely fail to conduct basic police work even when patients die under mysterious circumstances.
Most abuse cases simply are logged but never prosecuted, including the suspicious death of a severely autistic man whose neck was broken. Three medical experts said the 50-year-old patient, Van Ingraham, likely had been killed. But the center's detective, a former nurse who had never investigated a suspicious death, failed to identify what or who had caused the fatal injury.
The police force, called the Office of Protective Services, often learns about potential criminal abuse hours or days after the fact if officers find out at all. Of the hundreds of abuse cases reported at the centers since 2006, California Watch could find just two cases where the department made an arrest.
The people officers are sworn to protect have profound developmental disabilities and live in a different world from most Californians. Some patients have spent decades in the centers, from childhood to death. Some cannot form words and have IQ scores in the single digits.
Federal audits and investigations by disability-rights groups, as well as hundreds of pages of case files and other data reviewed by California Watch, show staff members allegedly involved in choking, shoving, hitting and sexually assaulting patients at the facilities. None of these cases was prosecuted.
California is budgeted to spend $577 million this fiscal year to operate the centers, or roughly $320,000 per patient. More than 5,200 people work in the institutions roughly 2.5 staff members for each patient. The five centers are in Los Angeles, Orange, Riverside, Sonoma and Tulare counties.
In most other states, local law enforcement or state police take the lead in conducting criminal investigations at developmental centers.
Critics of the state Department of Developmental Services, which oversees the institutions and the Office of Protective Services, have said the tight-knit atmosphere between police and staff makes it difficult to create a separation between the investigators and the investigated.
In a few cases, caregivers and others with minimal police training have been hired to work as law enforcement in the same facility. The commander at the Lanterman Developmental Center in Pomona worked there as a primary caregiver. The force's police chief is a former firefighter at the Sonoma Developmental Center.
The police force also suffers from a convoluted chain of command, interviews and records show. Detectives cannot make arrests without checking with department lawyers in Sacramento. Local police must be informed when serious injuries or deaths occur, leaving law enforcement agencies pointing the finger of responsibility at each other.
"It seems like something is not working in California. And that's probably a major understatement," said Tamie Hopp, an official with the national organization Voice of the Retarded, who noted the volume of abuse cases in California, and the lack of prosecutions, is cause for alarm.
Over the past eight months, California Watch has provided state officials with the findings of its investigation, including inspection records, activity logs, interviews with family members, case files and data on suspected abuse cases.
Terri Delgadillo, director of the Department of Developmental Services, said her department has a zero-tolerance policy that includes reporting any injuries, even those remotely suspicious, to the state Department of Public Health. She said the department is committed to conducting thorough investigations.
Delgadillo nevertheless has asked an outside consulting group, the Consortium on Innovative Practices based in Alabama, to review the methods and training of her police force. The nonprofit group was recommended by the U.S. Department of Justice, which issued a scathing critique of the department in 2006.
"For the department, the priority is to make sure that we're doing the best job providing consumer safety and services," Delgadillo said. "And if there are issues that need to be addressed and there's always room for improvement we're looking to do that."
The department said that from January 2008 to last month, 67 developmental center employees were fired for "client-related" offenses. But officials declined to say how many of those, if any, were dismissed for abusing patients, where they worked or if any of them had been arrested.
Delgadillo also declined to comment on specific cases of alleged abuse or mistreatment at the centers, citing patient privacy laws.
Corey Smith, the former firefighter who is now police chief, said he was not permitted to speak with reporters.
Injuries could be crimes
The developmental centers have been the scene of 327 patient abuse cases since 2006, according to inspection data from the California Department of Public Health. Patients have suffered an additional 762 injuries of "unknown origin" often a signal of abuse that under state policy should be investigated as a potential crime.
At the state's five centers, the list of unexplained injuries includes patients who suffered deep cuts on the head; a fractured pelvis; a broken jaw; busted ribs, shins and wrists; bruises and tears to male genitalia; and burns on the skin the size and shape of a cigarette butt.
Delays by the Office of Protective Services often make investigations harder, if not impossible, to solve. California Watch was able to identify at least a dozen incidents in which delays from 24 hours to several days occurred.
In one case from 2005, Timothy Lazzini, a 25-year-old quadriplegic patient with cerebral palsy, coughed up a bloody glycerin swab at the Sonoma Developmental Center. He died from internal bleeding that night, Oct. 22.
Three swabs each 4 inches long and twice as thick as a Q-tip had torn Lazzini's esophagus. He coughed out one, but two others remained lodged in his stomach, autopsy records show.
At that point in his life, Lazzini's disabilities had left him mostly paralyzed, and he received food through a tube in his abdomen. Someone at the developmental center likely put the swabs inside his mouth before he died. Dr. Ken Christensen, Lazzini's doctor, told Office of Protective Services investigators that it was possible for Lazzini to swallow the swabs, but "it is unlikely for him to be able to pick it up and put it into his mouth." The pathologist who performed Lazzini's autopsy noted the same thing.
The Office of Protective Services assigned the case to a detective more than 24 hours after a caregiver discovered Lazzini bleeding from the mouth, the police file shows. By then, if any evidence had been available at the scene, it was gone.
"I noted the area was cleaned up," Rod Beck, the detective, wrote in his report. "I did not note G-swabs in the bedroom area and none were seen in the drawers of his dresser."
Lazzini's death, and the slow response by the Office of Protective Services, has left his family heartbroken and without a conclusive answer as to how he was killed.
"He is gone and they really haven't given us as a family the information that we need to be at peace," said Stephanie Contreras, Lazzini's sister.
In the case of the 50-year-old autistic man, Van Ingraham, his family received $800,000 in a settlement with the state, but no arrests were ever made. Ingraham died after sustaining a broken neck while in his room at the Fairview Developmental Center in Orange County.
Fairview officers didn't collect physical evidence from Ingraham's room, records show. Detectives overlooked evidence that a caregiver last seen with Ingraham had altered the log of his activities. And they omitted from the case file an expert's opinion that Ingraham's death "was likely a homicide" one of two medical experts who said Ingraham likely had been put in a headlock.
"This incompetent, horrendous organization called Office of Protective Services takes it and just makes a mess, just a complete mangled mess of the investigation," said Larry Ingraham, the patient's older brother by six years and a veteran of the San Diego Police Department.
Chicago police homicide Detective Mark Czworniak, who reviewed the Ingraham case for California Watch, said the Office of Protective Services waited too long to collect evidence and interview witnesses, and he questioned why they omitted the biomechanical expert's opinion that Ingraham was killed.
"Personally, I think it's better to include as much information as possible when constructing a final report, than to pick and choose what goes in," he said.
"This is because of exactly what happened down the road with this investigation. Someone started reviewing it and now, because information was excluded, it has an appearance that things were being covered up."
The Ingraham case remains unsolved.
Assaults not prosecuted
Sex abuse cases, too, have been shelved without prosecution.
In April 2010, at the Canyon Springs Developmental Center in Riverside County, a janitor twice sexually abused a mentally disabled female patient when caregivers were out of sight. Under California law, having sex with any developmentally disabled person who is incapable of giving consent is considered rape.
The patient, who is not identified in state records, had a history of being assaulted. She was institutionalized at age 12 after her father impregnated her, a state health department citation shows.
The patient had been diagnosed with moderate mental retardation, schizoaffective disorder and post-traumatic stress disorder. Canyon Springs staff had been working with her to curb any behavior "possibly leading to sexual activity," her file states.
The female patient, then 39, told center employees she "did it" with the janitor in the women's bathroom and in a hallway during a fire drill. An unidentified Canyon Springs employee notified the state Department of Public Health.
The Office of Protective Services investigated but made no arrests. State regulators also investigated and ruled the incidents as sexual abuse, according to a citation issued to Canyon Springs.
In December 2010, Canyon Springs was fined $800 by public health officials for the incidents. No criminal charges followed the Riverside County District Attorney's Office said it has no record of receiving any case referrals from Canyon Springs.
Rather than placing the janitor under arrest, developmental center officials ordered him to undergo training on his "legal duty" regarding patient abuse, according to state records.
In another case with even fewer details available, a female patient at the Sonoma Developmental Center accused a male caregiver of sexually assaulting her during a bath in early 2000, police records show. The institution responded by assigning two men to bathe the patient.
On July 6, 2000, both caregivers allegedly raped her, again during bathing.
The institution did not inform its own police officers about the details of either incident. Records show Ed Contreras, then Sonoma's police commander, received an anonymous tip four days after the second alleged rape.
"They weren't following the law," Contreras said. "They weren't reporting it to the police department. They weren't reporting it to me."
Contreras said no arrests were made.
Outside of California, local or state police most often are responsible for investigating criminal cases at institutions. But city and county law enforcement agencies inside the state have not shown an interest in developmental center cases and don't have funding to expand their scope, according to Delgadillo.
"Oftentimes, local law enforcement does not want to get involved," said Delgadillo, who in the past has worked for the California Department of Corrections and Rehabilitation as a manager in the juvenile justice division.
Local police or sheriff's deputies can act more independently than an internal police force responsible for probes into their colleagues and bosses, said Jane Hudson, senior staff attorney for the National Disability Rights Network, a patient advocacy organization.
"If there's a crime committed," Hudson said, "you let the criminal investigators go in first, rather than the institution bagging the bloody shirt."