The investigation concluded that five prison guards pinned down, kicked and stomped a handcuffed inmate so violently that one nearby onlooker wept, closed her eyes and began to pray.
A second woman watched the officers beat the handcuffed African American male, according to a heavily redacted judicial narrative obtained by The Bee, and said it reminded her of the infamous Rodney King incident.
The crying woman didn't respond, but a third observer agreed: "They're kicking the s--- out of him," she said.
But a judge said there was no beating on that June morning two years ago at Susanville's High Desert State Prison.
The state board that referees contested terminations earlier this year agreed and ordered reinstatement for the five officers. The back pay, benefits and interest will come to about $1 million, their union estimates.
Now the California Correctional Peace Officers Association wants the investigators investigated.
Last month, the union asked the State Personnel Board to consider action against the three internal affairs employees who handled the case. The investigators' names, like the names of all involved in the matter, are not public record.
Union leaders have multiple questions:
Why were eyewitnesses the judge referred to as "the Three Women" at the heart of the investigation allowed to commiserate over what they saw? Why did investigators ignore physical evidence exonerating the officers? Why didn't they talk to eyewitnesses or consider some accounts including statements from the prisoner himself saying there was no beating?
The case highlights what the union claims is regularly slipshod work by the department's internal investigative unit and those overseeing it.
"This isn't an isolated case of a botched investigation," said Chuck Alexander, the union's executive vice president. "But this one is particularly egregious, and no one's been held accountable for it."
A Department of Corrections and Rehabilitation spokeswoman defended the investigation and declined to comment on the union's request to file charges against the investigators.
"We are now considering our options for further appeal," spokeswoman Deborah Hoffman said.
The 33-page decision by Teri Block, an administrative law judge who hears termination-dispute cases for the State Personnel Board, includes a rare glimpse into how the state investigates cases of inmate abuse. Her narrative is built on investigative records and testimony from a hearing conducted last fall:
On the morning of June 29, 2011, two officers were walking the inmate for a doctor-ordered psychiatric evaluation after the man threatened to harm prison staff members and himself.
The inmate, who weighed 120 pounds and stood 5-foot-7, was handcuffed behind his back with a guard on each arm. As they approached a secured area for vehicle transports, the inmate pulled his left arm away and turned toward one of the officers, who immediately shouted, "Get down!"
Those two words triggered a "Code 1" alarm. Within seconds, other correctional officers, managers and medical staff members ran to assist, the court narrative said.
The escorting officers took the inmate to the ground, face down, in keeping with their training.
One "placed his arm on the (inmate's) neck and shoulder area, and maintained control of the inmate's arm," according to Block's description of events. The other pinned down the inmate's legs and feet with both hands.
Two other officers arrived about 10 seconds after the Code 1. One "placed his knee swiftly and firmly on the right side of the inmate's mid-back," according to the court narrative, and the other did the same on the inmate's left side, "consistent with CDCR use-of-physical-force training."
The fifth officer arrived and stood near the left torso of the inmate, who briefly struggled. But with four officers restraining him, he gave up. He complained that he couldn't breathe, according to the court record, so two officers adjusted their positions to give him relief.
Within 90 seconds, 15 to 20 medical staff members, correctional officers, a lieutenant and a captain were there. An officer fetched leg restraints.
About five minutes after the Code 1 alarm, officers pulled the inmate to his feet, still in handcuffs and his legs now in restraints.
"(The) inmate was upbeat and laughing at the time, commenting, 'It takes all you guys to hold me down,' or words to that effect," Block wrote in her summary of eyewitness accounts.
Four physical examinations of the inmate over the next seven hours revealed minor abrasions and nothing more. Photos taken that day and the next showed no signs of injuries where the three women said he was kicked.
The inmate said the next day in his written account that the guards had pulled out one of his dreadlocks and threatened "to break my neck on the spot."
In an interview with prison staff members he said he suffered injuries from being slammed to the ground and pinned, but "it didn't feel like striking at all," he said. "It was pain, though. I couldn't breathe."
In April 2012, the prison system's internal affairs office launched a probe and filed a report the following month. The Department of Corrections fired the five officers on June 6.
Block noted that investigators made nine factual errors in the report, failed to interview some witnesses and didn't separate the three women after the incident to get their individual accounts.
During the hearing, the guards presented a renowned expert in eyewitness testimony, psychologist Elizabeth Loftus. She suggested that the women honestly believed they saw a violent beating, but that their memories probably were contaminated.
The stress of the moment, one woman's comment about the Rodney King affair and the epithet-laced affirmation of another likely cemented visions of an infamous scene: officers beating a black man while others stood by, Loftus testified.
Then the women talked among themselves about the incident several times that day, including at lunch and during a group interview, where they filled in the details for one another.
Loftus said "there is a strong likelihood that the witnesses did not and could not provide independent recollections because they had irreparably influenced one another's memories," Block wrote. She determined that they were not credible witnesses.
The State Personnel Board affirmed Block's conclusion that the department had wrongly terminated the guards: "In this case CDCR fell short on the investigation of the matter."
Hoffman, the corrections spokeswoman, said in an email that the department "strictly followed the policies and procedures in place for such an investigation. This case was closely monitored, reviewed and approved by the state Office of the Inspector General, an outside, independent oversight agency."
Inspector General Bob Barton said he couldn't comment on the High Desert case.
His office does monitor and review corrections internal investigations, but it doesn't have the power to tell the corrections agency to proceed or drop cases.
"They're free to ignore us," Barton said, "and they have on many occasions."