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Questions surround state agency in wake of autistic man's death

February 24, 2012 12:00:00 AM PST
Hundreds of thousands of Americans suffer from developmental disabilities like cerebral palsy and mental retardation. In California, some of the most severely disabled are cared for at several state-run facilities with around-the-clock supervision.

But while the state spends about $300,000 a year on each patient, an investigation by Eyewitness News media partner California Watch has uncovered a pattern of abuse and neglect at the centers and a failure to hold staff and administrators accountable.

When he was a child, Van Ingraham was diagnosed with mental retardation and severe autism. As he grew older, his family found they could not cope with his disabilities. His older brother Larry recalls their dilemma.

"It became very clear that he was not going to be able to ever talk or function on his own, in society," said Larry Ingraham.

The Ingrahams turned to Fairview Developmental Center in Orange County. It's one of five state-run institutions in California for those with severe developmental disabilities, serving roughly 2,000 patients who need full-time supervision and care.

"We would go up and visit and Van seemed happy there," said Larry.

But one day in 2007, Larry Ingraham, a retired police officer, got a call that his brother Van had been rushed to the hospital.

"He was in ICU, intensive care, Hoag Memorial Hospital," said Larry. "I've seen a lot of bad sights in my life, but this is one of the worst."

The staff at Fairview Developmental Center said Van had simply fallen out of bed. But a neurosurgeon at the hospital said Van's injury was no accident.

"They said either your brother was bodysurfing at The Wedge in Huntington Beach and had a severe impact into the sand with a large wave, or somebody did this to your brother," said Larry.

Van Ingraham died as result of his injuries.

If Van had been an ordinary citizen, his death would likely have been investigated by local police. But California's developmental centers have their own in-house police force, hired by the same administrators who run the centers. In Van's case, those in-house police waited five days before interviewing potential suspects.

"We had found out by then that there was no crime scene investigation at the time of the incident," said Larry. "We found out that no evidence was collected."

No one was ever charged in Van's case.

The director of the Department of Developmental Services, Terri Delgadillo, said she could not comment on individual cases because of patient privacy laws, but said that all incidents were taken seriously.

"We keep track of every allegation that is made," said Delgadillo. "We then investigate it internally, and we track everything that happens, and we're always looking for opportunities to improve."

Yet during a recent three-year period, there were more than 250 confirmed abuse cases and over 600 other unexplained injuries, among the system's roughly 2,000 patients. Rarely has violence against the patients led to arrest or prosecution.

"That means that we didn't really find out what really happened," said state Assemblyman Jim Beall (D-San Jose) "That disturbs me."

Beall is chair of the Human Services Committee. He says injuries of unknown origin should be further investigated.

"As a parent of somebody that's developmentally disabled and as a legislator, it is cause for alarm," said Beall. "I want to know if those investigations were completed properly."

Director Delgadillo says her department is working to improve the quality of its police force.

"We will be retraining every one of our staff to make sure that indeed they are providing the highest level of service," said Delgadillo.

The problem appears to go beyond just shoddy police work. Dr. Van Pena was a doctor at Sonoma Developmental Center for 10 years.

"Every shift I had, there were injuries," said Dr. Pena.

Pena said he would document patient injuries by placing photographs in the medical records. But someone else, he says, would remove the photos.

"I would go to see the patient perhaps at another time, and lo and behold, the area where the photograph was placed would be cut out, nice sharp edges such as one would do with a scissors," said Pena.

When he complained, Pena says he was asked outright by administrators to stop taking photos.

"I believe that the administration wished to cover up the reality of these often graphic and severe injuries to patients under their care," said Pena.

Pena was fired, he says, for refusing to cooperate. The U.S. 9th Circuit Court of Appeals found evidence to support Pena's allegations and a wrongful termination suit is pending.

The state of California paid $800,000 to the family of Van Ingraham to settle a civil suit. But the case remains unsolved.

"I look at his picture and you know, it was wrong for him to die like that," said Larry Ingraham.

Read more California investigative reports at CaliforniaWatch.com.