Skip to main content









Donation Heart Ribbon
Visit the Midday Edition homepage

Allegations Of Abuse Cover-Up At Calif. Centers For Developmentally Disabled

February 27, 2012 1:13 p.m.


Ryan Gabrielson covers public safety for California Watch and the Center for Investigative Reporting. Gabrielson's investigation reveals a failure to protect and serve the state’s most vulnerable residents.

Larry Ingraham is a former San Diego police officer whose brother Van died while living at Fairview Developmental Center in Orange County.

Related Story: Investigation Alleges Abuse Cover-Up At Calif. Centers For Developmentally Disabled


This is a rush transcript created by a contractor for KPBS to improve accessibility for the deaf and hard-of-hearing. Please refer to the media file as the formal record of this interview. Opinions expressed by guests during interviews reflect the guest’s individual views and do not necessarily represent those of KPBS staff, members or its sponsors.

CAVANAUGH: Reports of patient abuse of California's institutions for the severely disabled have increased dramatically in recent years. A new investigative report says practically no one is being held accountable for crimes against these vulnerable patients. And that may be due to an unusual in-house police force monitoring the facilities. That police force is called the office of protective services. My guests, Ryan Gabrielson, public safety reporter for California watch, a publication for the nonprofit center for investigative reporting.
GABRIELSON: Thanks for having me to the show.
CAVANAUGH: And Larry Ingram is I former San Diego police officer whose brother van died while living at fairview center in Orange County. Thanks for coming in.
Give us some background on the facilities that we're talking about. How many are there, and where are they located?
GABRIELSON: There are about 1,800 patients remaining at California's 5 developmental centers. And these are people with cerebral palsy, profound mental retardation, severe autism, who for the most part are found to not be able to live safely in the community.
CAVANAUGH: Now, you mentioned that there are 1,800 patients left living in these facilities. Have the number of patients in the facilities decreased in recent years?
GABRIELSON: Significantly. And they have been decreasing for the better part of 30 years. There's been a movement to deinstitutionalize people with developmental disabilities. So in many cases. At this point, we're getting down to a very small population that remains behind these walls.
CAVANAUGH: What about the incidents of abuse? Have they decreased along with the population?
GABRIELSON: No, we found the opposite. We found that reported and substantiated cases of outright patient abuse have increased even as the population dropped about 12%. And that is substantiated by the department of public health. Also, unexplained injuries have remained steady evens it is population as declined.
CAVANAUGH: What kinds of abuse are we talking about?
GABRIELSON: It runs the gamut. Some of these are fairly small injuries, but they involve hitting and shoving of patienting, choking patients, unexplained injuries that included broken jaws, ribs, and other problems, even genital lacerations.
CAVANAUGH: Your series of reports focused on the unusual police force handling the allegations of abuse. Tell us about the office of protective services.
GABRIELSON: It's an in-house police department that operates at the developmental centers for the most patient. There's 90 sworn officers. They're motional stationed at the center, so they have a few investigators at the department of public -- sorry, department of developmental services headquarters in Sacramento. The chief of the force is a former firefighter who had no police experience prior to overseeing the criminal investigations.
CAVANAUGH: And you found that that -- that thing that happens in the office of protective services, not many of the officers have actual police experience; is that right?
GABRIELSON: That's true. Most of them have just a minimal amount of training to become what's called post-certified. And to actually, peace officers and make arrests. But a huge share of the force has -- more than a third of the force has no other outside law enforcement experience, and that often includes the chief of the office of protective services.
CAVANAUGH: What is the chain of command? How do they report to?
GABRIELSON: The police report to the State Department of developmental services, which is a $4 billion a year state agency based of course out of Sacramento.
CAVANAUGH: And you spoke I believe about the office of protective services with the actual head of the department of developmental services; is that right?
GABRIELSON: That's correct. His criminal abuse investigations often stay in-house, we went to the head of the agency to find out her response to what we found, which is that very few cases which lead to anything. And here's what she said.
CAVANAUGH: We keep track of every allegation that is made. We then investigate it internally, and we track everything that happens and we're always looking for opportunities to improve.
GABRIELSON: Yeah. She is the director, says they've even hired an outside consulting firm to help upgrade the police force. And the state health and human services department has apparently engaged -- they call it the services of special investigators. We don't know who those investigators are or what they're going to be doing, but apparently something is on the other handway.
CAVANAUGH: My guest in-studio, Larry Ingram is a former San Diego police officer. And his brother, van, was living at the fairview developmental center. What happened to your brother?
INGRAM: He had his neck severely fractured, broken while in the case of this fairview developmental center.
CAVANAUGH: And how did they say that happened to your brother?
INGRAM: He -- they stated he had -- and put it in writing, he had slipped out of bed.
CAVANAUGH: Now, how did you find out that van's death, his injury, was not an accident?
INGRAM: Well, when I walked into the emergency room after it occurred, and I saw him, I knew from my experience as a police officer that there's no way he had slipped out of bed and broken his neck. And within a few hours, they -- the neurosurgeon that had performed the surgery to support my brother's broken neck and try to realign the spinal cord came in and told me that this had been done to him by somebody. He -- quote, stated either your brother was body surfing at the wedge in Huntington Beach in a large wave pushed him into the sand and snapped his neck, or somebody did this to him. And he fully believed that somebody had done this to my brother.
CAVANAUGH: Who investigated the incident at the Orange County facility?
INGRAM: At the time, it was the office of protective services. And I believe I had two homicide investigators and I later learned that one was a registered nurse, and the other has some limited reserve officer it is training as a volunteer officer, and security guard training, unarmed, and they were the quote unquote homicide investigators for my brother's homicide.
CAVANAUGH: Now, one of the things that Ryan points out in his article, and I think one of the things that you experienced in the investigation into your brother's death, Larry, is that the crime scene was not investigated properly.
INGRAM: Yes, Maureen. As a matter of fact, the crime scene was not investigated at all. There was a -- a took a few photos. There was nothing done. Literally nothing done. No forensic, no collection of everything. Nothing at all.
CAVANAUGH: I want to ask you more about that. That's one of the things that pops up again and again in the cases that you document is that there's -- the investigation is done sometimes days after the event occurred.
GABRIELSON: Yes, that's absolutely true. It was especially surprising that in at least two death cases that were suspicious in nature, not necessarily always potentially a homicide, but no matter what, they oftentimes officers would go in a day or several days later. And those delays make it impossible to collect evidence. Ten years ago, the attorney general's office commissioned a report to look at the competence of this police force, and they found that they -- that the officers didn't know how to competently process a crime scene. And that doesn't appear to have changed.
CAVANAUGH: Larry, not only the surgeon came back to you and said your brother's injury was not caused the way that the developmental center said it was caused. What did the medical examiner say about your brother's cause of death?
INGRAM: The medical examiner, doctor FUKAMOTO stated that it was in all likelihood done at the hands of another. And he -- I don't know if I'm jumping ahead, but he referred us to a doctor Theila, a biomechanical scientist who had done a study on the incident, and the scientist had concheweded that it was a homicidicide.
CAVANAUGH: A homicide. So how did the department of developmental services revolve van's case?
INGRAM: They basically cold cased it, they closed it, basically. They did not, in other words. It has in the been revolved. The individual they solidly believe as a suspect is still working with the disabled.
CAVANAUGH: Now, Ryan in your series of reports, and that series of reports is called broken shield, what other cases of unsolved death and injury did you do you want? One of the other compelling ones was the death case of Timothy thee Lazinni. He was a patient at Sonoma medical center who died of internal bleeding that was caused by large swabs that he in somehow ingested. It's very unlikely due to his disability that he put those in his mouth. By the time the investigator got to the room, it had all been cleaned up. The swabs that were found within the patient at autopsy were all gone, are the records had gone missing. And that is also unresolved. They never determined who had put what into Timothy Lazinni.
CAVANAUGH: And the reason that he couldn't put it in his own mouth is because he was basically paralyzed, right?
GABRIELSON: Basically, yeah. He could move some. And he could -- but in terms of the motor skills to take a swab and put if in his mouth, let alone three different swabs in his mouth, his doctor, and the forensic pathologist agreed that that was very, very unlikely. Somebody approximate put these in his mouth. Of
CAVANAUGH: Now, did any outside law enforcement outside of the office of protective services, were they called in on these cases?
>> On the Lazinni case, the Sonoma county sheriff's office did come in. But by then, a lot of the evidence that should have been collected by the office of protective services was gone. So there was only so much that they could do. So that basically became a cold case. An investigation that didn't go anywhere. With van's case, the Costa Mesa police department could have certainly come in and taken over but opted not to.
CAVANAUGH: Now, Larry says that he believes that the suspect in his brother's death is still working with the disabled. Has anyone been prosecuted in these cases of abuse?
GABRIELSON: We've found only 2 cases where there were arrests, but very, very few. There have been hundreds obviously of substantiated patient abuse from 2006 through 2011. And we found almost no charges ever under Penal Code 368, which is specifically the patient abuse charge. And
CAVANAUGH: Is anyone discharged? Is there any consequence of any kind?
GABRIELSON: The vast majority of these cases are sealed because they involve cases. But we found very little evident that anything ever happens. Now, the department of developmental services says it has a zero tolrants policy on abuse. And they say more than 60 people have been fired not necessarily for abuse but for incidents involving patients. They won't say those are in response to patient abuse, but they say they've taken action against some 60 people.
CAVANAUGH: Throughout your investigation, what did you find find that would indicate that the abuse is being covered up?
GABRIELSON: Well, are the biggest thing is that there have been a number of cases where evidence is tampered with or destroyed. In the Lazinni case, documents were literally blacked out, whole sets of records went missing. In van Ingram's investigated, the final report omitted the findings of the biomechanical expert that called the case likely a homicide. And other staff have found incidents where evidence of injuries put into patients' files has been removed.
CAVANAUGH: You spoke with doctor van Peña, I believe who said that they had been a problem with photographs that he'd taken, right?
GABRIELSON: He said he repeatedly found his bosses undermining his effort to document injuries.
CAVANAUGH: We have a clip from doctor Peña. And here's that clip. New my I believe that the administration wished to cover up the reality of these often graphic and severe injuries to patients under their care.
CAVANAUGH: That doctor van Peña who used to go into facilities and take photographs of at this time alleged abuses that patients were being suffered, but he was ultimately fired wasn't he?
GABRIELSON: He was fired in 2002 from Sonoma developmental center. And he is -- has waged a decade-long fight, wrongful termination suit that is still pending that could go to trial this year. And he alleged that he was fired because in part because he continued to document patient injures.
CAVANAUGH: What does the department of developmental services say about the abuse and injuries and the lack of criminal prosecutions?
GABRIELSON: Well, they acknowledge that things have happened. Clearly there have been cases of abuse and injuries. They have a zero tolpolicy, they say. Abuse and injuries are endemic to the severe developmentally disabled. It's unlikely that the number of cases could ever go to zero. Regarding prosecutions, they don't say much besides that they are looking to improve the police force.
CAVANAUGH: Here once again is Terry del Gadillo.
NEW SPEAKER: We will be retraining all of our staff to be sure they are providing the highest level of service.
CAVANAUGH: She is the director of the department of developmental services; correct?
GABRIELSON: That is correct. And she says they've hired outside consultants to assess the police force, and that process has been going on for about 20 months. So those consultants and the office of protective services are supposed to recommend changes for the officers and detectives in about a month.
CAVANAUGH: Larry, how do you think things would have been different if people who had police training had investigated your brother's death?
INGRAM: We would have a suspect in custody and being prosecuted by now for at least, the very least, involuntary manslaughter, assuming he just lost his temper when he got my brother in a half Nelson and broke his neck. But literally, had it not been for the teneighborsness of my attorney, and obviously the teneighborsness of Ryan Gabrielson, we wouldn't be sitting here today, and we wouldn't have got as far as we have. This is literally no effort at all to prosecute anyone. They actually tried to blame it on another residence, another retarded individual, who supposedly witnessed -- was witnessed coming out of my brother's room, and the witness was a blind, retarded individual.
CAVANAUGH: There is a century amount of helplessness that -- that you must feel in this.
INGRAM: It's wreaked havoc. Well, we have God in our lives, but basically -- I always believed in the institution. And I still believe in the institution. I no longer believe in those who run it. I believe the system is broken. The system should be completely revamped or they should get rid of it. And my family -- it's torn my family apart. I have a 90 year-old mother in Montana, and she's still asking five years later, why is he still working there? Why is this individual still working there that broke my son's neck? It's -- it's been horrible. And the true suspect in this case, at this point, is the office of protective services. And God bless Ryan Gabrielson for digging this up. I am truly appalled at what I have witnessed as a previous law enforcement officer, and as one who teaches at the academy, run mice own academy, I'm appalled at what I have learned and seen and witnessed through the office of protective services, and the department of developmental services, and their $4.5 billion budget.
CAVANAUGH: Let me ask you Ryan, there are now calls by state lawmakers for hearings into the office of protective services. Tell us about that.
GABRIELSON: That just came on Friday. Of the Senate human services committee announced is that it's concerned about the quality of investigative work, especially on death cases, and potential patient abuse cases. So they say they're going to schedule hearings and investigate the matter. So we'll have to see if that results in legislation or -- and what the department of developmental services and the police force has to say there.
CAVANAUGH: And will you be continuing your reporting on in?
GABRIELSON: Absolutely, no doubt.
CAVANAUGH: Thank you both very much.
GABRIELSON: Thank you.
INGRAM: Thank you, Maureen.