Reports of patient abuse at California’s institutions for the severely disabled have increased dramatically in recent years. But 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, called the Office of Protective Services.
Six days before he died, Van Ingraham was found on the floor of his room. His neck was broken and his spinal cord was crushed and disfigured. The injury was so severe, medical experts said it looked like he could have been put in a headlock or hanged.
But even if Ingraham knew how he’d been injured, his severe autism prevented him from revealing it. He’d never uttered a word in his life – only his injuries could speak for him.
Solving the mystery of Ingraham’s death in the summer of 2007 was left to the detectives at the Fairview Developmental Center, a state-run institution in Costa Mesa where Ingraham lived in a sterile room. A tiny window allowed only a sliver of light into his world.
Ingraham’s family sent him to Fairview when he was just 8 years old. He lived under the care of the state for 42 years. Restless, he would sprint through hallways. He would urinate on himself when upset. At his worst, he would strike at his own face, though never at his three roommates or others around him.
The coarseness of Ingraham’s life at Fairview was matched only by the sloppiness of the investigation into his death.
The police force at Fairview failed to collect blood samples, fingerprints and other physical specimens from his room. On the day of the injury, they took one photograph – a headshot of Ingraham, 50, as he lay on a stretcher, his eyes open and glassy, an abrasion above his left brow.
Later, Fairview detectives noted that Ingraham’s caregiver had changed the institution’s log documenting what the patient was doing at the time of the injury. But detectives never pressed the issue.
The lead detective, a former nurse, had minimal police training and no experience investigating suspicious deaths.
In the case file, she left out the opinion from a biomechanical specialist that Ingraham’s death “was likely a homicide” – one of three medical experts to raise alarms about the injury. Two of those experts concluded that Ingraham likely had been put in a headlock.
Fairview detectives eventually focused on another patient without proof he was even near the scene. The key testimony leading detectives down that road came from a blind patient.
The detectives also surmised that Ingraham could have fallen out of bed, which was about two feet off the ground. Medical experts said that scenario was highly unlikely given the force required to produce Ingraham’s injury.
No arrests have been made in the case, and the Fairview caregiver last seen with Ingraham continues to work at the center.
Ingraham’s death illustrates how an ill-equipped, inexperienced and poorly trained police force has dealt with a rising number of unexplained injuries and abuse cases inside facilities managed by the Department of Developmental Services.
California Watch enlisted homicide detectives from the Seattle and Chicago police departments to review hundreds of pages from case files on the Fairview investigation. The two investigators each pinpointed six mistakes made by officers and detectives at Fairview – the most significant of which came in the hours and days after Ingraham was discovered on the linoleum floor of his room.
The Seattle and Chicago detectives, who have a combined 51 years of experience in law enforcement, noted that Fairview police did not secure Ingraham’s room to protect evidence, did not promptly interview witnesses, and did not realize that the patient’s broken neck should have been investigated immediately.