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The first part of a
California Watch story:
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'd 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 they 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 they 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.
Records indicate that caregivers have inflicted abuse on patients without facing prosecution. The precise number of times nurses, janitors or staff supervisors have been implicated is unknown - the state has censored thousands of pages of documents detailing the cases.
But federal audits and investigations by disability-rights groups, as well as hundreds of pages of case files and other data, show staff members allegedly involved in choking, shoving, hitting and sexually assaulting patients at the facilities. None of these cases were 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 the in-house 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.
"For the department, the priority is to make sure that we're doing the best job providing consumer safety and services," Delgadillo said in an interview. "And if there are issues that need to be addressed - and there's always room for improvement - we're looking to do that."
She has hired a 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.
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 prosecuted.
Delgadillo also declined to comment on specific cases of alleged abuse or mistreatment at the developmental centers, citing patient privacy laws. Corey Smith, the former firefighter who is now police chief, said he was not permitted to speak with reporters for this story.
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.
Timothy Lazzini, a quadriplegic cerebral palsy patient at the Sonoma Developmental Center, died in 2005 after he swallowed 4-inch swabs that shredded his esophagus. After his death, Lazzini's doctor and a pathologist concluded it was highly unlikely that Lazzini could have placed the swabs in his own mouth.
But records show detectives waited too long to start their investigation.
His death, and the slow response by the Office of Protective Services, has left Lazzini's 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. "There is no peace at all."
The rate of suspected abuse cases within the walls of the five institutions has risen - even as hundreds of developmentally disabled patients have been moved to group homes and smaller nursing facilities.
The patient population at developmental centers dropped by 12 percent from 2008 to 2010, state records show, but reports of abuse have increased 43 percent during those three years. Unexplained injuries jumped 8 percent in the same period.
Public health officials acknowledged the state doesn't keep a tally of the number of times caregivers have abused patients. That information is kept hidden from the public in individual case files.
Kathleen Billingsley, director of policy and programs for the Department of Public Health, said she didn't know whether inspectors were notifying law enforcement agencies when they uncover evidence of abuse. She said public health inspectors conduct thorough investigations separately from the police.
"If there is any cross between enforcement individuals at the state facility and the work we do, I am not familiar with that," Billingsley said.
The Los Angeles County district attorney's office, which oversees Lanterman, couldn't identify a single criminal case referred from the center's police force. District attorneys in Tulare, Orange and Riverside counties also reported no prosecutions for patient abuse in the past decade. Sonoma County refused to disclose its records.
On average, police in California solve about two-thirds of all homicides and about half of all aggravated assaults - or at least make an arrest and "clear" the cases. The clearance rate for the Office of Protective Services is unknown because the department keeps the information secret.
