Some of the most severely disabled people in California are cared for at state-run developmental centers. The state spends about $300,000 a year on each of the 1,800 patients living at the centers. But an eight-month investigation with KQED's partner California Watch has uncovered a pattern of abuse, and a failure to hold staff accountable
For 42 years, Van Ingraham lived in a Spartan room at Fairview Developmental Center in Costa Mesa, one of five centers for the disabled around the state.
As a child, Ingraham couldn't form words and was diagnosed with severe autism and other disabilities. As he grew, he was constantly in motion and difficult to control. So his parents turned to Fairview for help.
"They saw that it was a safe environment for him, that he was gonna be safe and taken care of," Larry Ingraham, Van's brother, said.
Van Ingraham seemed happy at Fairview, his brother recalled, but there were unexplained injuries -- broken bones, a black eye, abrasions. When Van Ingraham was nine his mother discovered bite marks around his penis. Larry said the family was concerned, but had trust in the institution.
"I honestly believed that it was just natural occurrences, accidents," he said.
But one day in 2007, Van Ingraham was rushed from Fairview to the emergency ward at Hoag Memorial Hospital Presbyterian in Newport Beach.
Larry Ingraham walked into the hospital room to find his brother confined with a head brace and with tubes running in and out of his nose and arms.
Ingraham recalled a neurosurgeon telling him his brother had a broken neck and a crushed spinal cord.
"And he told me adamantly that he felt that this was done ‘to' Van. That it was not an accident," he said.
Van Ingraham died six days later. As a retired police officer, Larry Ingraham blames himself for missing what he now suspects were earlier signs of abuse.
"I should have known that something was going on," he said. "The signs were there. I was a cop? I was his brother and my job was to make sure that everything's okay."
Three outside medical experts raised alarms about the way Van Ingraham died. One said his broken neck was likely a homicide. But staff at Fairview maintained his injuries were caused by a fall from his bed.
Larry Ingraham never accepted what officials at Fairview told him about his brother's injuries. He suspected it was a whitewash. So he decided to begin his own investigation with his friend Donovan Jacobs, another ex-cop who's also a lawyer.
"For one of those facility people, professionals, to write that somebody severely breaks his neck by slipping out of bed is just ludicrous," said Jacobs.
Documents from the case paint a picture of a bungled investigation by Fairview's in-house police. They waited five days to interview witnesses and failed to collect blood samples and fingerprints from Van Ingraham's room.
Van Ingraham's caregiver also changed a logbook entry to indicate the patient was resting and awake, and not sleeping. On the page, an R has been penciled over with an S. To Jacobs, this might be evidence of a cover-up.
"What we later found out was they made that change two hours after Larry asked that that logbook be preserved and not changed," he said.
Fairview's in-house police never investigated the changes to the log. The caregiver who made them was the last man known to have seen Van Ingraham prior to his injury.
This wasn't the only time officers working for the state developmental centers failed to conduct a thorough investigation. Hundreds of cases of patient abuse and unexplained injuries have been documented at the state's developmental centers, and then dropped without arrests or prosecutions.
"It's really a closed world that doesn't get the light of day, even from local law enforcement," said Sally Lieber, a former state assembly member who authored a 2008 that would have required outside law enforcement agencies handle criminal investigations at the developmental centers instead of the in-house force.
Lieber said her goal with the legislation was greater accountability for patient abuse, but it never passed. For Lieber, rising abuse rates and few prosecutions indicate little has changed at the centers.
"Have they ever been held accountable?" she said. "I think the answer is no."
But Terry Delgadillo, director of the Department of Developmental Services, which overseas Fairview and the state's other four centers, said protecting patients was a top priority.
"We don't compromise," Delgadillo said.
She declined to discuss specific cases, citing privacy laws. When it comes to patient abuse, Delgadillo said her department enforces a zero-tolerance policy.
"When something goes wrong we take very, very aggressive action," she said. "If we identify somebody's been involved in abuse, we terminate them."
Department officials reported that 67 employees had been dismissed in client-related actions since 2008, though they couldn't say how many were connected to patient abuse. They also couldn't say how many center employees have been arrested or prosecuted.
On a recent sunny morning, Larry Ingraham and Jacobs planted themselves in front of the District Attorney's office on a busy street in downtown in Santa Ana, carrying hand-drawn pickets and fliers which they passed out to pedestrians.
"Our goal is to get the DA in gear," said Ingraham as he handed a paper to a young woman pushing a baby stroller. "Get him off his rear and get him to take some action on my brother's homicide."
After about an hour, District Attorney Investigator Eric Ackerman emerged from the building to talk. Ackerman didn't commit to anything but said he'd look into the case.
"Sorry for the loss of your brother," he said to Ingraham.
Ingraham has already won an $800,000 dollar civil settlement from the state, but he said he won't settle until there is a criminal prosecution.
"What concerns me is the only reason we got this far is that Don is an ex-cop and I'm an ex-cop," he said. "What's happening with the other abuse cases and deaths at the facilities? There's hundreds of cases around the state where disabled people are getting abused. I just have to wonder how many of them are being properly investigated."