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LYNN NEARY, HOST:

Over the last year or so, we've told you about violence at California's state psychiatric hospitals. The Center for Investigative Reporting's California Watch has uncovered patterns of abuse at another set of state institutions - developmental centers. These are homes to people with developmental disabilities who can't care for themselves. From member station KQED, Michael Montgomery reports on the death of one patient, and his brother's effort to hold the system accountable.

MICHAEL MONTGOMERY, BYLINE: Fairview Developmental Center is a sprawling facility of offices, residential buildings and therapy rooms, set between a noisy boulevard and a golf course in Costa Mesa, California. Just over 350 people with developmental disabilities live here.

And while minor scratches and bruises are not uncommon for these patients, over the years Fairview has seen scores of serious injuries and even deaths. One case involved a man named Van Ingraham. As a child, Ingraham couldn't form words, and was almost impossible to control. After he was diagnosed with severe autism, his older brother, Larry, says their parents turned to Fairview for help.

LARRY INGRAHAM: They saw that it was a safe environment for him; that he was going to be safe and taken care of.

MONTGOMERY: Van Ingraham entered Fairview at age 8, and lived there for 42 years. Then one day in 2007, Larry Ingraham got a phone call.

(SOUNDBITE OF PHONE RECORDING)

COMPUTERIZED VOICE: 9:43 a.m.

ALEX: This is Alex from Residence 31, calling regarding Van Ingraham.

MONTGOMERY: A supervisor at Fairview left a message saying Van Ingraham had been taken to the hospital. When Larry Ingraham got there, his brother was in the emergency ward. A neurosurgeon told him Van had a broken neck and a crushed spinal cord.

INGRAHAM: And he told me, adamantly, that he felt that this was done to Van; that it was not an accident.

MONTGOMERY: Van Ingraham died six days later. Three outside medical experts raised alarm about the way he 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.

As a retired police officer, Larry blames himself for missing what he now suspects were earlier signs of abuse: broken bones, a black eye and abrasions.

INGRAHAM: (Crying) I should have known that something was going on. The signs were there. And I was a cop, you know?

MONTGOMERY: Documents from the case paint a picture of a bungled investigation. For starters, an internal logbook showing what Van Ingraham was doing at the time of his injury was altered by a caregiver, but Fairview's internal police never investigated. They also waited five days to interview witnesses, and never collected any physical evidence.

This wasn't the only time officers working for the state developmental centers failed to conduct a thorough investigation. We found hundreds of cases of reported patient abuse, and unexplained injuries, that were documented at the centers and then dropped without arrests or prosecutions. Former staffers we spoke with say the failure to hold people accountable for abuse isn't just the result of poor police work.

DR. VAN PENA: Every shift I had, there were injuries.

MONTGOMERY: Van Pena was a doctor at a state developmental center in Sonoma County for 10 years. Pena says he would document patients' injuries by placing photographs in their medical records. But someone else, he says, would cut them out. When he complained, Pena says he was asked by administrators to stop taking photos.

PENA: I believe that the administration wished to cover up the reality of these often graphic and severe injuries to patients under their care.

MONTGOMERY: Officials from the California Department of Developmental Services, which oversees the centers, wouldn't discuss specific cases, or comment on state data showing a 40 percent rise in reports of patient abuse. But department director Terry Delgadillo says protecting patients is a top priority.

TERRY DELGADILLO: We keep track of every allegation that is made.

MONTGOMERY: Delgadillo says her department enforces a zero-tolerance policy when it comes to patient abuse.

DELGADILLO: When something goes wrong we take very, very aggressive action.

MONTGOMERY: But of the hundreds of abuse cases reported at the centers since 2006, we could find just two where the department has actually made an arrest. And in the case of Van Ingraham, no charges were ever filed.

So recently, Larry Ingraham and a friend, Donovan Jacobs, planted themselves in front of the Orange County District Attorney's office on a busy street in downtown Santa Ana.

INGRAHAM: How are you doing today, sir?

UNIDENTIFIED MAN: Good, how are you?

MONTGOMERY: They held hand-drawn pickets, and were passing out fliers.

INGRAHAM: Our goal is to get the district attorney in gear, and get him to take some action on my brother's homicide.

MONTGOMERY: Ingraham has already won an $800,000 civil settlement from the state, but he's pressing for a criminal investigation.

INGRAHAM: The only reason we got this far in my brother's case,is because Don is an ex-cop; I'm an ex-cop.

MONTGOMERY: Ingraham says he believes most of the staff at Fairview work hard and are devoted to the patients. But he says investigating his brother's death showed that when something goes wrong, there's no effective system of accountability. Not for his brother and, he fears, not for others.

INGRAHAM: There's hundreds of cases around the state, in state facilities, where the disabled are getting abused. I just have to wonder how many of these cases are actually being properly investigated. To date, I've yet to see it.

MONTGOMERY: Recently, California health officials told lawmakers they're taking action. They've hired an independent expert to overhaul the small police force working at the developmental centers, and are tightening standards for securing evidence and potential crime scenes. Those changes are expected to roll out in the coming months.

For NPR News, I'm Michael Montgomery.

NEARY: This is NPR News.

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