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Unexplained deaths behind closed doors

Hundreds of thousands of Californians suffer from developmental disabilities like cerebral palsy and severe autism. Some of the most severely disabled are cared for at state-run facilities with around-the-clock supervision. But while the state spends about $300,000 a year on each patient, a months-long investigation has uncovered a lack of accountability for reported abuse at the centers.


Anchor introduction: Hundreds of thousands of Americans suffer from developmental disabilities like cerebral palsy and severe autism. In California, some of the most severely disabled are cared for at state-run facilities with around-the-clock supervision. But while the state spends about $300,000 a year on each patient, a months-long investigation has uncovered a pattern of abuse and neglect at the centers and a failure to hold staff and administrators accountable. This story is reported by Ryan Gabrielson and produced by Monica Lam at the Center for Investigative Reporting.

Producer Monica Lam: Stephanie Contreras remembers the joy that her baby brother Timothy Lazzini brought to the family. But early on, they realized that something was wrong.

Stephanie Contreras: He wasn’t developing like a normal, healthy baby boy would. There was no crawling, there was no walking, no talking.

Producer: As Lazzini grew older, his family found they could not cope with his disabilities. They turned to Sonoma Developmental Center in Northern California. It’s one of five state-run institutions for people with severe developmental disabilities, serving roughly 2000 patients who need full-time care.

Contreras: We thought at the time it was the right thing for him.

Producer: But one day, Stephanie learned that her brother had suddenly died of internal bleeding caused by a torn esophagus. She says an autopsy revealed why.

Contreras: It turns out he had three lemon glycerin swabs that were found: two that were in his stomach and one that was apparently on the bed that he was sleeping in.

Producer: Lazzini was paraplegic and wheelchair-bound. His doctor said the young man could not have put the swabs in his mouth on his own.

Contreras: Clearly, he couldn’t have put them there, and they couldn’t go through the feeding tube. They had no business even being anywhere near him at all.

Producer: Dr. Van Peña was a physician at Sonoma Developmental Center for 10 years, where he says he was disturbed by what he saw.

Dr. Van Peña: Every shift I had, there were injuries.

Producer: He said the staff often could not explain how the injuries occurred.

Peña: Often, the answers revolved around that the person did it to himself or herself. Very, very often, I would say, these explanations had no ring of truth or reality to them.

Producer: Ordinarily, injuries and deaths are investigated by local police. But California’s developmental centers have their own in-house police force. In Lazzini’s case, that police force waited over 24 hours before examining Lazzini’s room. By then, any potential evidence was gone. Medical records were missing. Others had details crossed out.

Contreras: Our brother died, and they can’t give us a reason why.

Producer: The director of the Department of Developmental Services, Terri Delgadillo, said she could not comment on individual cases because of patient privacy laws, but said that all incidents were taken seriously.

Terri Delgadillo: 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.

Producer: Yet during a recent three-year period, there were more than 250 confirmed abuse cases and over 600 other unexplained injuries among the system’s roughly 2,000 patients. Rarely has violence against the patients led to arrest or prosecution.

Jim Beall: That means we didn’t really find out what really happened. That disturbs me.

Producer: California Assemblyman Jim Beall is chair of the Human Services Committee. He says injuries of unknown origin should be further investigated.

Beall: As a parent of somebody who is developmentally disabled and as a legislator, it is cause for alarm. I want to know if those investigations were completed properly.

Producer: Take the case of Van Ingraham. When he was a child, he was diagnosed with mental retardation and severe autism. The Ingrahams turned to Fairview Developmental Center in Orange County.

Larry Ingraham: It became very clear that he was not going to be able to ever talk or function on his own in society.

Producer: But one day in 2007, Larry Ingraham, a retired police officer, got a call that his brother, Van, had been rushed to the hospital.

Ingraham: He was in ICU, intensive care, Hoag Memorial Hospital. I've seen a lot of bad sights in my life, but this was one of the worst.

Producer: A neurosurgeon at the hospital said Van’s injury was no accident.

Ingraham: They said either your brother was bodysurfing at the Wedge in Huntington Beach and had severe impact into the sand with a large wave, or somebody did this to your brother.

Producer: The staff at Fairview Developmental Center said Van had simply fallen out of bed. But Larry became suspicious of how the center was handling his brother’s case.

Ingraham: I talked with a supervisor, and the way he was handling it, the way he was acting ... “I don’t want to talk to you, can’t talk to you.” I became suspicious.

Producer: It turns out, Fairview’s in-house police waited five days to begin interviewing potential suspects.

Ingraham: We had found out by then that there was no crime scene investigation at the time of the incident. We found out that no evidence was collected.

Producer: In fact, evidence was altered. In this sleep log, entries for the hour when Van’s neck was likely broken were modified. Van’s caregiver, Johannes Sotingco, admitted to changing the log, but the center’s police didn’t dig deeply into why.

An independent medical expert said that Van’s death was likely a homicide. But his opinion was left out of the final police report. No one was ever arrested or prosecuted for Van’s death.

Director Delgadillo says her department is working to improve its police force.

Delgadillo: We are retraining all of our staff to make sure that, indeed, they are providing the highest level of service.

Producer: But the problem may go beyond shoddy police work. Dr. Peña said he would document patient injuries by placing photographs in the medical records. But someone else, he says, would remove the photos.

Peña: I would go to see the patient at another time, and lo and behold, the area where the photograph was placed would be cut out ¬– nice sharp edges such as one would do with scissors.

Producer: When he complained, Dr. Peña says he was asked outright by administrators to stop taking photos.

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

Producer: Dr. Peña was fired, he says, for refusing to cooperate. A federal court found evidence to support Peña’s allegations, and a wrongful termination suit is pending.

The state of California paid monetary settlements to the families of Van Ingraham and Timothy Lazzini. But the cases remain unsolved. 

Contreras: There needs to be justice served, and I don’t feel like there has been.

Ingraham: I look at his picture and, you know, it was wrong for him to die like that.


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