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Veteran detectives identify death investigation’s key mistakes

California Watch asked two veteran homicide detectives to review hundreds of pages from the investigation into the death of patient Van Ingraham, who was critically injured at the Fairview Developmental Center in Costa Mesa. Al Cruise of the Seattle Police Department and Mark Czworniak of the Chicago Police Department – with a combined 51 years of experience in law enforcement – found six critical errors in the 2007 case:

Fairview police did not secure Ingraham’s bedroom to protect evidence.
The institution police, the Office of Protective Services, appear to have treated the case as an accident and did not prevent Fairview staff from walking through and even cleaning the room. “It is my belief that the initial responders did not recognize the scene as a potential crime scene,” Cruise wrote. “It would be difficult for me to opine as to whether that was caused by incompetence, inexperience or influential situational and environmental factors at the scene.” Further, Czworniak wrote that police should have documented how the room looked by taking photographs. “In today’s digital era, it should always be done,” he wrote.

Fairview police failed to launch a full investigation upon learning Ingraham had suffered a broken neck.
Cruise wrote that investigators appear to have failed “to recognize the potential criminality of the incident,” and therefore did not see cause to gather physical evidence, secure medical records and question witnesses. Police might have overlooked the case because injuries are common at institutions, Czworniak theorized.

Investigators waited until five days after the injury to begin witness interviews.
The delay might have undermined the questioning, Czworniak wrote. “It gave several people the opportunity to speak about the events.” Cruise agreed, adding that Fairview police had enough information “several days prior to the initiation of the interviews to indicate a strong potential for a crime.”

Officers did not collect physical evidence from the scene.
The first time a Fairview investigator considered gathering physical evidence was on June 13, 2007, the case file shows, seven days after Ingraham was found with a broken neck. “Seven days is a long time to expect to recover any evidence, especially in a room that was not sealed from the onset,” Czworniak wrote. “In hindsight that seems to be irresponsible and negligent,” Cruise wrote. In addition to searching Ingraham’s room, Cruise wrote that investigators should have requested DNA samples and fingerprints from people who had come into contact with Ingraham before his death. “Even if there is no evidence to compare to, the resulting dialog when such a request is made can be telling,” he wrote.

The caregiver last seen with Ingraham altered records from the morning of the injury, but police did not investigate the changes.
Johannes Sotingco, a caregiver at Fairview, changed entries for Ingraham in the sleep log within 48 hours of the patient’s injury. The alteration might have been simply to correct the record, the detectives wrote. Regardless, police should have investigated the matter. “Any altering of records, especially after such an incident, is cause for concern,” Czworniak wrote.

Investigators omitted from their report a biomechanical expert’s finding that Ingraham’s death was “likely a homicide.”
Thay Lee, a biomechanical expert at UC Irvine, assessed evidence in the case at the request of the Orange County sheriff-coroner and determined that another person probably caused Ingraham’s broken neck. “It is undoubtedly comprehensive and compelling,” Cruise wrote of Lee’s report. But Fairview police did not include any of Lee’s findings in their case file. “This may be because they believed Thay Lee’s assessment had no merit,” Czworniak wrote. “Personally I think it’s better to include as much information when constructing a final report, than to ‘pick and choose,’ what goes in. This is because of exactly what happened down the road with this investigation. Someone started reviewing it and now, because information was excluded, it has an appearance that things were being covered up.”

This story was edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick.


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