Unsolved deaths, injuries at state-run facilities


In California, some of the most severely disabled are cared for at state-run facilities with around-the-clock supervision. One of those centers is located in Sonoma County. The state spends about $300,000 a year on each patient, but an investigation by ABC7 media partner California Watch has uncovered a pattern of abuse and neglect at the centers. What's more, a failure to hold staff and administrators accountable.

Timothy Lazzini was a quadriplegic patient at Sonoma Developmental Center in Northern California. He died from internal bleeding. Stephanie Contreras is his sister. "It turns out that 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,' she said.

Lazzini's doctor said he could not have put the swabs in his mouth on his own and no one could explain how they got there. The developmental center's 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. "Our brother died and they can't give us a reason why,' Contreras said.

If Timothy Lazzini had been anywhere else, his death would likely have been investigated by local police, but California's developmental centers have their own in-house police force. They are hired by the same administrators who run those facilities and receive limited training.

Sonoma Developmental Center is one of five state-run institutions in California for those with severe developmental disabilities. Those centers serve roughly 2,000 patients who need full-time supervision and care, patients like Van Ingraham. "It became very clear he's not going to be able to ever talk or function on his own in society," Larry, Van Ingraham's brother said.

Van Ingraham was diagnosed with mental retardation and severe autism as a child. As he grew older, his family found they could not cope with his disabilities. His older brother says they turned to Fairview Developmental Center in Orange County."We would go up and visit and Van seemed happy there," Larry recalled.

However, one day in 2007, Larry got a call that his brother Van had been rushed to the hospital. "He was in ICU, intensive care, Hoag Memorial Hospital. I've seen a lot of bad sights in my life, but this is one of the worst," he said tearfully. The staff at Fairview Developmental Center said Van had simply fallen out of bed, but a neurosurgeon at the hospital said Van's injury was no accident. "They said either your brother was body surfing at the Wedge in Huntington Beach and had severe impact into the sand with a large wave, or somebody did this to your brother," Larry recalled.

No one was ever charged in Van's death.

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

Yet, during a recent three-year period, there were more than 250 confirmed abuse cases and more than 600 other unexplained injuries among the system's roughly 2,000 patients. Rarely has violence against the patients led to arrest or prosecution. "That means we didn't really find out what really happened. That disturbs me," said California Asm. Jim Beall. Beall is chair of the Human Services Committee. He says injuries of unknown origin should be further investigated. "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," he told ABC7.

Director Delgadillo says her department is working to improve the quality of its police force. "We will be retraining every one of our staff to make sure that indeed, they are providing the highest level of service," she said.

Not everyone agrees. Dr. Van Peña was a doctor at Sonoma Developmental Center for 10 years. "Every shift I had, there were injuries," he recalled. Pena said he would document patient injuries, placing photographs in the medical records, but he says someone would remove the photos. "I would go to see the patient at perhaps 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 a scissors," he said.

When he complained, Dr. Peña says he was asked by administrators to stop taking photos. "I believe that the administration wished to cover up the reality of these often graphic and severe injuries to patients under their care," he said. He says he was fired for refusing to cooperate. The U.S. 9th Circuit Court of Appeals found evidence to support Peña's allegations and a wrongful termination suit is pending.

The state of California paid $800,000 to the family of Van Ingraham and $100,000 to the family of Timothy Lazzini to settle their civil suits, but the cases remain unsolved. "I look at his picture and you know, it was wrong for him to die like that," Larry told ABC7. "There needs to be justice served and I don't feel like there has been," Contreras said.

Written and produced by Ken Miguel

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