California Watch

One of the redacted documents
California Watch received.

In California Watch’s series Broken Shield, Ryan Gabrielson uncovered abuse and unknown injury cases at developmental centers that weren’t reported to the local police or district attorneys’ offices. 

Despite a number of condemning reports and a decreasing patient population, the number of abuse and unknown injury cases increased from 2008 to 2010 at developmental centers, which are state-run homes for people with developmental disabilities, such as autism and cerebral palsy.

Throughout Gabrielson’s investigation, the California Department of Public Health, which monitors the developmental centers’ oversight department, the Department of Developmental Services, has refused to hand over uncensored records, including inspections and citations.

“We fought, we do not agree, we are suing the Department of Public Health right now because they redacted nearly every word in the citations,” said Gabrielson, public safety reporter for California Watch, founded by the Center for Investigative Reporting.

The public health department stated that abuse investigations gather information about services provided to patients and are therefore confidential, said Gabrielson. California Watch disagreed and said the public health department is legally required to investigate suspicion of abuse. Citations that describe the circumstances behind each violation without patients’ names should be handed over, wrote Gabrielson.

“When instances of potential abuse or violations of the law occur at state institutions, the public and relatives of patients have a right to the truth,” said Robert J. Rosenthal, CIR’s executive director.

But even without these records Gabrielson was able to paint a vivid picture of the human rights abuses going on in the developmental centers. He used public databases, worked with local police officers to interpret documents and hopped from one source to the next to gather information.

In 2005, Disability Rights California issued a report on a pattern of unexplained genital lacerations suffered by male patients at an unnamed developmental center. The cases were potentially sex assaults, but the investigations were woefully incomplete, documents show.

Stories critical of the developmental centers first started to appear in 2000 to 2005 by the Sonoma Index-Tribune and the Inclusion Daily Express, an international disability rights news service.

However, Gabrielson became curious when he was tipped off about alleged financial fraud within the centers’ internal police force, called the Office of Protective Services.

“When I called the police chief to ask basic questions about their structure, and he said he couldn’t speak to me that got me interested,” Gabrielson said. 

So he started calling dozens of people that were involved in developmental centers. One person directed him to the public health department, which regulates the Department of Developmental Services.

The public health department sent him heavily redacted documents and the Department of Developmental Services refused to give out any records.

“Everything I got had to come from outside the agency,” Gabrielson said.

For the majority of the patient abuse and unknown injury cases that Gabrielson investigated, he took data from the Health Facilities Consumer Information System’s website. He pulled data from each type of license a developmental center is required to have, such as a skilled nurse facility or acute care hospital license.

“I looked up each of these licenses in the consumer info database and copied it into a text file using Google refine,” he said. “I cleaned it, some of the raw records had missing variables, cleaned that all up and loaded it into SPSS. I used a data manager as well for analysis and started running frequency tables by facility and by incident type.”

There were over 20 categories of incident type including neglect, quality of care, administrative issues, patient abuse and injury of unknown origin. He decided to focus his research on substantiated abuse and unknown injuries.  

He was able to compare an increase in abuse and unknown injury cases to a shrinking developmental center population. He found the population numbers on the Department of Developmental Services’ website. The list of cases also gave him an idea of what should have been reported to the local police.

By following up with local police and district attorneys’ offices he saw that many cases were not reported and when they were reported delays made it impossible to effectively investigate the cases.

In “Basic police work ignored in autistic patient’s suspicious death,” Gabrielson shows the extent of internal police officers’ failures.

Van Ingraham, a patient at Fairview Developmental Center, was found with a broken neck and a crushed spinal cord.

The police force at Fairview failed to collect blood samples, fingerprints and other physical specimens from his room. On the day of the injury, they took one photograph—a headshot of Ingraham, 50, as he lay on a stretcher, his eyes open and glassy, an abrasion above his left brow.

Gabrielson didn’t get this level of detail from the online database. Through other interviews, he tracked down the patient’s brother, Larry Ingraham, a retired San Diego police officer.

“Because I was searching for a case, I couldn’t just request all police cases because they don’t have to give those to me,” Gabrielson said. “I was asking everyone else in the world.”

Larry Ingraham who had collected his brother’s file was able to provide details to Gabrielson. California Watch also got additional expert advice from other officers to back up the story.

California Watch enlisted homicide detectives from the Seattle and Chicago police departments to review hundreds of pages from case files on the Fairview investigation. The two investigators each pinpointed six mistakes made by officers and detectives at Fairview – the most significant of which came in the hours and days after Ingraham was discovered on the linoleum floor of his room.

The Seattle and Chicago detectives, who have a combined 51 years of experience in law enforcement, noted that Fairview police did not secure Ingraham’s room to protect evidence, did not promptly interview witnesses, and did not realize that the patient’s broken neck should have been investigated immediately.

Providing police officers with examples of previous work and communicating in writing can help when working with police officers, Gabrielson said.

“Good cops like good police work, they were assessing what they saw in case files not bashing protective services,” he said.

While the police were willing to review these files, getting more internal inspection and citation files from the public health department continues to be a challenge.

“We are still fighting to get the basic dictation that were issued to the developmental centers that were completely blacked out,” Gabrielson said.

Johanna Somers is a graduate student at the University of Missouri School of Journalism