A collaborative investigation between KQED and media partner California Watch has found that sloppy investigations at California state-run homes for the disabled have left hundreds of official abuse cases — some even involving suspicious death — unsolved. Some 1,800 men and women with developmental disabilities such as cerebral palsy live in five state-run facilities.

Disabled Patients and Abuse 24 February,2012forum

Jim Beall, California assemblymember (D) representing the 24th District
Larry Ingraham, retired San Diego police officer and brother of Van Ingraham, a patient in the state's Fairview Developmental Center who died in 2007
Ryan Gabrielson, public safety reporter for California Watch

  • Greg

    Thank you California Watch! It’s about time someone investigated this travesty. The people with developmental disabilities lack the means to communicate effectively, yet those who are supposed to protect them from harm act as mute witnesses to these appalling events. In too many cases, facilities fail to report abuse and neglect because of “privacy” concerns. It’s preposterous. Time for a more humane system, and laws that make it crystal clear that these facilities and their staff MUST IMMEDIATELY REPORT suspicions of abuse and neglect or face criminal penalties.

    • Advocate

      The state is more interested in keeping large expensive institutions open that protect state worker jobs than it is in actually caring for the residents who live in these institutions. Although the cost per resident is roughly $300,000 per year, the care is sub-par at best. Closing the developmental centers has been “discussed” for many years, yet the process is pathetically slow. I hope the developmental centers are investigated and either completely overhauled or shut down.

  • Alisonguan

    Thank you Ryan Gabrielson, this story is shocking, saddening, and real action needs to be taken to protect this vulnerable population.

  • Justice

    I’ve worked in this population. We were regularly trained, supported and evaluated for not only our awareness of the clients vulnerability but for our own stress and response to being in an often violent/highly charged environment. Clients regularly assaulted staff and we had to be specially trained how to defend ourselves without hitting back.
    We were supported in reporting ANY type of suspected abuse.
    What isn’t being talked about is the psychological phenomenon that happens to the caregivers who try so hard to protect the client and yet degrade over time not unlike the “lord of the flies” degradation of civilized behavior when under extremely stressful situations.
    Just as we are seeing high risks of caregiver abuse in eldercare we do not address the stress that caregivers undergo.
    If we don’t address the cause we will never cure the problem.

    • Greg


      You’re correct — burnout is a real, tangible factor for any worker in a caregiving capacity. There should be more training and respite resources available to those in these challenging situations. However, that must not be used as rationalization or justification (i.e. ‘just desserts’) for allowing the disabled to be neglected or abused. In fact, your comment bears witness as to why the abuse is being perpetuated.

      • Justice

        I hope my post did not suggest that I am rationalizing or trying to decriminalize the atrocities. I just know from first hand that criminalization alone isn’t going to fix the problem. We’ve been there, done that. It’s not working.

        I worked for an exemplary facility. We heard horror stories of the big hospitals.

  • Orindan

    Our brother was a permanent resident at Lanterman in Pomona, who died of internal bleeding while living there.  

    He was severely disabled – in bed or strapped into a wheelchair at all times, couldn’t speak, etc.  We got a call one day that he had fainted at the lunch table.  We got to Lanterman within an hour;  he was in ICU with internal bleeding of several organs for “no apparent reason.”  Days later he died.  His death certificate noted cause of death as “Homicide.”  

    We notified the Pomona Sheriff’s Dept who conducted an investigation with Lanterman’s internal police dept.  One day later, we received a call that the investigation was completed and the death certificate was modified from “Homicide” to “Accidental.” We know our brother was the innocent victim of someone who was having a very bad day, and who got away with murder. The Pomona Police Dept and Lanterman were satisfied with their “investigation.”  My parents are too upset to take this any further.

    • Greg

      I’m so sorry to hear of your loss. The circumstances certainly sound suspicious. It sounds as if there was no autopsy, correct? That may have been the best method of investigating the cause (other than overt physical symptoms suggesting abuse), but as PBS’s Frontline has examined, hospitals and municipalities have become very reluctant to perform autopsies unless there’s overt evidence of foul play. I don’t know if there’s more than can be done at this stage, you may check Frontline’s resources to see if there’s a third-party who might be able to provide further guidance or review the case.

  • Justice

    On another note: I lost a friend in a state mental health facility. He checked himself in for severe depression. He was beaten to death by a schizophrenic who they put in his room. I understand that the overcrowding can cause this sort of horrific accident.
    Should the other patient been tried for murder?
    Would we want someone sick enough to kill put into the prison system?
    The problem is bigger than investigation and prosecution.

    We closed many facilities when we passed prop 13. There just aren’t decent resources to publicly provide a safe environment for those we as a society just don’t want to look at. Unless the public changes the problem won’t change.

    • Orindan

      Thank you, Justice, for ringing in.

      No thanks to you, Governor Reagan (now deceased from a mental disease), for making a successful campaign pledge to shut down all mental-care facilities in the state of CA. Way to take care of your helpless people, Ronnie, and we’re so grateful you had Nancy and millions of dollars of care to get you through your mental deficiency problem.  Thankfully you did not die of internal bleeding while you lie there helpless in your 6-month old state of mind near the end.My less-fortunate brother’s case (Lanterman, below):  he was in a ward with bed-ridden and tied-to-wheelchair patients, who were all 4 to 8 MONTH-olds mentally, but physically in their 20’s and 30’s.  None could not walk, talk, go to the bathroom, or understand the English language. But they could hold hands, hug, and eat ice cream served to them by the spoonful.  Bro died of “accidental internal bleeding” ; original death certifcate listed “homicide” as cause of death.  (Later changed by Pomona Sheriff to “accidental”.)I and my 3 other brothers are re-energized by the CALIFORNIA REPORT investigation, and wanting to uncover those who covered up our brother’s death, and who knows how many other “accidental deaths”.  We are long overdue for stopping the abuse and coverup, both at Lanterman and the Pomona Sheriff’s Dept.

  • Vol Fire

    Don’t blame the cops. Blame higher up admonstration for not letting the cops do the jobs.

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