Six days before he died, Van Ingraham was found on the floor of his room. His neck was broken and his spinal cord was crushed and disfigured. The injury was so severe, medical experts said it looked like he'd been put in a headlock or hanged.
But even if Ingraham knew how he'd been injured, his severe autism prevented him from revealing it. He'd never uttered a word in his life -- only his injuries could speak for him.
Solving the mystery of Ingraham's death in the summer of 2007 was left to the detectives at the Fairview Developmental Center, a state-run institution in Costa Mesa where Ingraham lived in a sterile room. A tiny window allowed only a sliver of light into his world.
Ingraham's family sent him to Fairview when he was just 8 years old. He lived under the care of the state for 42 years. Restless, he would sprint through hallways. He would urinate on himself when upset. At his worst, he would strike at his own face, though never at his three roommates or others around him.
The coarseness of Ingraham's life at Fairview was matched only by the sloppiness of the investigation into his death.
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.
Later, Fairview detectives noted that Ingraham's caregiver had changed the institution's log documenting what the patient was doing at the time of the injury. But detectives never pressed the issue.
The lead detective, a former nurse, had minimal police training and no experience investigating suspicious deaths.
In the case file, she left out the opinion from a biomechanical specialist that Ingraham's death "was likely a homicide" -- one of three medical experts to raise alarms about the injury. Two of those experts concluded that Ingraham likely had been put in a headlock.
Fairview detectives eventually focused on another patient without proof he was even near the scene. The key testimony leading detectives down that road came from a blind patient.
The detectives also surmised that Ingraham could have fallen out of bed, which was about two feet off the ground. Medical experts said that scenario was highly unlikely given the force required to produce Ingraham's injury.
No arrests have been made in the case, and the Fairview caregiver last seen with Ingraham continues to work at the center.
Ingraham's death illustrates how an ill-equipped, inexperienced and poorly trained police force has dealt with a rising number of unexplained injuries and abuse cases inside state-run facilities managed by the Department of Developmental Services.
The $4.5 billion Department of Developmental Services is responsible for about 1,800 patients with cerebral palsy, mental disabilities and severe autism at five centers in Los Angeles, Orange, Sonoma, Riverside and Tulare counties.
A California Watch investigation has found that detectives and officers working for the agency's police force, the Office of Protective Services, routinely mishandled reports of abuse at the facilities. Hundreds of cases of reported abuse and unexplained injuries have been documented and then dropped without prosecution or detailed follow-up.
Over the past six months, California Watch has provided state officials with documents, interviews and data from its investigation into Ingraham's death. But Department of Developmental Services officials declined to comment on the case, citing patient privacy laws.
Terri Delgadillo, director of the department based in Sacramento, said overall, "If there are issues that need to be addressed," the department is looking into making improvements.
Key players in the case, including Fairview detectives and officials with the Orange County sheriff-coroner's office, declined to comment or were instructed to remain silent. The circumstances of Ingraham's death were reconstructed based on interviews, police case files, autopsy examinations and other public records.
California Watch enlisted two experienced homicide detectives to review hundreds of pages from case files on the Fairview investigation. They each pinpointed six mistakes made by officers and detectives at the institution - the most significant of which came in the hours and days after Ingraham was discovered on the floor of his room.
Fairview police did not secure Ingraham's room to protect evidence, did not promptly interview witnesses, and failed to respond to the patient's broken neck as requiring immediate investigation, the detectives said.
"It is my belief that the initial responders did not recognize the scene as a potential crime scene," Det. Al Cruise of the Seattle Police Department wrote in his review.
Even after the Office of Protective Services learned that Ingraham's neck had been broken, they waited five days to begin witness interviews. This "gave several people the opportunity to speak about the events," Det. Mark Czworniak of the Chicago Police Department wrote of the delay, which could have potentially undermined witness statements.
As a baby, Van Ingraham didn't respond to voices. His parents feared their youngest son was deaf.
Ingraham's ears worked. His true disabilities would prove far more challenging. At 18 months, when most children are upwardly mobile, he wasn't walking. He made sounds, but could not form words.
"Right away, I started noticing things about him as a tiny baby," said Jane Robert, Van Ingraham's mother, now 90 years old. "He didn't want me to hold him and cuddle him. He would stiffen up when I would try to hold him."
But as he grew, Ingraham was giddy in his love for play.
A black-and-white family picture now fading shows him, about 6 years old, riding piggyback on his older brother's shoulders in their San Diego neighborhood. Both are smiling, but Van's mouth is open wide, like a kid screaming joyfully on a roller coaster. "We had a big family living in a small house," said Jane, who stayed at home to take care of her two sons and four daughters.
Van Ingraham's impulses grew more difficult to tame. He suffered severe seizures. When he was 8, Jane took him to a doctor specializing in a relatively new disorder called autism.
The doctor diagnosed him as being on the severe end of the autism spectrum. The conclusion was not so painful as the specialist's advice, which was "put him away; forget you had him," said Larry Ingraham, Van's older brother by six years.
"And that was the beginning of the nightmare," his mother recalled. "Because my husband said, 'Never, we'll never do that!' And I ran outside of the room. It was the worst day of my life."
They tried their own methods. When he finally started to walk, and had a tendency to bolt from the house, his family painted the walls of his bedroom yellow, his favorite color, in the hope it might induce him to stay put.
Less than a year after the diagnosis, Ingraham became agitated one day while his mother was caring for him alone. The door to the boy's bedroom locked only from the outside, so they could contain him. But Ingraham ran out of the room ahead of his mother and slammed the door, locking her in.
Van Ingraham was discovered hours later, naked and running down the middle of the street, following the yellow lane dividers.
It was too much. Jane first tried placing her son in a private group home. That arrangement lasted just 24 hours, as a distraught Van tore down curtains and nearly broke free from the facility.
Life at Fairview
The Fairview Developmental Center was a last resort and a welcome salvation from the stress of caring for a disabled child. A doctor had recommended the facility to Ingraham's family.
On a clear and cool April 20, 1964, Ingraham's parents loaded up their car and drove their youngest son to Costa Mesa, the suburban enclave in Orange County where five years earlier the state's newest institution for the developmentally disabled had been built on 752 acres.
From outside the fenced-in campus, Fairview now looks like a school built for thousands of children, with low-slung buildings painted blue and white. Patients wander the drab halls and common areas, which are serviced by the institution's own power plant and an industrial kitchen.
Richard "Dick" Ingraham, an executive at the defense contractor General Dynamics for 43 years, and Jane believed their son was safer at Fairview, protected and watched around the clock.
Jane co-founded the parents' organization - Fairview Family & Friends - that assists the institution to this day and embraces a philosophy that "all people have value as human beings and as members of the human family."
Over the years, the family would bring their son home on weekends. On one occasion when Ingraham was 9 years old, Jane said she noticed during a bath that he had "bite marks on his little penis." She said Fairview did not explain the marks.
The toll of institutionalizing the boy was deeply painful to the Ingrahams. Larry Ingraham said he believes it contributed to his parents' divorce a few years after Van Ingraham first entered Fairview.
Jane Robert said once her son became a teenager, bringing him home on weekends became too stressful for the family.
"Finally there came a day my husband said, 'Don't bring him home any more,' " Jane said, her voice quivering. "It was just too much for him. You know, he worked hard all week."
Ingraham grew into a healthy man at the institution. To control his moods, Fairview physicians prescribed him lithium and risperidone. Both medications are used to calm the behaviors of the severely autistic, according to the National Institutes of Health.
He stood 5 feet 9 inches tall, with the lean muscular build of a day laborer and full head of dark brown hair. He was social, though he avoided physical contact with others. This made grooming him a chore. Pictures that Larry Ingraham had taken show his brother with stubble visible along his jaw line and chin.
His tastes and activities changed little, a 2006 assessment by Fairview caregivers shows. Ingraham guzzled soda and generally preferred sweet foods. He "likes hot cereal with LOTS of sugar and cocoa," the assessment states. Larry Ingraham keeps a photograph of his brother chugging a plastic bottle of Sprite.
His communication skills developed, but they were basic. When Ingraham wanted someone to leave his room, he'd nudge them toward the exit with his elbow. But impulse control would bedevil Ingraham until the day he was paralyzed.
Predawn incident, then injury
Sometime between 4:30 and 5 a.m. on June 6, 2007, Johannes Sotingco, the Fairview caregiver on duty that morning, found Ingraham urinating in his pants. According to Sotingco's recollection to police, Ingraham then pushed his pants down to his ankles to get the wetness away.
Sotingco ordered him to pull up his pants, but he refused. He said Ingraham was standing.
About this time, a supervisor down the hall said she heard Ingraham scream. The supervisor, Florens Limbong, rushed to Ingraham's bedroom to check on the patient.
Opening the door, she saw Sotingco standing over Ingraham. The light was on in the room - it was always on, because Ingraham was afraid of the dark. Ingraham was lying face up on the brown vinyl floor.
Ingraham shared the room with three other patients; the roommates were asleep, accustomed to Ingraham roaming around at night. It's unclear from the record how Ingraham ended up on the floor.
"Is he OK?" Limbong asked.
"Yeah, he is OK," Sotingco replied, pulling the patient's pants back up while he was on the ground. "He doesn't want to wear his pants."
Limbong turned and left without further inquiry. She told investigators that she saw nothing more than Ingraham on his back, and said she trusted Sotingco's assertion that the patient was fine.
"No more problem, you know. I mean I don't hear any more screaming," she told the detectives.
Sotingco was on her heels, heading out the door. In a later interview with detectives, Sotingco insisted that he hadn't injured the patient during the predawn incident and claimed Ingraham had stood up before he left the room.
Ingraham, according to Sotingco, was checked again at 5:15 a.m., and was marked in a log as "R" - resting in his bed.
Sotingco wrote in another of the center's log - which Fairview officials labeled the Journal of Falls - that he first discovered Ingraham's injury when he made his rounds again. This was about 5:45 a.m.
In his interview with police, Sotingco said he found Ingraham lying face up on the floor - the same spot where Limbong had seen him more than an hour earlier. The patient couldn't lift his head. There was a cut above his left brow and tears welled in his eyes.
The record shows Sotingco quickly called for help in lifting Ingraham. Another caregiver, Alvin Tan, grabbed one side of Ingraham's body, witness interviews show, as they pulled the patient on to his mattress. Ingraham was dead weight.
Limbong, who had returned to the room, offered Ingraham a can of soda to see if he would respond to one of his few joys in life. But he didn't move.
With Limbong and Tan in the room, Sotingco theorized that Ingraham had slipped and fallen from his bed.
At 6:38 a.m., Sotingco picked up the phone and called Fairview police officer Pete Araujo. They chatted for about 20 minutes, but Sotingco did not mention a neck injury. He reported Ingraham had suffered an abrasion. Araujo said Sotingco did not have an urgent tone.
Araujo, the only Fairview officer on duty that morning, arrived at Ingraham's room just as an ambulance was pulling up. He quickly left to give the medics directions to the room, returning as they were wheeling Ingraham into the hallway.
Before paramedics left, Araujo took a single picture of Ingraham's face, Fairview police records show. Araujo gathered no other evidence. He didn't question possible witnesses or take custody of the Sleep Log, which documents what patients are doing every 30 minutes throughout the night.
Ingraham was rushed to the emergency room at Hoag Memorial Hospital Presbyterian in Newport Beach. X-rays taken at the hospital documented a hyperflexion injury, akin to that inflicted on people who've been hanged.
Ingraham would be paralyzed, at best, and most likely would die.
That morning, Larry Ingraham, a retired San Diego police officer, received a call from a supervisor at Fairview saying his brother had suffered a minor injury. He walked into the hospital room to find his brother confined with a head brace and with tubes running in and out of his nose and arms.
While there, Larry Ingraham said a neurosurgeon took him aside and surmised: "Somebody did this to your brother."
"I knew this was no minor fall like they'd said," Larry Ingraham said in an interview. "... Because being a cop all those years, being in the line of work I've been in, I knew there's a person out there right away that had done this to him."
The next day, Larry Ingraham decided to go to Fairview. He talked his way into the area where his brother had lived and asked to speak to a supervisor. He was told by a staff member to wait in an office.
"She went to find the supervisor," Larry Ingraham said, "and I started checking through files." He said he found the Journal of Falls noting his brother had suffered a slip out of bed.
"And I already knew that was not true," he said. "So I took it."
Armed with that information, and Sotingco's name, Larry Ingraham filed an abuse allegation with the Office of Protective Services.
Back at Fairview, Sotingco changed the Sleep Log entries for his rounds to reflect what he claimed was the more accurate version.
Originally, Sotingco wrote Ingraham was using the bathroom at 4:45 a.m., and then sleeping at 5:15 a.m. He would tell Fairview police that he changed the sleeping and bathroom notations to say Ingraham was resting and awake in bed on both occasions.
Fairview detectives waited five days to start interviewing Sotingco, Limbong and other witnesses. Sotingco and Limbong did not respond to interview requests from California Watch, including notes left at Sotingco's home in Anaheim and repeated calls to Limbong.
Theresa DePue, the former nurse and Fairview's lead detective investigating Ingraham's death, asked Sotingco why he changed the Sleep Log, according to the police case file. The caregiver said he'd just tried to make it more accurate.
"So that was just a - an error?" DePue said.
Sotingco replied yes, and the detective moved on. DePue did not investigate the alteration as potential evidence tampering. And she didn't press him on what Limbong had reported seeing, records show.
Later, during a deposition in a civil lawsuit over Ingraham's death, Sotingco was asked if he'd put him in a headlock. He replied: "No. I don't do that."
Before joining Fairview, Sotingco had worked at Metropolitan State Hospital in Los Angeles County, where he'd been investigated four times in alleged patient abuse cases, police records show. All four allegations were closed as unsubstantiated. The state hospital would not release the details of those cases.
In her interview with Limbong, DePue appeared skeptical about whether Ingraham had fallen out of bed, as Sotingco had speculated.
"There are some pretty big concerns, because of the fact that the injury you are telling me doesn't really match up to the client's injury," DePue said.
"OK," Limbong said.
"... Any indication that somebody physically caused these injuries? Nothing?" DePue asked her.
"No. No, I don't. No."
Death 'likely a homicide,' expert says
At the hospital, Larry Ingraham decided to take his brother off the machines that had been keeping him alive. Van Ingraham died just minutes after midnight on June 12, 2007.
At the autopsy that day, Dr. Richard Fukumoto theorized Ingraham's shattered spine "could have been caused by a blow to the back of the neck using a soft object," the Fairview police case file shows. Fukumoto was then Orange County's chief forensic pathologist.
Another staff pathologist, Dr. Aruna Singhania, thought it looked like a whiplash injury sustained in a car accident.
A day after Ingraham died, the Office of Protective Services finally asked for help from an outside agency.
On June 13, Peter Mastrosimone, a Fairview detective assisting DePue, sent an email to the Orange County Sheriff's Department asking officers to check Ingraham's bedroom "for anything of evidentiary value," according to police records.
The sheriff's office replied "that due to the time lapse and the day-to-day business in the room (routine cleaning and presence of clients and staff) and the possibility of subsequent contamination, no evidence could be recovered that would be of evidentiary value."
Both Mastrosimone and DePue declined requests for interviews from California Watch.
Ingraham's case was DePue's first suspicious death investigation. DePue had no police experience when the developmental center hired her as a detective in 2002, personnel records show. She'd previously worked as a Medicare inspector for the state Department of Health Care Services.
Mastrosimone joined the Fairview police force as a patrol officer in 1996, after more than 10 years as an unpaid volunteer reserve for the Alhambra Police Department, near Los Angeles.
Matt Murphy, a prosecutor with the Orange County district attorney's office, said he's worked with Mastrosimone multiple times over the years. While the Fairview detective doesn't have the skills of a city police detective, Murphy said Mastrosimone takes direction well.
"Pete is a man with no ego," Murphy said. "He does whatever I tell him to do."
Roughly a month into Fairview's investigation, a tip came in from another staff member that a patient, who was blind, had come forward. He claimed that on the morning of Ingraham's injury, a third patient was witnessed coming out of Ingraham's room. He said this third patient came up to him and whispered, "Don't tell anyone."
The detectives pursued the lead, questioning the patients, their doctors and psychologists, police records show.
This worried Carol Risley, a patient advocate at the developmental services department.
"I am beginning to feel as though the other resident is becoming the target as it will reduce liability," Risley wrote to department executives in an email, "since he probably cannot be held responsible for his actions."
Detectives focused on the patient because they believed he had a violent history at Fairview. But it turned out, he didn't. He'd been prone to taking credit for things he'd not done, like once saying he'd broken another patient's arm.
The Fairview detectives subjected the two developmentally disabled men -- the allegedly violent patient and his blind accuser -- to a voice stress test to determine if they were lying. The results were inconclusive. Detectives asked Sotingco to participate in the test, but he declined.
There were other delays. It took months for a coroner's office investigator to tell the Office of Protective Services that Fukumoto had ruled out an accidental fall as a possible cause of the injury.
In October 2007, Fairview detective Mastrosimone wrote in an email to his commander to convey the autopsy results: "The injury was most likely caused by force associated with a half nelson or some type of head lock."
During its own investigation, the Orange County sheriff-coroner's office was debating whether to rule Ingraham's death a homicide or an accident, said Jacque Berndt, the chief deputy coroner. Berndt asked Thay Lee, a biomechanical engineering professor at UC Irvine, to examine the evidence. Berndt directed Lee not to speak with California Watch about the Ingraham case.
"It is my opinion the manner of death was likely a homicide," Lee wrote in his report to the Orange County coroner and Office of Protective Services, which was filed in December 2007. The force that broke the Fairview patient's neck had to have come from another person, he ruled.
Lee's presentation included X-ray images of Ingraham's neck juxtaposed with the neck of a person who had jumped headfirst into a shallow pool. Ingraham was clearly in worse shape, his top vertebrae at unnatural angles, his spinal cord a set of derailed tracks.
Regardless, Berndt listed the manner of death as "undetermined."
DePue, the Fairview detective, noted in the file that she received Lee's report. But she omitted from the record his conclusion that Ingraham's death was likely a homicide. She also failed to document that the county's chief pathologist determined Ingraham couldn't have broken his neck in an accidental fall.
Instead, DePue wrote, "the possibility of a fall or accident could not be ruled out." The developmental center detectives also maintained that another patient might have broken Ingraham's neck.
In 2009, the state paid Ingraham's family $800,000 to settle a wrongful death lawsuit Larry Ingraham had filed two years earlier. In finally closing the case, DePue and Mastrosimone listed the allegedly violent patient as "suspect." Sotingco was listed as a "subject."
As far as the Office of Protective Services was concerned, that was the end of it.
10News' media partner, California Watch, is the state's largest investigative reporting team and is part of the independent, nonprofit Center for Investigative Reporting.