Solano County Won't Re-Check Autopsies Done by Pathologist Found to Be Incompetent
Police Force’s Sloppy Investigations Leave Abuse of Disabled Unsolved
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"content": "\u003cp>by Ryan Gabrielson, \u003ca href=\"http://californiawatch.org/dailyreport/release-uncensored-developmental-center-citations-ordered-18076\">California Watch\u003c/a>\u003c/p>\n\u003cp>A state court today ordered the California Department of Public Health to disclose uncensored copies of dozens of patient abuse cases at institutions for the developmentally disabled.\u003c/p>\n\u003cfigure id=\"attachment_76371\" class=\"wp-caption alignleft\" style=\"max-width: 300px\">\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/09/developmental-center.jpg\">\u003cimg class=\"size-medium wp-image-76371\" title=\"developmental center\" src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/09/developmental-center-300x169.jpg\" alt=\"\" width=\"300\" height=\"169\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Larry Ingraham holds a picket outside the Orange County District Attorney's Office in Santa Ana. Ingraham wants the office to open a homicide investigation into the 2007 death of his brother, Van. (Michael Montgomery/KQED)\u003c/figcaption>\u003c/figure>\n\u003cp>\u003ca href=\"https://www.documentcloud.org/documents/435882-cir-v-cdph-order.html\" target=\"_blank\">The ruling came\u003c/a>in a lawsuit filed by the Center for Investigative Reporting in Sacramento County Superior Court in January, seeking citations issued to developmental centers in Los Angeles, Orange, Sonoma, Riverside, Tulare and Santa Clara counties.\u003c/p>\n\u003cp>Nearly 1,700 patients with cerebral palsy and profound intellectual disabilities live at the state’s board-and-care institutions. For decades, the public has been denied access to records detailing violations within the centers.\u003c/p>\n\u003cp>\u003ca href=\"http://cironline.org\" target=\"_blank\">CIR\u003c/a>, parent organization of California Watch, filed its request in May 2011, and the department responded by releasing 55 citations, totaling 169 pages. But the department blacked out \u003ca href=\"https://www.documentcloud.org/documents/282329-170004097-redacted.html\" target=\"_blank\">almost every word\u003c/a>. Thirty-five of the reports appear to involve abuse of patients, and the rest outline medical care and neglect violations from 2007 to mid-2011.\u003c!--more-->\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>More recently, the department has censored records detailing a 2009 \u003ca href=\"http://californiawatch.org/dailyreport/state-withholds-details-developmental-center-slaying-16458\" target=\"_blank\">homicide at the Fairview Developmental Center\u003c/a> and \u003ca href=\"http://californiawatch.org/public-safety/questions-surround-handling-taser-assaults-disabled-patients-17345\" target=\"_blank\">stun gun assaults\u003c/a>against a dozen patients at the Sonoma Developmental Center last year.\u003c/p>\n\u003cp>\u003cimg title=\"More...\" src=\"http://ww2.kqed.org/news/wp-includes/js/tinymce/plugins/wordpress/img/trans.gif\" alt=\"\">\u003c/p>\n\u003cp>The Department of Public Health contended that because medical services provided to the developmentally disabled are considered confidential, the reports had to be “aggressively redacted” before disclosure, lawyers for the state wrote.\u003c/p>\n\u003cp>Judge Timothy Frawley dismissed that reasoning in the order.\u003c/p>\n\u003cp>“Under (the department’s) construction, redacting factual information from the citation, the public knows a violation has occurred, but cannot ascertain how the violation occurred, whether it has been corrected, or whether it is likely to be repeated,” Frawley wrote. “The purpose of making the citation public is defeated.”\u003c/p>\n\u003cp>Lawyers for the Department of Public Health argued that two laws, the Lanterman-Petris-Short Act and Lanterman Developmental Disabilities Service Act, both prohibit release of information pertaining to services to center patients. Meanwhile, another law, the Long Term Care Act mandates that facilities post citations in a public place.\u003c/p>\n\u003cp>Frawley decided the public’s right to know about abuse within state institutions outweighs laws making such information confidential. In the order, he wrote, “the Legislature already has made the determination that disclosure of the citations does not constitute an unwarranted invasion of personal privacy.”\u003c/p>\n\u003cp>The reports detail incidents in which the centers did not protect patients from harm, failed to provide competent medical care or violated patients' rights. They do not include the names of patients or employees.\u003c/p>\n\u003cp>The department has 20 days to appeal the ruling or comply by releasing the complete citations; only patient names can be removed.\u003c/p>\n\u003cp>In a prepared statement today, the Department of Public Health said it “is in the process of evaluating the court’s ruling.”\u003c/p>\n\u003cp>Robert Rosenthal, CIR's executive director, said the ruling means critical information will be released that will serve \"the public interest and help insure that some of the most vulnerable people in our society will be protected and treated in an appropriate manner.\"\u003c/p>\n\u003cp>Duffy Carolan, of the law firm Davis Wright Tremaine, represented CIR in the lawsuit.\u003c/p>\n\u003cp>Information about developmental center violations has historically been hard to get. Oftentimes, even relatives of patients injured or killed at the facilities have been blocked from obtaining details. The Department of Public Health frequently censors reports it provides to Disability Rights California, a protection organization with legal rights to patient records.\u003c/p>\n\u003cp>In \u003ca href=\"http://californiawatch.org/broken-shield\" target=\"_blank\">a series of stories\u003c/a> this year, California Watch has reported that an in-house police force at the state’s institutions routinely fails to conduct basic police work, even when patients die under mysterious circumstances. In case after case, detectives and officers have delayed interviews with witnesses or suspects – if they have conducted interviews at all.\u003c/p>\n\u003cp>The force, called the Office of Protective Services, has also waited too long to collect evidence or secure crime scenes and has been accused of going easy on co-workers who care for the disabled.\u003c/p>\n\u003cp>The Department of Public Health licenses and regulates the centers. Another state agency, the Department of Developmental Services, operates the centers and oversees the police.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>State officials have pledged to upgrade criminal investigations and to better protect patients from abuse and neglect. However, the public has not been able to see the full scope of violations documented at the centers.\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>by Ryan Gabrielson, \u003ca href=\"http://californiawatch.org/dailyreport/release-uncensored-developmental-center-citations-ordered-18076\">California Watch\u003c/a>\u003c/p>\n\u003cp>A state court today ordered the California Department of Public Health to disclose uncensored copies of dozens of patient abuse cases at institutions for the developmentally disabled.\u003c/p>\n\u003cfigure id=\"attachment_76371\" class=\"wp-caption alignleft\" style=\"max-width: 300px\">\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/09/developmental-center.jpg\">\u003cimg class=\"size-medium wp-image-76371\" title=\"developmental center\" src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/09/developmental-center-300x169.jpg\" alt=\"\" width=\"300\" height=\"169\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Larry Ingraham holds a picket outside the Orange County District Attorney's Office in Santa Ana. Ingraham wants the office to open a homicide investigation into the 2007 death of his brother, Van. (Michael Montgomery/KQED)\u003c/figcaption>\u003c/figure>\n\u003cp>\u003ca href=\"https://www.documentcloud.org/documents/435882-cir-v-cdph-order.html\" target=\"_blank\">The ruling came\u003c/a>in a lawsuit filed by the Center for Investigative Reporting in Sacramento County Superior Court in January, seeking citations issued to developmental centers in Los Angeles, Orange, Sonoma, Riverside, Tulare and Santa Clara counties.\u003c/p>\n\u003cp>Nearly 1,700 patients with cerebral palsy and profound intellectual disabilities live at the state’s board-and-care institutions. For decades, the public has been denied access to records detailing violations within the centers.\u003c/p>\n\u003cp>\u003ca href=\"http://cironline.org\" target=\"_blank\">CIR\u003c/a>, parent organization of California Watch, filed its request in May 2011, and the department responded by releasing 55 citations, totaling 169 pages. But the department blacked out \u003ca href=\"https://www.documentcloud.org/documents/282329-170004097-redacted.html\" target=\"_blank\">almost every word\u003c/a>. Thirty-five of the reports appear to involve abuse of patients, and the rest outline medical care and neglect violations from 2007 to mid-2011.\u003c!--more-->\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>More recently, the department has censored records detailing a 2009 \u003ca href=\"http://californiawatch.org/dailyreport/state-withholds-details-developmental-center-slaying-16458\" target=\"_blank\">homicide at the Fairview Developmental Center\u003c/a> and \u003ca href=\"http://californiawatch.org/public-safety/questions-surround-handling-taser-assaults-disabled-patients-17345\" target=\"_blank\">stun gun assaults\u003c/a>against a dozen patients at the Sonoma Developmental Center last year.\u003c/p>\n\u003cp>\u003cimg title=\"More...\" src=\"http://ww2.kqed.org/news/wp-includes/js/tinymce/plugins/wordpress/img/trans.gif\" alt=\"\">\u003c/p>\n\u003cp>The Department of Public Health contended that because medical services provided to the developmentally disabled are considered confidential, the reports had to be “aggressively redacted” before disclosure, lawyers for the state wrote.\u003c/p>\n\u003cp>Judge Timothy Frawley dismissed that reasoning in the order.\u003c/p>\n\u003cp>“Under (the department’s) construction, redacting factual information from the citation, the public knows a violation has occurred, but cannot ascertain how the violation occurred, whether it has been corrected, or whether it is likely to be repeated,” Frawley wrote. “The purpose of making the citation public is defeated.”\u003c/p>\n\u003cp>Lawyers for the Department of Public Health argued that two laws, the Lanterman-Petris-Short Act and Lanterman Developmental Disabilities Service Act, both prohibit release of information pertaining to services to center patients. Meanwhile, another law, the Long Term Care Act mandates that facilities post citations in a public place.\u003c/p>\n\u003cp>Frawley decided the public’s right to know about abuse within state institutions outweighs laws making such information confidential. In the order, he wrote, “the Legislature already has made the determination that disclosure of the citations does not constitute an unwarranted invasion of personal privacy.”\u003c/p>\n\u003cp>The reports detail incidents in which the centers did not protect patients from harm, failed to provide competent medical care or violated patients' rights. They do not include the names of patients or employees.\u003c/p>\n\u003cp>The department has 20 days to appeal the ruling or comply by releasing the complete citations; only patient names can be removed.\u003c/p>\n\u003cp>In a prepared statement today, the Department of Public Health said it “is in the process of evaluating the court’s ruling.”\u003c/p>\n\u003cp>Robert Rosenthal, CIR's executive director, said the ruling means critical information will be released that will serve \"the public interest and help insure that some of the most vulnerable people in our society will be protected and treated in an appropriate manner.\"\u003c/p>\n\u003cp>Duffy Carolan, of the law firm Davis Wright Tremaine, represented CIR in the lawsuit.\u003c/p>\n\u003cp>Information about developmental center violations has historically been hard to get. Oftentimes, even relatives of patients injured or killed at the facilities have been blocked from obtaining details. The Department of Public Health frequently censors reports it provides to Disability Rights California, a protection organization with legal rights to patient records.\u003c/p>\n\u003cp>In \u003ca href=\"http://californiawatch.org/broken-shield\" target=\"_blank\">a series of stories\u003c/a> this year, California Watch has reported that an in-house police force at the state’s institutions routinely fails to conduct basic police work, even when patients die under mysterious circumstances. In case after case, detectives and officers have delayed interviews with witnesses or suspects – if they have conducted interviews at all.\u003c/p>\n\u003cp>The force, called the Office of Protective Services, has also waited too long to collect evidence or secure crime scenes and has been accused of going easy on co-workers who care for the disabled.\u003c/p>\n\u003cp>The Department of Public Health licenses and regulates the centers. Another state agency, the Department of Developmental Services, operates the centers and oversees the police.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>State officials have pledged to upgrade criminal investigations and to better protect patients from abuse and neglect. However, the public has not been able to see the full scope of violations documented at the centers.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Obama Deportation Review Might Shrink Calif. Court Backlog",
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"content": "\u003cp>\u003cstrong>by Ryan Gabrielson, \u003ca href=\"http://www.baycitizen.org/immigration/story/obama-deportation-review-might-shrink/\">The Bay Citizen\u003c/a>\u003c/strong>\u003c/p>\n\u003cp>California’s clogged immigration courts are likely to receive relief under an Obama administration plan to avoid deporting young illegal immigrants brought into the country as children.\u003c/p>\n\u003cdiv id=\"rpuCopySelection\">\n\u003cp>\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/06/BayCitizenLogo7.png\">\u003cimg class=\"alignleft size-full wp-image-69055\" title=\"BayCitizenLogo\" src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/06/BayCitizenLogo7.png\" alt=\"\" width=\"218\" height=\"74\">\u003c/a>The court in Los Angeles has a backlog of nearly 52,000 deportation cases, the nation’s largest, according to the Executive Office for Immigration Review. San Francisco’s immigration court has more than 18,000 cases awaiting a ruling.\u003c/p>\n\u003cp>“Oftentimes, you can go to court and you can’t get anything done,” said David Gardner, an immigration attorney in Los Angeles. “There’s a tension between moving cases forward efficiently and fair and giving people due process rights.”\u003c/p>\n\u003cp>Later this summer, U.S. Immigration and Customs Enforcement will begin using \u003ca href=\"http://www.dhs.gov/xlibrary/assets/s1-exercising-prosecutorial-discretion-individuals-who-came-to-us-as-children.pdf\" target=\"_blank\">greater prosecutorial discretion\u003c/a> in deciding which deportation cases to pursue\u003cstrong>.\u003c/strong> Specifically, the department will grant a two-year reprieve to illegal immigrants who are younger than 30 years old, entered the United States before turning 16, are enrolled in school or honorably discharged from the military, and have no felony convictions or repeat misdemeanor convictions. The reprieve doesn't offer a path to citizenship or permanent residency; those who qualify must seek an extension after two years. \u003c!--more-->The selective enforcement will allow an estimated 800,000 illegal immigrants to remain in the country and apply for temporary work permits. It also could remove the burden of thousands of deportation cases from the immigration courts' dockets. \u003c!--more-->However, there is no count of how many deportation cases might close due to the Obama administration’s policy change. Kathryn Mattingly, spokeswoman for the Executive Office for Immigration Review, said the office does not track cases by the new enforcement criteria announced June 15.\u003c/p>\n\u003cp>Shiu-Ming Cheer, an attorney with the National Immigration Law Center, said she doubts the prosecutorial discretion will result in much change for illegal immigrants now facing deportation proceedings or for courts' backlogs.\u003c/p>\n\u003cp>“There might be some cases that are identified through that procedure,” Cheer said, “but it probably wouldn’t be more than a couple hundred in L.A.”\u003c/p>\n\u003cdiv id=\"rpuCopySelection\">\n\u003cp>Separate from the Obama administration’s latest move, ICE has reviewed more than 200,000 pending deportations nationwide during the past seven months to locate and close low-priority cases.\u003c/p>\n\u003cp>Of those, prosecutors have ended \u003ca href=\"https://www.documentcloud.org/documents/372265-ice-case-by-case-review-statistics-04-24-12.html\" target=\"_blank\">357 deportation proceedings\u003c/a> involving young illegal immigrants who likely meet the Obama administration’s new criteria, according to ICE figures.\u003c/p>\n\u003cp>This population of illegal immigrants is often called “dreamers,” as the intended beneficiaries of the federal DREAM Act, which would allow them to remain in the United States. The bill has repeatedly failed to pass through Congress.\u003c/p>\n\u003cp>Immigrant advocates and their legislative allies have criticized the previous deportation case review as ineffective. “It’s a lot of work for not very much,” U.S. Rep. Zoe Lofgren, a San Jose Democrat, \u003ca href=\"http://www.nytimes.com/2012/06/07/us/politics/deportations-continue-despite-us-review-of-backlog.html?_r=1&pagewanted=all\" target=\"_blank\">told The New York Times\u003c/a> earlier this month.\u003c/p>\n\u003cp>Meanwhile, the immigration court backlog has continued to grow.\u003c/p>\n\u003cp>Since March, the Los Angeles and San Francisco court dockets have added more than 5,000 pending cases, data from the federal immigration review office and Transactional Records Access Clearinghouse at Syracuse University shows. That marks an 8 percent increase in less than three months.\u003c/p>\n\u003cp>\u003cem>This story was produced by The Bay Citizen, a project of the Center for Investigative Reporting. Learn more at www.baycitizen.org.\u003c/em>\u003c/p>\n\u003c/div>\n\u003c/div>\n\u003cp>[ad fullwidth]\u003c/p>\u003cp>\u003c/p>\n",
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"description": "by Ryan Gabrielson, The Bay Citizen California’s clogged immigration courts are likely to receive relief under an Obama administration plan to avoid deporting young illegal immigrants brought into the country as children. The court in Los Angeles has a backlog of nearly 52,000 deportation cases, the nation’s largest, according to the Executive Office for Immigration Review.",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cstrong>by Ryan Gabrielson, \u003ca href=\"http://www.baycitizen.org/immigration/story/obama-deportation-review-might-shrink/\">The Bay Citizen\u003c/a>\u003c/strong>\u003c/p>\n\u003cp>California’s clogged immigration courts are likely to receive relief under an Obama administration plan to avoid deporting young illegal immigrants brought into the country as children.\u003c/p>\n\u003cdiv id=\"rpuCopySelection\">\n\u003cp>\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/06/BayCitizenLogo7.png\">\u003cimg class=\"alignleft size-full wp-image-69055\" title=\"BayCitizenLogo\" src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/06/BayCitizenLogo7.png\" alt=\"\" width=\"218\" height=\"74\">\u003c/a>The court in Los Angeles has a backlog of nearly 52,000 deportation cases, the nation’s largest, according to the Executive Office for Immigration Review. San Francisco’s immigration court has more than 18,000 cases awaiting a ruling.\u003c/p>\n\u003cp>“Oftentimes, you can go to court and you can’t get anything done,” said David Gardner, an immigration attorney in Los Angeles. “There’s a tension between moving cases forward efficiently and fair and giving people due process rights.”\u003c/p>\n\u003cp>Later this summer, U.S. Immigration and Customs Enforcement will begin using \u003ca href=\"http://www.dhs.gov/xlibrary/assets/s1-exercising-prosecutorial-discretion-individuals-who-came-to-us-as-children.pdf\" target=\"_blank\">greater prosecutorial discretion\u003c/a> in deciding which deportation cases to pursue\u003cstrong>.\u003c/strong> Specifically, the department will grant a two-year reprieve to illegal immigrants who are younger than 30 years old, entered the United States before turning 16, are enrolled in school or honorably discharged from the military, and have no felony convictions or repeat misdemeanor convictions. The reprieve doesn't offer a path to citizenship or permanent residency; those who qualify must seek an extension after two years. \u003c!--more-->The selective enforcement will allow an estimated 800,000 illegal immigrants to remain in the country and apply for temporary work permits. It also could remove the burden of thousands of deportation cases from the immigration courts' dockets. \u003c!--more-->However, there is no count of how many deportation cases might close due to the Obama administration’s policy change. Kathryn Mattingly, spokeswoman for the Executive Office for Immigration Review, said the office does not track cases by the new enforcement criteria announced June 15.\u003c/p>\n\u003cp>Shiu-Ming Cheer, an attorney with the National Immigration Law Center, said she doubts the prosecutorial discretion will result in much change for illegal immigrants now facing deportation proceedings or for courts' backlogs.\u003c/p>\n\u003cp>“There might be some cases that are identified through that procedure,” Cheer said, “but it probably wouldn’t be more than a couple hundred in L.A.”\u003c/p>\n\u003cdiv id=\"rpuCopySelection\">\n\u003cp>Separate from the Obama administration’s latest move, ICE has reviewed more than 200,000 pending deportations nationwide during the past seven months to locate and close low-priority cases.\u003c/p>\n\u003cp>Of those, prosecutors have ended \u003ca href=\"https://www.documentcloud.org/documents/372265-ice-case-by-case-review-statistics-04-24-12.html\" target=\"_blank\">357 deportation proceedings\u003c/a> involving young illegal immigrants who likely meet the Obama administration’s new criteria, according to ICE figures.\u003c/p>\n\u003cp>This population of illegal immigrants is often called “dreamers,” as the intended beneficiaries of the federal DREAM Act, which would allow them to remain in the United States. The bill has repeatedly failed to pass through Congress.\u003c/p>\n\u003cp>Immigrant advocates and their legislative allies have criticized the previous deportation case review as ineffective. “It’s a lot of work for not very much,” U.S. Rep. Zoe Lofgren, a San Jose Democrat, \u003ca href=\"http://www.nytimes.com/2012/06/07/us/politics/deportations-continue-despite-us-review-of-backlog.html?_r=1&pagewanted=all\" target=\"_blank\">told The New York Times\u003c/a> earlier this month.\u003c/p>\n\u003cp>Meanwhile, the immigration court backlog has continued to grow.\u003c/p>\n\u003cp>Since March, the Los Angeles and San Francisco court dockets have added more than 5,000 pending cases, data from the federal immigration review office and Transactional Records Access Clearinghouse at Syracuse University shows. That marks an 8 percent increase in less than three months.\u003c/p>\n\u003cp>\u003cem>This story was produced by The Bay Citizen, a project of the Center for Investigative Reporting. Learn more at www.baycitizen.org.\u003c/em>\u003c/p>\n\u003c/div>\n\u003c/div>\n\u003cp>\u003c/p>\u003c/div>",
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"disqusTitle": "Solano County Won't Re-Check Autopsies Done by Pathologist Found to Be Incompetent",
"title": "Solano County Won't Re-Check Autopsies Done by Pathologist Found to Be Incompetent",
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"content": "\u003cp>From \u003ca href=\"http://californiawatch.org/dailyreport/solano-county-won-t-review-300-more-autopsies-16225\">\u003cstrong>California Watch\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>Dr. Thomas Gill’s forensic pathology career already was scarred by numerous autopsy mistakes before he started ruling on causes of death for the Solano County sheriff-coroner in 2007.\u003c/p>\n\u003cfigure id=\"attachment_66168\" class=\"wp-caption alignleft\" style=\"max-width: 300px\">\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/05/Dr-Gill-Michael-McClure-photo-350px.jpg\">\u003cimg src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/05/Dr-Gill-Michael-McClure-photo-350px-300x300.jpg\" alt=\"\" title=\"Dr-Gill--Michael-McClure-photo-350px\" width=\"300\" height=\"300\" class=\"size-medium wp-image-66168\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Dr. Thomas Gill, shown in 2004. (Courtesy of Michael McClure)\u003c/figcaption>\u003c/figure>\n\u003cp>Gill examined 332 deaths for the county in three years. Following a series of news stories last year detailing Gill’s history of inaccurate autopsy findings, Solano County Sheriff Gary Stanton ordered an outside review of 32 of the cases. The \u003ca href=\"http://www.baycitizen.org/crime/story/defendants-murder-case-didnt-see-report/\" target=\"_blank\">results were alarming\u003c/a>: A respected forensic pathologist determined Gill’s conclusions on eight of the deaths were “unreasonable” and more than half had “critical errors.”\u003c/p>\n\u003cp>The sheriff’s office, however, does not intend to continue checking Gill’s past autopsies, said Lt. Gary Faulkner, the chief deputy coroner. None of the other 300 cases is believed to have involved foul play or illegal activity.\u003c/p>\n\u003cp>“During the course of those other autopsies, there was no evidence uncovered that led the pathologist, or anyone from our office, to believe that a crime had been committed,” Faulkner said.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>The sheriff’s office does not have the resources to open every post-mortem examination Gill did for Solano County, Faulkner said. “In many cases, there’s really nothing left to work with,” he said. \u003c!--more-->\u003c/p>\n\u003cp>Stanton hired Dr. Bennet Omalu, chief medical examiner for the San Joaquin County Sheriff’s Office, to re-examine 32 of Gill’s autopsies, several of which involved a death that resulted from violent crimes. Omalu found problems in more than half of the post-mortem reports, the \u003ca href=\"https://www.documentcloud.org/documents/291049-2008-0054-ricky-vincent-meyi-autopsy-review-report.html\" target=\"_blank\">most egregious example\u003c/a> being the 2008 death of Ricky Meyi.\u003c/p>\n\u003cp>The remains of Meyi, a 50-year-old Vallejo resident, were found burned and left in a ditch. Gill performed Meyi's autopsy and concluded that the man died of “complications of blunt force injuries.”\u003c/p>\n\u003caside class=\"pullquote alignleft\">\u003ca href=\"http://www.pbs.org/wgbh/pages/frontline/post-mortem/second-chances/\">\u003cstrong>Frontline/California Watch investigation: Second chances underscore flaws in death investigations\u003c/strong>\u003c/a>\u003c/aside>\n\u003cp>But Gill’s initial report did not document any blunt-force trauma. During a second exam, Gill listed blunt-force injuries on Meyi’s back, though Omalu disputed that such injuries could have killed the man. Those markings might have not been injuries at all, as blood settles after death, leaving marks that Gill might have mistaken for trauma, Omalu said.\u003c/p>\n\u003cp>Seven people accepted plea agreements with prison sentences related to Meyi’s death, despite the lack of evidence proving what killed him. The Solano County district attorney based much of the case on witness statements that said Meyi was beaten by a group at a party. Julie Underwood, the lead prosecutor on the case, told California Watch that she did not read Omalu's review and dismissed it as \"one person's opinion.\" \u003c!--more-->\u003c/p>\n\u003cp>A joint investigation by California Watch, ProPublica and PBS Frontline last year detailed how Gill, 68, has repeatedly \u003ca href=\"http://californiawatch.org/postmortem\" target=\"_blank\">resurrected his career\u003c/a> in coroners’ offices across the United States over the past two decades after autopsy errors undermined criminal cases and misdiagnosed causes of death. The California State Bar called the doctor “incompetent” in a 2006 report on a botched homicide investigation in Sonoma County.\u003c/p>\n\u003cp>Gill was working for a private firm, Forensic Medical Group, when he performed the Solano County autopsies. The firm provides forensic pathology services to more than a dozen Northern California jurisdictions.\u003c/p>\n\u003cp>Forensic Medical Group fired Gill in early 2011, saying it did not have enough cases to keep the doctor.\u003c/p>\n\u003cp>Omalu discovered Gill continued to struggle with identifying evidence during autopsies and interpreting test results.\u003c/p>\n\u003cp>In 2007, Christina Baxley, a 41-year-old woman, was shot to death while walking her dog. Although the cause of Baxley’s death was not in question, Gill’s \u003ca href=\"https://www.documentcloud.org/documents/291043-2007-1033-christina-lee-baxley-autopsy-report.html\" target=\"_blank\">autopsy appears incomplete\u003c/a>, as he misidentified certain injuries and entirely overlooked a bullet hole, according to Omalu.\u003c/p>\n\u003cp>“Review of the scene and autopsy pictures reveals a vividly obvious gunshot wound in the left anterior chest, which was not described in the autopsy report,” Omalu wrote.\u003c/p>\n\u003cp>Gill also allegedly \u003ca href=\"https://www.documentcloud.org/documents/291052-2008-0080-david-emerson-slaughter-autopsy-review.html\" target=\"_blank\">misinterpreted a toxicology report\u003c/a> in the death of David Slaughter, who was discovered unresponsive in his cell at California State Prison, Solano in January 2008.\u003c/p>\n\u003cp>In the autopsy report, Gill listed Slaughter’s cause of death as “morphine toxicity.” Omalu’s review of Slaughter’s blood results determined the death was caused instead by a toxic combination of amphetamines and heroin – a significant discrepancy.\u003c/p>\n\u003cp>Omalu noted another key shortcoming in Gill’s work on Slaughter’s death: no visual evidence.\u003c/p>\n\u003cp>“Digital photographic documentation of autopsy findings are expected accompaniments of autopsy reports in this modern day, especially in homicidal cases and unique cases like this case involving sudden in-custody deaths,” Omalu wrote. “This is a critical flaw.\"\u003c/p>\n\u003cp>Omalu argues that Gill repeatedly failed to meet basic standards of the profession. In multiple reviews, Omalu wrote in all caps: “There is a constellation of critical flaws in this case.”\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\u003cem>Ryan Gabrielson is an investigative reporter for \u003ca href=\"http://californiawatch.org/\">California Watch\u003c/a>\u003c/em>.\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>From \u003ca href=\"http://californiawatch.org/dailyreport/solano-county-won-t-review-300-more-autopsies-16225\">\u003cstrong>California Watch\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>Dr. Thomas Gill’s forensic pathology career already was scarred by numerous autopsy mistakes before he started ruling on causes of death for the Solano County sheriff-coroner in 2007.\u003c/p>\n\u003cfigure id=\"attachment_66168\" class=\"wp-caption alignleft\" style=\"max-width: 300px\">\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/05/Dr-Gill-Michael-McClure-photo-350px.jpg\">\u003cimg src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/05/Dr-Gill-Michael-McClure-photo-350px-300x300.jpg\" alt=\"\" title=\"Dr-Gill--Michael-McClure-photo-350px\" width=\"300\" height=\"300\" class=\"size-medium wp-image-66168\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Dr. Thomas Gill, shown in 2004. (Courtesy of Michael McClure)\u003c/figcaption>\u003c/figure>\n\u003cp>Gill examined 332 deaths for the county in three years. Following a series of news stories last year detailing Gill’s history of inaccurate autopsy findings, Solano County Sheriff Gary Stanton ordered an outside review of 32 of the cases. The \u003ca href=\"http://www.baycitizen.org/crime/story/defendants-murder-case-didnt-see-report/\" target=\"_blank\">results were alarming\u003c/a>: A respected forensic pathologist determined Gill’s conclusions on eight of the deaths were “unreasonable” and more than half had “critical errors.”\u003c/p>\n\u003cp>The sheriff’s office, however, does not intend to continue checking Gill’s past autopsies, said Lt. Gary Faulkner, the chief deputy coroner. None of the other 300 cases is believed to have involved foul play or illegal activity.\u003c/p>\n\u003cp>“During the course of those other autopsies, there was no evidence uncovered that led the pathologist, or anyone from our office, to believe that a crime had been committed,” Faulkner said.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>The sheriff’s office does not have the resources to open every post-mortem examination Gill did for Solano County, Faulkner said. “In many cases, there’s really nothing left to work with,” he said. \u003c!--more-->\u003c/p>\n\u003cp>Stanton hired Dr. Bennet Omalu, chief medical examiner for the San Joaquin County Sheriff’s Office, to re-examine 32 of Gill’s autopsies, several of which involved a death that resulted from violent crimes. Omalu found problems in more than half of the post-mortem reports, the \u003ca href=\"https://www.documentcloud.org/documents/291049-2008-0054-ricky-vincent-meyi-autopsy-review-report.html\" target=\"_blank\">most egregious example\u003c/a> being the 2008 death of Ricky Meyi.\u003c/p>\n\u003cp>The remains of Meyi, a 50-year-old Vallejo resident, were found burned and left in a ditch. Gill performed Meyi's autopsy and concluded that the man died of “complications of blunt force injuries.”\u003c/p>\n\u003caside class=\"pullquote alignleft\">\u003ca href=\"http://www.pbs.org/wgbh/pages/frontline/post-mortem/second-chances/\">\u003cstrong>Frontline/California Watch investigation: Second chances underscore flaws in death investigations\u003c/strong>\u003c/a>\u003c/aside>\n\u003cp>But Gill’s initial report did not document any blunt-force trauma. During a second exam, Gill listed blunt-force injuries on Meyi’s back, though Omalu disputed that such injuries could have killed the man. Those markings might have not been injuries at all, as blood settles after death, leaving marks that Gill might have mistaken for trauma, Omalu said.\u003c/p>\n\u003cp>Seven people accepted plea agreements with prison sentences related to Meyi’s death, despite the lack of evidence proving what killed him. The Solano County district attorney based much of the case on witness statements that said Meyi was beaten by a group at a party. Julie Underwood, the lead prosecutor on the case, told California Watch that she did not read Omalu's review and dismissed it as \"one person's opinion.\" \u003c!--more-->\u003c/p>\n\u003cp>A joint investigation by California Watch, ProPublica and PBS Frontline last year detailed how Gill, 68, has repeatedly \u003ca href=\"http://californiawatch.org/postmortem\" target=\"_blank\">resurrected his career\u003c/a> in coroners’ offices across the United States over the past two decades after autopsy errors undermined criminal cases and misdiagnosed causes of death. The California State Bar called the doctor “incompetent” in a 2006 report on a botched homicide investigation in Sonoma County.\u003c/p>\n\u003cp>Gill was working for a private firm, Forensic Medical Group, when he performed the Solano County autopsies. The firm provides forensic pathology services to more than a dozen Northern California jurisdictions.\u003c/p>\n\u003cp>Forensic Medical Group fired Gill in early 2011, saying it did not have enough cases to keep the doctor.\u003c/p>\n\u003cp>Omalu discovered Gill continued to struggle with identifying evidence during autopsies and interpreting test results.\u003c/p>\n\u003cp>In 2007, Christina Baxley, a 41-year-old woman, was shot to death while walking her dog. Although the cause of Baxley’s death was not in question, Gill’s \u003ca href=\"https://www.documentcloud.org/documents/291043-2007-1033-christina-lee-baxley-autopsy-report.html\" target=\"_blank\">autopsy appears incomplete\u003c/a>, as he misidentified certain injuries and entirely overlooked a bullet hole, according to Omalu.\u003c/p>\n\u003cp>“Review of the scene and autopsy pictures reveals a vividly obvious gunshot wound in the left anterior chest, which was not described in the autopsy report,” Omalu wrote.\u003c/p>\n\u003cp>Gill also allegedly \u003ca href=\"https://www.documentcloud.org/documents/291052-2008-0080-david-emerson-slaughter-autopsy-review.html\" target=\"_blank\">misinterpreted a toxicology report\u003c/a> in the death of David Slaughter, who was discovered unresponsive in his cell at California State Prison, Solano in January 2008.\u003c/p>\n\u003cp>In the autopsy report, Gill listed Slaughter’s cause of death as “morphine toxicity.” Omalu’s review of Slaughter’s blood results determined the death was caused instead by a toxic combination of amphetamines and heroin – a significant discrepancy.\u003c/p>\n\u003cp>Omalu noted another key shortcoming in Gill’s work on Slaughter’s death: no visual evidence.\u003c/p>\n\u003cp>“Digital photographic documentation of autopsy findings are expected accompaniments of autopsy reports in this modern day, especially in homicidal cases and unique cases like this case involving sudden in-custody deaths,” Omalu wrote. “This is a critical flaw.\"\u003c/p>\n\u003cp>Omalu argues that Gill repeatedly failed to meet basic standards of the profession. In multiple reviews, Omalu wrote in all caps: “There is a constellation of critical flaws in this case.”\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\u003cem>Ryan Gabrielson is an investigative reporter for \u003ca href=\"http://californiawatch.org/\">California Watch\u003c/a>\u003c/em>.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Police Force’s Sloppy Investigations Leave Abuse of Disabled Unsolved",
"title": "Police Force’s Sloppy Investigations Leave Abuse of Disabled Unsolved",
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"content": "\u003cp>From \u003ca href=\"http://californiawatch.org/public-safety/police-force-s-sloppy-investigations-leave-abuse-disabled-unsolved-14971\">\u003cstrong>California Watch\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>California has assembled a unique police force to protect about 1,800 of its most vulnerable patients – men and women with cerebral palsy, severe autism and other mental disabilities who live in state institutions and require round-the-clock monitoring and protection from abuse.\u003c/p>\n\u003cfigure id=\"attachment_57538\" class=\"wp-caption alignleft\" style=\"max-width: 300px\">\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/02/lazzini5.jpg\">\u003cimg src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/02/lazzini5-300x199.jpg\" alt=\"\" title=\"lazzini\" width=\"300\" height=\"199\" class=\"size-medium wp-image-57538\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Donna Lazzini embraces her son, Timothy Lazzini, a resident of the Sonoma Developmental Center who died in 2005. The picture is part of a family photo collage celebrating his life. (Monica Lam/ California Watch)\u003c/figcaption>\u003c/figure>\n\u003cp>But an investigation by California Watch has found that detectives and patrol officers at the state’s five board-and-care institutions routinely fail to conduct basic police work even when patients die under mysterious circumstances.\u003c/p>\n\u003cp>Federal audits and investigations by disability-rights groups, as well as thousands of pages of case files, government data and lawsuits dating back to 2000, show caregivers and other facility staff allegedly involved in choking, shoving, hitting and sexually assaulting patients. None of these cases were prosecuted. \u003c!--more-->\u003c/p>\n\u003cp>Cases investigated as possible crimes include the death of a severely autistic man whose neck was broken. Three medical experts said the 50-year-old patient, Van Ingraham, likely had been killed. But the developmental center’s detective, a former nurse who’d never handled a suspicious death, failed to identify how the fatal injury occurred.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>The police force, called the Office of Protective Services, often learns about potential criminal abuse hours or days after the fact – if they find out at all. Of the hundreds of abuse cases reported at the centers since 2006, California Watch could find just two cases where the department made an arrest.\u003c/p>\n\u003cp>The people that the police force is sworn to protect have profound developmental disabilities and live in a different world from most Californians. Some patients have spent decades in the centers, from childhood to death. Some cannot form words and have IQ scores in the single digits.\u003c/p>\n\u003cp>The precise number of times nurses, janitors or staff supervisors have been implicated in patient abuse cases is unknown; the state has censored thousands of pages of documents detailing the cases.\u003c/p>\n\u003cp>California is budgeted to spend $577 million this fiscal year to operate the centers, or roughly $320,000 per patient. More than 5,200 people work in the institutions – roughly 2.5 staff members for each patient. The five centers are in Los Angeles, Orange, Riverside, Sonoma and Tulare counties.\u003c/p>\n\u003cp>In most other states, local law enforcement or state police take the lead in conducting criminal investigations at developmental centers.\u003c/p>\n\u003cp>Critics of the state Department of Developmental Services, which oversees the institutions and the Office of Protective Services, have said the tight-knit atmosphere between the in-house police and staff makes it difficult to create a separation between the investigators and the investigated.\u003c/p>\n\u003cp>In a few cases, caregivers and others with minimal police training have been hired to work as law enforcement in the same facility. The commander at the Lanterman Developmental Center in Pomona worked there as a primary caregiver. The force’s police chief is a former firefighter at the Sonoma Developmental Center.\u003c/p>\n\u003cp>The police force also suffers from a convoluted chain of command, interviews and records show. Detectives cannot make arrests without checking with department lawyers in Sacramento. Local police must be informed when serious injuries or deaths occur, but most defer investigations to the Office of Protective Services.\u003c/p>\n\u003cp>“It seems like something is not working in California. And that’s probably a major understatement,” said Tamie Hopp, an official with the national organization Voice of the Retarded, who noted the volume of abuse cases in California, and the lack of prosecutions, is cause for alarm.\u003c/p>\n\u003cp>Terri Delgadillo, director of the Department of Developmental Services, said her department has a zero-tolerance policy that includes reporting any injuries, even those remotely suspicious, to the state Department of Public Health. She said the department is committed to conducting thorough investigations.\u003c/p>\n\u003cp>“For the department, the priority is to make sure that we’re doing the best job providing consumer safety and services,” Delgadillo said in an interview. “And if there are issues that need to be addressed – and there’s always room for improvement – we’re looking to do that.”\u003c/p>\n\u003cp>She has hired a consulting group, the Consortium on Innovative Practices based in Alabama, to review the methods and training of her police force. The nonprofit group was recommended by the U.S. Department of Justice, which issued a \u003ca href=\"https://www.documentcloud.org/documents/256286-justicedept-lanterman-findings.html#document/p11/a35580\" target=\"_blank\">scathing critique\u003c/a> of the department in 2006.\u003c/p>\n\u003cp>The department said that from January 2008 to last month, 67 developmental center employees were fired for “client-related” offenses. But officials declined to say how many of those, if any, were dismissed for abusing patients, where they worked or if any of them had been arrested.\u003c/p>\n\u003cp>Delgadillo also declined to comment on specific cases of alleged abuse or mistreatment at the developmental centers, citing patient privacy laws. Corey Smith, the former firefighter who is now police chief, said he was not permitted to speak with reporters for this story.\u003c/p>\n\u003cp>\u003cstrong>\u003ca name=\"facts\">\u003c/a>Abuse cases increase\u003c/strong>\u003c/p>\n\u003cp>\u003ca name=\"since06\">\u003c/a>The developmental centers have been the scene of 327 patient abuse cases since 2006, according to inspection data from the California Department of Public Health. Patients have suffered an additional 762 injuries of “unknown origin” – often a signal of abuse that under state policy should be investigated as a potential crime.\u003c/p>\n\u003cp>At the state’s five centers, the list of unexplained injuries includes patients who suffered deep cuts on the head; a fractured pelvis; a broken jaw; busted ribs, shins and wrists; bruises and tears to male genitalia; and burns on the skin the size and shape of a cigarette butt.\u003c/p>\n\u003cp>Timothy Lazzini, a quadriplegic cerebral palsy patient at the Sonoma Developmental Center, died in 2005 after he swallowed 4-inch swabs that shredded his esophagus. After his death, Lazzini’s doctor and a \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p23/a45400\" target=\"_blank\">pathologist concluded\u003c/a> it was highly unlikely that Lazzini could have placed the swabs in his own mouth.\u003c/p>\n\u003cp>But records show detectives waited too long to start their investigation. If any physical evidence was left in Lazzini's room, it had been removed by the time investigators arrived.\u003c/p>\n\u003cp>His death, and the slow response by the Office of Protective Services, has left Lazzini’s family heartbroken and without a conclusive answer as to how he was killed.\u003c/p>\n\u003cp>“He is gone and they really haven’t given us as a family the information that we need to be at peace,” said Stephanie Contreras, Lazzini’s sister. “There is no peace at all.”\u003c/p>\n\u003cp>The rate of suspected abuse cases within the walls of the five institutions has risen – even as hundreds of developmentally disabled patients have been moved to group homes and smaller nursing facilities.\u003c/p>\n\u003cp>The patient population at developmental centers \u003ca href=\"http://www.dds.ca.gov/DevCtrs/AllFacPop.cfm\" target=\"_blank\">dropped by 12 percent\u003c/a> from 2008 to 2010, state records show, but reports of abuse have increased 43 percent during those three years. \u003ca href=\"http://projects.californiawatch.org/broken-shield\" target=\"_blank\">Unexplained injuries\u003c/a> jumped 8 percent in the same period.\u003c/p>\n\u003cp>Public health officials acknowledged the state doesn’t keep a tally of the number of times caregivers have abused patients. That information is kept hidden from the public in individual case files.\u003c/p>\n\u003cp>Kathleen Billingsley, director of policy and programs for the Department of Public Health, said she also didn’t know whether inspectors were notifying law enforcement agencies when they uncover evidence of abuse. She said public health inspectors conduct thorough investigations separately from the police.\u003c/p>\n\u003cp>“If there is any cross between enforcement individuals at the state facility and the work we do, I am not familiar with that,” Billingsley said.\u003c/p>\n\u003cp>The Los Angeles County district attorney’s office, which oversees Lanterman, couldn’t identify a single criminal case referred from the center’s police force. District attorneys in Tulare, Orange and Riverside counties also reported no prosecutions for patient abuse in the past decade. Sonoma County refused to disclose its records.\u003c/p>\n\u003cp>On average, police in California solve about two-thirds of all homicides and about half of all aggravated assaults – or at least make an arrest and “clear” the cases. The clearance rate for the Office of Protective Services is unknown because the department keeps the information secret.\u003c/p>\n\u003cp>\u003cstrong>Thankless jobs, hidden from the public\u003c/strong>\u003c/p>\n\u003cp>The Office of Protective Services has existed in various forms and names since the late 19\u003csup>th\u003c/sup> century, when California opened its first institution for the developmentally disabled. That facility in San Jose – first known as the Agnews Insane Asylum – opened in 1885 and closed in 2009.\u003c/p>\n\u003cp>Interviews with current and former Office of Protective Services employees suggest the organization’s structure from its beginning has contributed to its dysfunction.\u003c/p>\n\u003cp>Patrol officers dress much like those at any other police department. They wear tan and green uniforms with gold badges. Handcuffs are hooked to their belts. They drive marked squad cars. But there are key differences.\u003c/p>\n\u003cp>Officers and caregivers are confined together in a 24-hour facility monitoring an unpredictable, sometimes uncontrollable population. Beyond a paycheck, the job is mostly thankless and hidden from the public. Officers are not allowed to carry guns; many carry pepper spray instead. They often work their shifts alone.\u003c/p>\n\u003cp>Greg Wardwell, a sergeant who spent more than 20 years patrolling the Sonoma Developmental Center before retiring last year, said the state has undermined its own police force through neglect and incompetence.\u003c/p>\n\u003cp>“You can look like a cop and we’ll call you a cop, but you don’t really have any way of being a cop,” Wardwell said. “Because we’re not going to train you, we won’t provide safety equipment. The salary will be so bad that we won’t be able to recruit anybody of talent.”\u003c/p>\n\u003cp>Salaries for the roughly 90 sworn officers are half of what police earn in the state’s big city departments. Yet, roughly a third of officers within the Office of Protective Services are among the best compensated in California law enforcement, with much of their pay gained through overtime. One officer’s income has topped $200,000 a year.\u003c/p>\n\u003cp>Families must rely on the Office of Protective Services to provide evidence for lawsuits when their relatives are harmed or killed at a developmental center. Records show the state paid out nearly $9 million in legal settlements – out of 68 separate lawsuits – from 2004 to 2010.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“Photographs were not taken,” the report states. “Not all witnesses, nor all key witnesses, were interviewed. Physical evidence was not collected. Victims did not receive thorough medical workups to look for other indications of abuse.”\u003c/p>\n\u003cp>Leslie Morrison, director of investigations at \u003ca href=\"http://www.disabilityrightsca.org/\" target=\"_blank\">Disability Rights California\u003c/a>, said the report showed how the developmentally disabled can be treated as second-class citizens.\u003c/p>\n\u003cp>“If this had happened to 3-year-old boys in a day care center, people would have been alarmed, police would have been called, there would have been an outrage,” Morrison said. “It wouldn't have just been treated as just, 'Oh, look, there's a cut, we better sew that up.' ”\u003c/p>\n\u003cp>In the case of the 50-year-old autistic man, Van Ingraham, his family received $800,000 in a settlement with the state. Ingraham died in 2007 after sustaining a broken neck while in his room at the Fairview Developmental Center in Orange County.\u003c/p>\n\u003cp>Fairview officers didn’t collect physical evidence from Ingraham’s room, records show. Detectives overlooked evidence that a caregiver last seen with Ingraham had \u003ca href=\"https://www.documentcloud.org/documents/251733-ops-ingraham-casefile-rg.html#document/p15/a45401\" target=\"_blank\">altered the log of his activities\u003c/a>. And they omitted from the case file an expert’s opinion that Ingraham’s death “was likely a homicide.”\u003c/p>\n\u003cp>“This incompetent, horrendous organization called Office of Protective Services takes it and just makes a mess, just a complete mangled mess of the investigation,” said Larry Ingraham, the patient’s older brother and a veteran of the San Diego Police Department.\u003c/p>\n\u003cp>\u003cstrong>Sexual assaults unprosecuted\u003c/strong>\u003c/p>\n\u003cp>Sex abuse cases, too, have been shelved without prosecution.\u003c/p>\n\u003cp>In April 2010, at the Canyon Springs Developmental Center in Riverside County, a janitor twice sexually abused a mentally disabled female patient when caregivers were out of sight. Under California law, having sex with any developmentally disabled person who is incapable of giving consent is considered rape.\u003c/p>\n\u003cp>The patient, who is not identified in state records, had a history of being assaulted. She was institutionalized at age 12 after her father impregnated her, a state health department citation shows.\u003c/p>\n\u003cp>The patient had been diagnosed with moderate mental retardation, schizoaffective disorder and post-traumatic stress disorder. Canyon Springs staff had been working with her to curb any behavior “possibly leading to sexual activity,” her file states.\u003c/p>\n\u003cp>The female patient, then 39 years old, \u003ca href=\"https://www.documentcloud.org/documents/282341-170007499-redacted.html#document/p1/a42068\" target=\"_blank\">told center employees\u003c/a> she “did it” with the janitor in the women’s bathroom and in a hallway during a fire drill. An unidentified Canyon Springs employee notified the state Department of Public Health.\u003c/p>\n\u003cp>The Office of Protective Services investigated the case but made no arrests. State regulators also investigated and ruled the incidents as sexual abuse, according to a citation issued to Canyon Springs.\u003c/p>\n\u003cp>In December 2010, Canyon Springs was fined $800 by public health officials for the incidents. No criminal charges followed. The Riverside County district attorney’s office said it has no record of receiving any case referrals from Canyon Springs, which houses about 50 patients.\u003c/p>\n\u003cp>Rather than placing the janitor under arrest, developmental center officials ordered him to undergo training on his “legal duty” regarding patient abuse, according to state records.\u003c/p>\n\u003cp>The Office of Protective Services concluded that the janitor didn’t commit a crime, Delgadillo said. She declined to answer other questions about the incident or to say whether the janitor, whose name the state has redacted from case files, continues to work at Canyon Springs.\u003c/p>\n\u003cp>\u003ca name=\"sexualabuse2\">\u003c/a>In another case with even fewer details available, a female patient at the Sonoma Developmental Center accused a male caregiver of sexually assaulting her during a bath in early 2000, police records show. The institution responded by assigning two men to bathe the patient.\u003c/p>\n\u003cp>On July 6, 2000, both caregivers allegedly raped her, again during bathing.\u003c/p>\n\u003cp>The institution did not inform its own police officers about the details of either incident. Records show Ed Contreras, then Sonoma’s police commander, received an anonymous tip four days after the second alleged rape.\u003c/p>\n\u003cp>“They weren’t following the law,” Contreras said in an interview. “They weren’t reporting it to the police department. They weren’t reporting it to me.”\u003c/p>\n\u003cp>Contreras said no arrests were made in the sex assaults. The Sonoma County district attorney’s office declined to release records on the cases or any other criminal allegations from the developmental center.\u003c/p>\n\u003cp>\u003cstrong>Inside institutions, a different world\u003c/strong>\u003c/p>\n\u003cp>The Sonoma Developmental Center is located in a quaint neighborhood in the middle of wine country. Fairview in Costa Mesa is near the Orange County fairgrounds and surrounded by strip malls and a golf course. Lanterman is wedged between train tracks and a highway east of Los Angeles.\u003c/p>\n\u003cp>Next door to a Cathedral City cemetery, tiny Canyon Springs could be mistaken for an office park. The Porterville Developmental Center, southeast of Visalia, does have the look of an institution. Among the 500 patients, the facility houses about 200 developmentally disabled patients who have committed crimes or who are under arrest.\u003c/p>\n\u003cp>Inside, the centers feature wide hallways. Walls are decorated much the same as elementary school classrooms, with colors and construction paper cutouts to signal upcoming holidays.\u003c/p>\n\u003cp>Primary caregivers, called psychiatric technicians, guide patients from place to place, feeding them and distributing medication. Each patient communicates differently, and the units are filled with shouts, groans, shrieks and crying. Patients share bedrooms. Some are crowded with stuffed animals, posters and family pictures. Others are empty, save for the full-sized beds and a cabinet.\u003c/p>\n\u003cp>Parents and siblings can visit every week for hours at a time. Fairview patients range from 15 to 94 years old, said Bill Wilson, the institution’s executive director. Most are between the ages of 40 and 60.\u003c/p>\n\u003cp>More than two-thirds of patients are diagnosed with profound mental disabilities, \u003ca href=\"https://www.documentcloud.org/documents/295214-factors-associated-with-living-in-developmental.html#document/p7/a45411\" target=\"_blank\">according to research\u003c/a> from UC San Francisco. The institutions have whole units for patients who are emotionally volatile, prone to striking themselves and others.\u003c/p>\n\u003cp>The disabled population adds greater complexity to criminal investigations. For a host of reasons, their observations can be tainted by fantasies and falsehoods. Their emotions veer from happy to inconsolable without warning. Patients slap and punch at their faces and legs, and at each other.\u003c/p>\n\u003cp>“They come to us after they’ve burned every bridge in the community,” said Erinn Kanney, a program manager at Fairview.\u003c/p>\n\u003cp>Outside of California, local or state police most often are responsible for investigating criminal cases at institutions. But city and county law enforcement agencies inside the state have not shown an interest in developmental center cases and don’t have funding to expand their scope, according to Delgadillo.\u003c/p>\n\u003cp>“Oftentimes, local law enforcement does not want to get involved,” said Delgadillo, who in the past has worked for the California Department of Corrections and Rehabilitation as a manager in the juvenile justice division.\u003c/p>\n\u003cp>Local police or sheriff’s deputies can act more independently than an internal police force responsible for probes into their colleagues and bosses, said Jane Hudson, senior staff attorney for the National Disability Rights Network, a patient advocacy organization\u003c/p>\n\u003cp>\u003ca name=\"quote\">\u003c/a>“If there’s a crime committed,” Hudson said, “you let the criminal investigators go in first rather than the institution bagging the bloody shirt.”\u003c/p>\n\u003cp>\u003cstrong>Delayed notification hinders investigations\u003c/strong>\u003c/p>\n\u003cp>Delays by the Office of Protective Services often make cases harder to solve.\u003c/p>\n\u003cp>\u003ca name=\"dozen\">\u003c/a>Although no public records exist showing how frequently the police force receives late notification of potential abuse cases, California Watch was able to identify at least a dozen incidents in which delays from 24 hours to several days occurred.\u003c/p>\n\u003cp>Forensic experts say the first hours following a crime are critical. A person walking through a crime scene can ruin fingerprints, DNA samples and other evidence, said Dennis Kilcoyne, a Los Angeles Police Department homicide detective. Witness statements can change with time, especially after they’ve conferred with others, he said.\u003c/p>\n\u003cp>“People’s emotions are in play, and they may say things that, after they’ve thought about it or consulted with an attorney, (they) won’t say a week from now,” said Kilcoyne, a 27-year veteran.\u003c/p>\n\u003cp>Delays have hurt criminal investigations and given the centers’ employees time to alter and destroy evidence, records and interviews show.\u003c/p>\n\u003cp>That’s what happened in the case of Timothy Lazzini, the 25-year-old quadriplegic patient with cerebral palsy, who coughed up a bloody glycerin swab at the Sonoma Developmental Center. He died from internal bleeding that night, Oct. 22, 2005.\u003c/p>\n\u003cp>Three swabs – each 4 inches long and twice as thick as a Q-tip – had torn Lazzini’s esophagus. He coughed out one, but two others remained lodged in his stomach, autopsy records show.\u003c/p>\n\u003cp>At that point in his life, Lazzini’s disabilities had left him mostly paralyzed, and he received food through a tube in his abdomen.\u003c/p>\n\u003cp>Someone at the developmental center likely put the swabs inside his mouth before he died. Dr. Ken Christensen, Lazzini’s doctor, told Office of Protective Services investigators that it was possible for Lazzini to swallow the swabs, but “it is unlikely for him to be able to pick it up and put it into his mouth.” The pathologist who performed Lazzini’s autopsy \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p13/a45403\" target=\"_blank\">noted the same thing\u003c/a>.\u003c/p>\n\u003cp>The Office of Protective Services assigned the case to a detective more than 24 hours after a caregiver discovered Lazzini bleeding from the mouth, the police file shows. By then, if any evidence was available at the scene, it was gone.\u003c/p>\n\u003cp>“\u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p17/a13\" target=\"_blank\">I noted the area was cleaned up\u003c/a>,” Rod Beck, the detective, wrote in his report. “I did not note G-swabs in the bedroom area and none were seen in the drawers of his dresser.”\u003c/p>\n\u003cp>The glycerin swabs are lemon flavored and intended to moisten a patient’s mouth, but caregivers were not supposed to use them on Lazzini, \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p18/a45405\" target=\"_blank\">according to the case file\u003c/a>. The patient did not have the physical ability to remove the swabs himself, one of Lazzini’s doctors told police.\u003c/p>\n\u003cp>During his \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p37/a45407\" target=\"_blank\">interviews with caregivers\u003c/a>, Beck learned that some technicians had been using the glycerin swabs as a pacifier for Lazzini, putting them in his mouth when he “got vocal.”\u003c/p>\n\u003cp>Lazzini’s caregivers all denied ever putting swabs in his mouth, however. Only one of the seven questioned by police admitted to using them on any patient.\u003c/p>\n\u003cp>Records that might have proven otherwise were destroyed, according to the police report. Daily caregiver notes from the previous week went missing. Someone blacked out information in two separate logs documenting patient care on the day Sonoma employees discovered Lazzini bleeding.\u003c/p>\n\u003cp>“The initials were heavily lined out,” Beck wrote.\u003c/p>\n\u003cp>Mark Czworniak, a Chicago Police Department homicide detective, reviewed the Lazzini case file for California Watch. He said that without records, crime scene evidence or corroborating statements from witnesses, there is no way to link anyone to the swabs that killed Lazzini.\u003c/p>\n\u003cp>It might have been multiple caregivers, Czworniak wrote, “or a completely unobservant health care worker, supplying Timothy L. with the G-swab one after another, not noticing, or caring where each swab disappeared to, and not surmising that Timothy L. was swallowing them.”\u003c/p>\n\u003cp>Lazzini's sister, Stephanie Contreras, who lives in the Sonoma County town of Windsor, and other family members sued the state in 2006 over Lazzini’s death and settled two years later for $100,000.\u003c/p>\n\u003cp>The Department of Public Health also fined the Sonoma Developmental Center $90,000 in August 2007, citing “mistreatment, neglect or misappropriation of resident property” – the failure to prevent Lazzini from swallowing the swabs.\u003c/p>\n\u003cp>But the Office of Protective Services closed the Lazzini case without determining what had happened.\u003c/p>\n\u003cp>\u003cstrong>Oversight reorganized\u003c/strong>\u003c/p>\n\u003cp>For much of its history, the Office of Protective Services was fragmented, with officers reporting only to administrators at their own facility.\u003c/p>\n\u003cp>Then, after a \u003ca href=\"http://www.inclusiondaily.com/news/institutions/ca/sdc.htm\" target=\"_blank\">series of critical stories\u003c/a> about the Sonoma center in the local Index-Tribune newspaper, Sacramento officials took greater control of the Office of Protective Services. They created a statewide police chief and borrowed veteran officers from the California Highway Patrol to fill the job.\u003c/p>\n\u003cp>In 2006, the U.S. Justice Department’s Civil Rights Division criticized the care at Lanterman, in Pomona, in a letter sent to Gov. Arnold Schwarzenegger. They noted a failure to properly collect evidence, inadequate witness interviews, delays in beginning investigations and the inability to close unsolved cases.\u003c/p>\n\u003cp>\u003ca href=\"https://www.documentcloud.org/documents/256286-justicedept-lanterman-findings.html#document/p4/a45408\" target=\"_blank\">The audit outlined\u003c/a> the case of a patient, identified only as A.Z., who died on Aug. 7, 2002. The federal audit did not include details of the case but said the patient “died of multiple blunt force trauma after being stomped repeatedly in his bedroom at Lanterman.”\u003c/p>\n\u003cp>The Office of Protective Services identified two suspects – the patient’s caregiver and a roommate. Although there was evidence pointing to both men, the audit said, Lanterman police concluded the roommate had committed the crime but was too mentally impaired to face charges.\u003c/p>\n\u003cp>“Regardless of who was responsible,” the auditors said, “the fact that A.Z. suffered severe pain and ultimately died at Lanterman, in spite of the state’s obligation to keep him safe, is deeply disturbing.”\u003c/p>\n\u003cp>Patricia Flannery, the state official responsible for developmental center operations, said Lanterman has remedied the deficiencies documented by the justice department. “We haven’t heard from them in two years,” she said.\u003c/p>\n\u003cp>During the Schwarzenegger administration, however, the Department of Developmental Services hired less-experienced candidates to run the police force.\u003c/p>\n\u003cp>In 2007, the department hired Nancy Irving, a longtime government labor mediator, analyst and program manager, as the force’s interim police chief. She had not been certified as a law enforcement officer.\u003c/p>\n\u003cp>The career path of Victor Davis is not unusual.\u003c/p>\n\u003cp>Davis started at Lanterman as a part-time psychiatric technician in 1989, working his way up to a supervising caregiver. In 1998, the Department of Developmental Services put him on the police force as an investigator, skipping him over two ranks of police officers despite his lack of law enforcement background.\u003c/p>\n\u003cp>Today, Davis is Lanterman’s commanding officer, in charge of all criminal investigations. Davis declined to comment in detail, and attempts to interview him during a tour of Lanterman were cut off by a top-level official with the department.\u003c/p>\n\u003cp>The police force in 2008 added its first policies on investigating abuse and neglect, closing investigations, responding to sex assault and responding to a crime scene or emergency. But policies on preserving evidence, managing investigations and collaborating with outside law enforcement remain unwritten to this day.\u003c/p>\n\u003cp>Detectives have not had the authority to send investigations to prosecutors themselves. In most police departments, officers and detectives begin working with prosecutors in the early stages of an investigation. Some district attorneys send their prosecutors to work hand in hand with police at crime scenes.\u003c/p>\n\u003cp>But the Office of Protective Services follows a different playbook. The agency’s manual states that detectives and commanders must clear cases with administrators and civil attorneys at the Sacramento headquarters before sharing cases with local police or prosecutors.\u003c/p>\n\u003cp>Delgadillo, director of the Department of Developmental Services for the past five years, said the police agency follows state standards for evidence collection.\u003c/p>\n\u003cp>Delgadillo said she has reorganized the force so that police commanders answer to Sacramento rather than local administrators at the centers. This move, which was fully enacted in 2007, is intended to protect against interference by employees and officials who might be implicated in wrongdoing, she said.\u003c/p>\n\u003cp>Delgadillo acknowledged the old policy had been a potential conflict of interest.\u003c/p>\n\u003cp>“They're reporting directly up to us to make sure that there's no conflict between the developmental center and the investigation that's actually being conducted,” Delgadillo said.\u003c/p>\n\u003cp>The department’s legal team exists to protect the state from civil liability claims, a fact that raises concerns among patient advocates and legal experts who say prosecutions and arrests for abuse of patients have taken a back seat.\u003c/p>\n\u003cp>Delgadillo said the Office of Protective Services submits cases to department lawyers first to ensure “the investigation and the information is as complete as possible.”\u003c/p>\n\u003cp>Since 2006, state regulators have confirmed 21 patient abuse cases and 173 injuries of unknown origin at the Lanterman Developmental Center in Pomona. But the Los Angeles County district attorney’s office said it is unable to find a single case referred by Lanterman investigators in the past decade.\u003c/p>\n\u003cp>And the head of the district attorney’s elder abuse and dependent adult section, Robin Allen, said she didn’t know the developmental center had its own officers and detectives. With more than 300 patients, Lanterman is one of the largest elder caregivers in Los Angeles County.\u003c/p>\n\u003cp>Department of Developmental Services officials provided California Watch with the case numbers for six incidents they claim had been forwarded to prosecutors in Los Angeles County. But the district attorney’s office said the case numbers didn’t match anything in their records.\u003c/p>\n\u003cp>Even cases of brazenly documented abuse have ended without criminal charges.\u003c/p>\n\u003cp>In 2005, a caregiver at Lanterman \u003ca href=\"https://www.documentcloud.org/documents/256224-scan0002.html\" target=\"_blank\">took a cell phone picture\u003c/a> of her co-worker with his hands wrapped around the neck of a 48-year-old male patient with mental disabilities.\u003c/p>\n\u003cp>In the photo, the patient’s “facial expression showed that he was not enjoying the action,” a state Department of Public Health inspector \u003ca href=\"https://www.documentcloud.org/documents/256224-scan0002.html#document/p2/a45410\" target=\"_blank\">wrote in a report\u003c/a> about the incident.\u003c/p>\n\u003cp>The photograph, taken May 5, 2005, was e-mailed to the phones of multiple Lanterman employees – itself a violation of patient privacy laws. Another caregiver witnessed the choking and anonymously reported it a week later in a letter to public health officials and Lanterman administrators.\u003c/p>\n\u003cp>But the Office of Protective Services did not arrest the employees involved or forward the case to prosecutors. Inspection records don’t say whether the caregivers were reprimanded or fired, but Lanterman itself was fined $800 by the Department of Public Health.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>\u003cem>Ryan Gabrielson is an investigative journalist for \u003ca href=\"http://californiawatch.org/\">California Watch\u003c/a>. CIR staff writers Agustin Armendariz, Emily Hartley and Michael Montgomery contributed to this report. This story was edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick. \u003c/em>\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>From \u003ca href=\"http://californiawatch.org/public-safety/police-force-s-sloppy-investigations-leave-abuse-disabled-unsolved-14971\">\u003cstrong>California Watch\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>California has assembled a unique police force to protect about 1,800 of its most vulnerable patients – men and women with cerebral palsy, severe autism and other mental disabilities who live in state institutions and require round-the-clock monitoring and protection from abuse.\u003c/p>\n\u003cfigure id=\"attachment_57538\" class=\"wp-caption alignleft\" style=\"max-width: 300px\">\u003ca href=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/02/lazzini5.jpg\">\u003cimg src=\"http://ww2.kqed.org/news/wp-content/uploads/sites/10/2012/02/lazzini5-300x199.jpg\" alt=\"\" title=\"lazzini\" width=\"300\" height=\"199\" class=\"size-medium wp-image-57538\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Donna Lazzini embraces her son, Timothy Lazzini, a resident of the Sonoma Developmental Center who died in 2005. The picture is part of a family photo collage celebrating his life. (Monica Lam/ California Watch)\u003c/figcaption>\u003c/figure>\n\u003cp>But an investigation by California Watch has found that detectives and patrol officers at the state’s five board-and-care institutions routinely fail to conduct basic police work even when patients die under mysterious circumstances.\u003c/p>\n\u003cp>Federal audits and investigations by disability-rights groups, as well as thousands of pages of case files, government data and lawsuits dating back to 2000, show caregivers and other facility staff allegedly involved in choking, shoving, hitting and sexually assaulting patients. None of these cases were prosecuted. \u003c!--more-->\u003c/p>\n\u003cp>Cases investigated as possible crimes include the death of a severely autistic man whose neck was broken. Three medical experts said the 50-year-old patient, Van Ingraham, likely had been killed. But the developmental center’s detective, a former nurse who’d never handled a suspicious death, failed to identify how the fatal injury occurred.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>The police force, called the Office of Protective Services, often learns about potential criminal abuse hours or days after the fact – if they find out at all. Of the hundreds of abuse cases reported at the centers since 2006, California Watch could find just two cases where the department made an arrest.\u003c/p>\n\u003cp>The people that the police force is sworn to protect have profound developmental disabilities and live in a different world from most Californians. Some patients have spent decades in the centers, from childhood to death. Some cannot form words and have IQ scores in the single digits.\u003c/p>\n\u003cp>The precise number of times nurses, janitors or staff supervisors have been implicated in patient abuse cases is unknown; the state has censored thousands of pages of documents detailing the cases.\u003c/p>\n\u003cp>California is budgeted to spend $577 million this fiscal year to operate the centers, or roughly $320,000 per patient. More than 5,200 people work in the institutions – roughly 2.5 staff members for each patient. The five centers are in Los Angeles, Orange, Riverside, Sonoma and Tulare counties.\u003c/p>\n\u003cp>In most other states, local law enforcement or state police take the lead in conducting criminal investigations at developmental centers.\u003c/p>\n\u003cp>Critics of the state Department of Developmental Services, which oversees the institutions and the Office of Protective Services, have said the tight-knit atmosphere between the in-house police and staff makes it difficult to create a separation between the investigators and the investigated.\u003c/p>\n\u003cp>In a few cases, caregivers and others with minimal police training have been hired to work as law enforcement in the same facility. The commander at the Lanterman Developmental Center in Pomona worked there as a primary caregiver. The force’s police chief is a former firefighter at the Sonoma Developmental Center.\u003c/p>\n\u003cp>The police force also suffers from a convoluted chain of command, interviews and records show. Detectives cannot make arrests without checking with department lawyers in Sacramento. Local police must be informed when serious injuries or deaths occur, but most defer investigations to the Office of Protective Services.\u003c/p>\n\u003cp>“It seems like something is not working in California. And that’s probably a major understatement,” said Tamie Hopp, an official with the national organization Voice of the Retarded, who noted the volume of abuse cases in California, and the lack of prosecutions, is cause for alarm.\u003c/p>\n\u003cp>Terri Delgadillo, director of the Department of Developmental Services, said her department has a zero-tolerance policy that includes reporting any injuries, even those remotely suspicious, to the state Department of Public Health. She said the department is committed to conducting thorough investigations.\u003c/p>\n\u003cp>“For the department, the priority is to make sure that we’re doing the best job providing consumer safety and services,” Delgadillo said in an interview. “And if there are issues that need to be addressed – and there’s always room for improvement – we’re looking to do that.”\u003c/p>\n\u003cp>She has hired a consulting group, the Consortium on Innovative Practices based in Alabama, to review the methods and training of her police force. The nonprofit group was recommended by the U.S. Department of Justice, which issued a \u003ca href=\"https://www.documentcloud.org/documents/256286-justicedept-lanterman-findings.html#document/p11/a35580\" target=\"_blank\">scathing critique\u003c/a> of the department in 2006.\u003c/p>\n\u003cp>The department said that from January 2008 to last month, 67 developmental center employees were fired for “client-related” offenses. But officials declined to say how many of those, if any, were dismissed for abusing patients, where they worked or if any of them had been arrested.\u003c/p>\n\u003cp>Delgadillo also declined to comment on specific cases of alleged abuse or mistreatment at the developmental centers, citing patient privacy laws. Corey Smith, the former firefighter who is now police chief, said he was not permitted to speak with reporters for this story.\u003c/p>\n\u003cp>\u003cstrong>\u003ca name=\"facts\">\u003c/a>Abuse cases increase\u003c/strong>\u003c/p>\n\u003cp>\u003ca name=\"since06\">\u003c/a>The developmental centers have been the scene of 327 patient abuse cases since 2006, according to inspection data from the California Department of Public Health. Patients have suffered an additional 762 injuries of “unknown origin” – often a signal of abuse that under state policy should be investigated as a potential crime.\u003c/p>\n\u003cp>At the state’s five centers, the list of unexplained injuries includes patients who suffered deep cuts on the head; a fractured pelvis; a broken jaw; busted ribs, shins and wrists; bruises and tears to male genitalia; and burns on the skin the size and shape of a cigarette butt.\u003c/p>\n\u003cp>Timothy Lazzini, a quadriplegic cerebral palsy patient at the Sonoma Developmental Center, died in 2005 after he swallowed 4-inch swabs that shredded his esophagus. After his death, Lazzini’s doctor and a \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p23/a45400\" target=\"_blank\">pathologist concluded\u003c/a> it was highly unlikely that Lazzini could have placed the swabs in his own mouth.\u003c/p>\n\u003cp>But records show detectives waited too long to start their investigation. If any physical evidence was left in Lazzini's room, it had been removed by the time investigators arrived.\u003c/p>\n\u003cp>His death, and the slow response by the Office of Protective Services, has left Lazzini’s family heartbroken and without a conclusive answer as to how he was killed.\u003c/p>\n\u003cp>“He is gone and they really haven’t given us as a family the information that we need to be at peace,” said Stephanie Contreras, Lazzini’s sister. “There is no peace at all.”\u003c/p>\n\u003cp>The rate of suspected abuse cases within the walls of the five institutions has risen – even as hundreds of developmentally disabled patients have been moved to group homes and smaller nursing facilities.\u003c/p>\n\u003cp>The patient population at developmental centers \u003ca href=\"http://www.dds.ca.gov/DevCtrs/AllFacPop.cfm\" target=\"_blank\">dropped by 12 percent\u003c/a> from 2008 to 2010, state records show, but reports of abuse have increased 43 percent during those three years. \u003ca href=\"http://projects.californiawatch.org/broken-shield\" target=\"_blank\">Unexplained injuries\u003c/a> jumped 8 percent in the same period.\u003c/p>\n\u003cp>Public health officials acknowledged the state doesn’t keep a tally of the number of times caregivers have abused patients. That information is kept hidden from the public in individual case files.\u003c/p>\n\u003cp>Kathleen Billingsley, director of policy and programs for the Department of Public Health, said she also didn’t know whether inspectors were notifying law enforcement agencies when they uncover evidence of abuse. She said public health inspectors conduct thorough investigations separately from the police.\u003c/p>\n\u003cp>“If there is any cross between enforcement individuals at the state facility and the work we do, I am not familiar with that,” Billingsley said.\u003c/p>\n\u003cp>The Los Angeles County district attorney’s office, which oversees Lanterman, couldn’t identify a single criminal case referred from the center’s police force. District attorneys in Tulare, Orange and Riverside counties also reported no prosecutions for patient abuse in the past decade. Sonoma County refused to disclose its records.\u003c/p>\n\u003cp>On average, police in California solve about two-thirds of all homicides and about half of all aggravated assaults – or at least make an arrest and “clear” the cases. The clearance rate for the Office of Protective Services is unknown because the department keeps the information secret.\u003c/p>\n\u003cp>\u003cstrong>Thankless jobs, hidden from the public\u003c/strong>\u003c/p>\n\u003cp>The Office of Protective Services has existed in various forms and names since the late 19\u003csup>th\u003c/sup> century, when California opened its first institution for the developmentally disabled. That facility in San Jose – first known as the Agnews Insane Asylum – opened in 1885 and closed in 2009.\u003c/p>\n\u003cp>Interviews with current and former Office of Protective Services employees suggest the organization’s structure from its beginning has contributed to its dysfunction.\u003c/p>\n\u003cp>Patrol officers dress much like those at any other police department. They wear tan and green uniforms with gold badges. Handcuffs are hooked to their belts. They drive marked squad cars. But there are key differences.\u003c/p>\n\u003cp>Officers and caregivers are confined together in a 24-hour facility monitoring an unpredictable, sometimes uncontrollable population. Beyond a paycheck, the job is mostly thankless and hidden from the public. Officers are not allowed to carry guns; many carry pepper spray instead. They often work their shifts alone.\u003c/p>\n\u003cp>Greg Wardwell, a sergeant who spent more than 20 years patrolling the Sonoma Developmental Center before retiring last year, said the state has undermined its own police force through neglect and incompetence.\u003c/p>\n\u003cp>“You can look like a cop and we’ll call you a cop, but you don’t really have any way of being a cop,” Wardwell said. “Because we’re not going to train you, we won’t provide safety equipment. The salary will be so bad that we won’t be able to recruit anybody of talent.”\u003c/p>\n\u003cp>Salaries for the roughly 90 sworn officers are half of what police earn in the state’s big city departments. Yet, roughly a third of officers within the Office of Protective Services are among the best compensated in California law enforcement, with much of their pay gained through overtime. One officer’s income has topped $200,000 a year.\u003c/p>\n\u003cp>Families must rely on the Office of Protective Services to provide evidence for lawsuits when their relatives are harmed or killed at a developmental center. Records show the state paid out nearly $9 million in legal settlements – out of 68 separate lawsuits – from 2004 to 2010.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“Photographs were not taken,” the report states. “Not all witnesses, nor all key witnesses, were interviewed. Physical evidence was not collected. Victims did not receive thorough medical workups to look for other indications of abuse.”\u003c/p>\n\u003cp>Leslie Morrison, director of investigations at \u003ca href=\"http://www.disabilityrightsca.org/\" target=\"_blank\">Disability Rights California\u003c/a>, said the report showed how the developmentally disabled can be treated as second-class citizens.\u003c/p>\n\u003cp>“If this had happened to 3-year-old boys in a day care center, people would have been alarmed, police would have been called, there would have been an outrage,” Morrison said. “It wouldn't have just been treated as just, 'Oh, look, there's a cut, we better sew that up.' ”\u003c/p>\n\u003cp>In the case of the 50-year-old autistic man, Van Ingraham, his family received $800,000 in a settlement with the state. Ingraham died in 2007 after sustaining a broken neck while in his room at the Fairview Developmental Center in Orange County.\u003c/p>\n\u003cp>Fairview officers didn’t collect physical evidence from Ingraham’s room, records show. Detectives overlooked evidence that a caregiver last seen with Ingraham had \u003ca href=\"https://www.documentcloud.org/documents/251733-ops-ingraham-casefile-rg.html#document/p15/a45401\" target=\"_blank\">altered the log of his activities\u003c/a>. And they omitted from the case file an expert’s opinion that Ingraham’s death “was likely a homicide.”\u003c/p>\n\u003cp>“This incompetent, horrendous organization called Office of Protective Services takes it and just makes a mess, just a complete mangled mess of the investigation,” said Larry Ingraham, the patient’s older brother and a veteran of the San Diego Police Department.\u003c/p>\n\u003cp>\u003cstrong>Sexual assaults unprosecuted\u003c/strong>\u003c/p>\n\u003cp>Sex abuse cases, too, have been shelved without prosecution.\u003c/p>\n\u003cp>In April 2010, at the Canyon Springs Developmental Center in Riverside County, a janitor twice sexually abused a mentally disabled female patient when caregivers were out of sight. Under California law, having sex with any developmentally disabled person who is incapable of giving consent is considered rape.\u003c/p>\n\u003cp>The patient, who is not identified in state records, had a history of being assaulted. She was institutionalized at age 12 after her father impregnated her, a state health department citation shows.\u003c/p>\n\u003cp>The patient had been diagnosed with moderate mental retardation, schizoaffective disorder and post-traumatic stress disorder. Canyon Springs staff had been working with her to curb any behavior “possibly leading to sexual activity,” her file states.\u003c/p>\n\u003cp>The female patient, then 39 years old, \u003ca href=\"https://www.documentcloud.org/documents/282341-170007499-redacted.html#document/p1/a42068\" target=\"_blank\">told center employees\u003c/a> she “did it” with the janitor in the women’s bathroom and in a hallway during a fire drill. An unidentified Canyon Springs employee notified the state Department of Public Health.\u003c/p>\n\u003cp>The Office of Protective Services investigated the case but made no arrests. State regulators also investigated and ruled the incidents as sexual abuse, according to a citation issued to Canyon Springs.\u003c/p>\n\u003cp>In December 2010, Canyon Springs was fined $800 by public health officials for the incidents. No criminal charges followed. The Riverside County district attorney’s office said it has no record of receiving any case referrals from Canyon Springs, which houses about 50 patients.\u003c/p>\n\u003cp>Rather than placing the janitor under arrest, developmental center officials ordered him to undergo training on his “legal duty” regarding patient abuse, according to state records.\u003c/p>\n\u003cp>The Office of Protective Services concluded that the janitor didn’t commit a crime, Delgadillo said. She declined to answer other questions about the incident or to say whether the janitor, whose name the state has redacted from case files, continues to work at Canyon Springs.\u003c/p>\n\u003cp>\u003ca name=\"sexualabuse2\">\u003c/a>In another case with even fewer details available, a female patient at the Sonoma Developmental Center accused a male caregiver of sexually assaulting her during a bath in early 2000, police records show. The institution responded by assigning two men to bathe the patient.\u003c/p>\n\u003cp>On July 6, 2000, both caregivers allegedly raped her, again during bathing.\u003c/p>\n\u003cp>The institution did not inform its own police officers about the details of either incident. Records show Ed Contreras, then Sonoma’s police commander, received an anonymous tip four days after the second alleged rape.\u003c/p>\n\u003cp>“They weren’t following the law,” Contreras said in an interview. “They weren’t reporting it to the police department. They weren’t reporting it to me.”\u003c/p>\n\u003cp>Contreras said no arrests were made in the sex assaults. The Sonoma County district attorney’s office declined to release records on the cases or any other criminal allegations from the developmental center.\u003c/p>\n\u003cp>\u003cstrong>Inside institutions, a different world\u003c/strong>\u003c/p>\n\u003cp>The Sonoma Developmental Center is located in a quaint neighborhood in the middle of wine country. Fairview in Costa Mesa is near the Orange County fairgrounds and surrounded by strip malls and a golf course. Lanterman is wedged between train tracks and a highway east of Los Angeles.\u003c/p>\n\u003cp>Next door to a Cathedral City cemetery, tiny Canyon Springs could be mistaken for an office park. The Porterville Developmental Center, southeast of Visalia, does have the look of an institution. Among the 500 patients, the facility houses about 200 developmentally disabled patients who have committed crimes or who are under arrest.\u003c/p>\n\u003cp>Inside, the centers feature wide hallways. Walls are decorated much the same as elementary school classrooms, with colors and construction paper cutouts to signal upcoming holidays.\u003c/p>\n\u003cp>Primary caregivers, called psychiatric technicians, guide patients from place to place, feeding them and distributing medication. Each patient communicates differently, and the units are filled with shouts, groans, shrieks and crying. Patients share bedrooms. Some are crowded with stuffed animals, posters and family pictures. Others are empty, save for the full-sized beds and a cabinet.\u003c/p>\n\u003cp>Parents and siblings can visit every week for hours at a time. Fairview patients range from 15 to 94 years old, said Bill Wilson, the institution’s executive director. Most are between the ages of 40 and 60.\u003c/p>\n\u003cp>More than two-thirds of patients are diagnosed with profound mental disabilities, \u003ca href=\"https://www.documentcloud.org/documents/295214-factors-associated-with-living-in-developmental.html#document/p7/a45411\" target=\"_blank\">according to research\u003c/a> from UC San Francisco. The institutions have whole units for patients who are emotionally volatile, prone to striking themselves and others.\u003c/p>\n\u003cp>The disabled population adds greater complexity to criminal investigations. For a host of reasons, their observations can be tainted by fantasies and falsehoods. Their emotions veer from happy to inconsolable without warning. Patients slap and punch at their faces and legs, and at each other.\u003c/p>\n\u003cp>“They come to us after they’ve burned every bridge in the community,” said Erinn Kanney, a program manager at Fairview.\u003c/p>\n\u003cp>Outside of California, local or state police most often are responsible for investigating criminal cases at institutions. But city and county law enforcement agencies inside the state have not shown an interest in developmental center cases and don’t have funding to expand their scope, according to Delgadillo.\u003c/p>\n\u003cp>“Oftentimes, local law enforcement does not want to get involved,” said Delgadillo, who in the past has worked for the California Department of Corrections and Rehabilitation as a manager in the juvenile justice division.\u003c/p>\n\u003cp>Local police or sheriff’s deputies can act more independently than an internal police force responsible for probes into their colleagues and bosses, said Jane Hudson, senior staff attorney for the National Disability Rights Network, a patient advocacy organization\u003c/p>\n\u003cp>\u003ca name=\"quote\">\u003c/a>“If there’s a crime committed,” Hudson said, “you let the criminal investigators go in first rather than the institution bagging the bloody shirt.”\u003c/p>\n\u003cp>\u003cstrong>Delayed notification hinders investigations\u003c/strong>\u003c/p>\n\u003cp>Delays by the Office of Protective Services often make cases harder to solve.\u003c/p>\n\u003cp>\u003ca name=\"dozen\">\u003c/a>Although no public records exist showing how frequently the police force receives late notification of potential abuse cases, California Watch was able to identify at least a dozen incidents in which delays from 24 hours to several days occurred.\u003c/p>\n\u003cp>Forensic experts say the first hours following a crime are critical. A person walking through a crime scene can ruin fingerprints, DNA samples and other evidence, said Dennis Kilcoyne, a Los Angeles Police Department homicide detective. Witness statements can change with time, especially after they’ve conferred with others, he said.\u003c/p>\n\u003cp>“People’s emotions are in play, and they may say things that, after they’ve thought about it or consulted with an attorney, (they) won’t say a week from now,” said Kilcoyne, a 27-year veteran.\u003c/p>\n\u003cp>Delays have hurt criminal investigations and given the centers’ employees time to alter and destroy evidence, records and interviews show.\u003c/p>\n\u003cp>That’s what happened in the case of Timothy Lazzini, the 25-year-old quadriplegic patient with cerebral palsy, who coughed up a bloody glycerin swab at the Sonoma Developmental Center. He died from internal bleeding that night, Oct. 22, 2005.\u003c/p>\n\u003cp>Three swabs – each 4 inches long and twice as thick as a Q-tip – had torn Lazzini’s esophagus. He coughed out one, but two others remained lodged in his stomach, autopsy records show.\u003c/p>\n\u003cp>At that point in his life, Lazzini’s disabilities had left him mostly paralyzed, and he received food through a tube in his abdomen.\u003c/p>\n\u003cp>Someone at the developmental center likely put the swabs inside his mouth before he died. Dr. Ken Christensen, Lazzini’s doctor, told Office of Protective Services investigators that it was possible for Lazzini to swallow the swabs, but “it is unlikely for him to be able to pick it up and put it into his mouth.” The pathologist who performed Lazzini’s autopsy \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p13/a45403\" target=\"_blank\">noted the same thing\u003c/a>.\u003c/p>\n\u003cp>The Office of Protective Services assigned the case to a detective more than 24 hours after a caregiver discovered Lazzini bleeding from the mouth, the police file shows. By then, if any evidence was available at the scene, it was gone.\u003c/p>\n\u003cp>“\u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p17/a13\" target=\"_blank\">I noted the area was cleaned up\u003c/a>,” Rod Beck, the detective, wrote in his report. “I did not note G-swabs in the bedroom area and none were seen in the drawers of his dresser.”\u003c/p>\n\u003cp>The glycerin swabs are lemon flavored and intended to moisten a patient’s mouth, but caregivers were not supposed to use them on Lazzini, \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p18/a45405\" target=\"_blank\">according to the case file\u003c/a>. The patient did not have the physical ability to remove the swabs himself, one of Lazzini’s doctors told police.\u003c/p>\n\u003cp>During his \u003ca href=\"https://www.documentcloud.org/documents/243541-ops-lazzini.html#document/p37/a45407\" target=\"_blank\">interviews with caregivers\u003c/a>, Beck learned that some technicians had been using the glycerin swabs as a pacifier for Lazzini, putting them in his mouth when he “got vocal.”\u003c/p>\n\u003cp>Lazzini’s caregivers all denied ever putting swabs in his mouth, however. Only one of the seven questioned by police admitted to using them on any patient.\u003c/p>\n\u003cp>Records that might have proven otherwise were destroyed, according to the police report. Daily caregiver notes from the previous week went missing. Someone blacked out information in two separate logs documenting patient care on the day Sonoma employees discovered Lazzini bleeding.\u003c/p>\n\u003cp>“The initials were heavily lined out,” Beck wrote.\u003c/p>\n\u003cp>Mark Czworniak, a Chicago Police Department homicide detective, reviewed the Lazzini case file for California Watch. He said that without records, crime scene evidence or corroborating statements from witnesses, there is no way to link anyone to the swabs that killed Lazzini.\u003c/p>\n\u003cp>It might have been multiple caregivers, Czworniak wrote, “or a completely unobservant health care worker, supplying Timothy L. with the G-swab one after another, not noticing, or caring where each swab disappeared to, and not surmising that Timothy L. was swallowing them.”\u003c/p>\n\u003cp>Lazzini's sister, Stephanie Contreras, who lives in the Sonoma County town of Windsor, and other family members sued the state in 2006 over Lazzini’s death and settled two years later for $100,000.\u003c/p>\n\u003cp>The Department of Public Health also fined the Sonoma Developmental Center $90,000 in August 2007, citing “mistreatment, neglect or misappropriation of resident property” – the failure to prevent Lazzini from swallowing the swabs.\u003c/p>\n\u003cp>But the Office of Protective Services closed the Lazzini case without determining what had happened.\u003c/p>\n\u003cp>\u003cstrong>Oversight reorganized\u003c/strong>\u003c/p>\n\u003cp>For much of its history, the Office of Protective Services was fragmented, with officers reporting only to administrators at their own facility.\u003c/p>\n\u003cp>Then, after a \u003ca href=\"http://www.inclusiondaily.com/news/institutions/ca/sdc.htm\" target=\"_blank\">series of critical stories\u003c/a> about the Sonoma center in the local Index-Tribune newspaper, Sacramento officials took greater control of the Office of Protective Services. They created a statewide police chief and borrowed veteran officers from the California Highway Patrol to fill the job.\u003c/p>\n\u003cp>In 2006, the U.S. Justice Department’s Civil Rights Division criticized the care at Lanterman, in Pomona, in a letter sent to Gov. Arnold Schwarzenegger. They noted a failure to properly collect evidence, inadequate witness interviews, delays in beginning investigations and the inability to close unsolved cases.\u003c/p>\n\u003cp>\u003ca href=\"https://www.documentcloud.org/documents/256286-justicedept-lanterman-findings.html#document/p4/a45408\" target=\"_blank\">The audit outlined\u003c/a> the case of a patient, identified only as A.Z., who died on Aug. 7, 2002. The federal audit did not include details of the case but said the patient “died of multiple blunt force trauma after being stomped repeatedly in his bedroom at Lanterman.”\u003c/p>\n\u003cp>The Office of Protective Services identified two suspects – the patient’s caregiver and a roommate. Although there was evidence pointing to both men, the audit said, Lanterman police concluded the roommate had committed the crime but was too mentally impaired to face charges.\u003c/p>\n\u003cp>“Regardless of who was responsible,” the auditors said, “the fact that A.Z. suffered severe pain and ultimately died at Lanterman, in spite of the state’s obligation to keep him safe, is deeply disturbing.”\u003c/p>\n\u003cp>Patricia Flannery, the state official responsible for developmental center operations, said Lanterman has remedied the deficiencies documented by the justice department. “We haven’t heard from them in two years,” she said.\u003c/p>\n\u003cp>During the Schwarzenegger administration, however, the Department of Developmental Services hired less-experienced candidates to run the police force.\u003c/p>\n\u003cp>In 2007, the department hired Nancy Irving, a longtime government labor mediator, analyst and program manager, as the force’s interim police chief. She had not been certified as a law enforcement officer.\u003c/p>\n\u003cp>The career path of Victor Davis is not unusual.\u003c/p>\n\u003cp>Davis started at Lanterman as a part-time psychiatric technician in 1989, working his way up to a supervising caregiver. In 1998, the Department of Developmental Services put him on the police force as an investigator, skipping him over two ranks of police officers despite his lack of law enforcement background.\u003c/p>\n\u003cp>Today, Davis is Lanterman’s commanding officer, in charge of all criminal investigations. Davis declined to comment in detail, and attempts to interview him during a tour of Lanterman were cut off by a top-level official with the department.\u003c/p>\n\u003cp>The police force in 2008 added its first policies on investigating abuse and neglect, closing investigations, responding to sex assault and responding to a crime scene or emergency. But policies on preserving evidence, managing investigations and collaborating with outside law enforcement remain unwritten to this day.\u003c/p>\n\u003cp>Detectives have not had the authority to send investigations to prosecutors themselves. In most police departments, officers and detectives begin working with prosecutors in the early stages of an investigation. Some district attorneys send their prosecutors to work hand in hand with police at crime scenes.\u003c/p>\n\u003cp>But the Office of Protective Services follows a different playbook. The agency’s manual states that detectives and commanders must clear cases with administrators and civil attorneys at the Sacramento headquarters before sharing cases with local police or prosecutors.\u003c/p>\n\u003cp>Delgadillo, director of the Department of Developmental Services for the past five years, said the police agency follows state standards for evidence collection.\u003c/p>\n\u003cp>Delgadillo said she has reorganized the force so that police commanders answer to Sacramento rather than local administrators at the centers. This move, which was fully enacted in 2007, is intended to protect against interference by employees and officials who might be implicated in wrongdoing, she said.\u003c/p>\n\u003cp>Delgadillo acknowledged the old policy had been a potential conflict of interest.\u003c/p>\n\u003cp>“They're reporting directly up to us to make sure that there's no conflict between the developmental center and the investigation that's actually being conducted,” Delgadillo said.\u003c/p>\n\u003cp>The department’s legal team exists to protect the state from civil liability claims, a fact that raises concerns among patient advocates and legal experts who say prosecutions and arrests for abuse of patients have taken a back seat.\u003c/p>\n\u003cp>Delgadillo said the Office of Protective Services submits cases to department lawyers first to ensure “the investigation and the information is as complete as possible.”\u003c/p>\n\u003cp>Since 2006, state regulators have confirmed 21 patient abuse cases and 173 injuries of unknown origin at the Lanterman Developmental Center in Pomona. But the Los Angeles County district attorney’s office said it is unable to find a single case referred by Lanterman investigators in the past decade.\u003c/p>\n\u003cp>And the head of the district attorney’s elder abuse and dependent adult section, Robin Allen, said she didn’t know the developmental center had its own officers and detectives. With more than 300 patients, Lanterman is one of the largest elder caregivers in Los Angeles County.\u003c/p>\n\u003cp>Department of Developmental Services officials provided California Watch with the case numbers for six incidents they claim had been forwarded to prosecutors in Los Angeles County. But the district attorney’s office said the case numbers didn’t match anything in their records.\u003c/p>\n\u003cp>Even cases of brazenly documented abuse have ended without criminal charges.\u003c/p>\n\u003cp>In 2005, a caregiver at Lanterman \u003ca href=\"https://www.documentcloud.org/documents/256224-scan0002.html\" target=\"_blank\">took a cell phone picture\u003c/a> of her co-worker with his hands wrapped around the neck of a 48-year-old male patient with mental disabilities.\u003c/p>\n\u003cp>In the photo, the patient’s “facial expression showed that he was not enjoying the action,” a state Department of Public Health inspector \u003ca href=\"https://www.documentcloud.org/documents/256224-scan0002.html#document/p2/a45410\" target=\"_blank\">wrote in a report\u003c/a> about the incident.\u003c/p>\n\u003cp>The photograph, taken May 5, 2005, was e-mailed to the phones of multiple Lanterman employees – itself a violation of patient privacy laws. Another caregiver witnessed the choking and anonymously reported it a week later in a letter to public health officials and Lanterman administrators.\u003c/p>\n\u003cp>But the Office of Protective Services did not arrest the employees involved or forward the case to prosecutors. Inspection records don’t say whether the caregivers were reprimanded or fired, but Lanterman itself was fined $800 by the Department of Public Health.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003cem>Ryan Gabrielson is an investigative journalist for \u003ca href=\"http://californiawatch.org/\">California Watch\u003c/a>. CIR staff writers Agustin Armendariz, Emily Hartley and Michael Montgomery contributed to this report. This story was edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick. \u003c/em>\u003c/p>\n\n\u003c/div>\u003c/p>",
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"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/The-California-Report-Podcast-Tile-703x703-1.jpg",
"imageAlt": "KQED The California Report",
"officialWebsiteLink": "/californiareport",
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"source": "kqed",
"order": 8
},
"link": "/californiareport",
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"amazon": "https://music.amazon.com/podcasts/26099305-72af-4542-9dde-ac1807fe36d5/kqed-s-the-california-report",
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"rss": "https://ww2.kqed.org/news/tag/tcram/feed/podcast"
}
},
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"id": "californiareportmagazine",
"title": "The California Report Magazine",
"tagline": "Your state, your stories",
"info": "Every week, The California Report Magazine takes you on a road trip for the ears: to visit the places and meet the people who make California unique. The in-depth storytelling podcast from the California Report.",
"airtime": "FRI 4:30pm-5pm, 6:30pm-7pm, 11pm-11:30pm",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/The-California-Report-Magazine-Podcast-Tile-703x703-1.jpg",
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"officialWebsiteLink": "/californiareportmagazine",
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"order": 10
},
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"google": "https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5tZWdhcGhvbmUuZm0vS1FJTkM3NjkwNjk1OTAz",
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"rss": "https://ww2.kqed.org/news/tag/tcrmag/feed/podcast"
}
},
"city-arts": {
"id": "city-arts",
"title": "City Arts & Lectures",
"info": "A one-hour radio program to hear celebrated writers, artists and thinkers address contemporary ideas and values, often discussing the creative process. Please note: tapes or transcripts are not available",
"imageSrc": "https://ww2.kqed.org/radio/wp-content/uploads/sites/50/2018/05/cityartsandlecture-300x300.jpg",
"officialWebsiteLink": "https://www.cityarts.net/",
"airtime": "SUN 1pm-2pm, TUE 10pm, WED 1am",
"meta": {
"site": "news",
"source": "City Arts & Lectures"
},
"link": "https://www.cityarts.net",
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"rss": "https://www.cityarts.net/feed/"
}
},
"closealltabs": {
"id": "closealltabs",
"title": "Close All Tabs",
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"info": "Close All Tabs breaks down how digital culture shapes our world through thoughtful insights and irreverent humor.",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2025/02/CAT_2_Tile-scaled.jpg",
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"officialWebsiteLink": "/podcasts/closealltabs",
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"order": 1
},
"link": "/podcasts/closealltabs",
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"code-switch-life-kit": {
"id": "code-switch-life-kit",
"title": "Code Switch / Life Kit",
"info": "\u003cem>Code Switch\u003c/em>, which listeners will hear in the first part of the hour, has fearless and much-needed conversations about race. Hosted by journalists of color, the show tackles the subject of race head-on, exploring how it impacts every part of society — from politics and pop culture to history, sports and more.\u003cbr />\u003cbr />\u003cem>Life Kit\u003c/em>, which will be in the second part of the hour, guides you through spaces and feelings no one prepares you for — from finances to mental health, from workplace microaggressions to imposter syndrome, from relationships to parenting. The show features experts with real world experience and shares their knowledge. Because everyone needs a little help being human.\u003cbr />\u003cbr />\u003ca href=\"https://www.npr.org/podcasts/510312/codeswitch\">\u003cem>Code Switch\u003c/em> offical site and podcast\u003c/a>\u003cbr />\u003ca href=\"https://www.npr.org/lifekit\">\u003cem>Life Kit\u003c/em> offical site and podcast\u003c/a>\u003cbr />",
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"meta": {
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"google": "https://podcasts.google.com/feed/aHR0cHM6Ly93d3cubnByLm9yZy9yc3MvcG9kY2FzdC5waHA_aWQ9NTEwMzEy",
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"id": "commonwealth-club",
"title": "Commonwealth Club of California Podcast",
"info": "The Commonwealth Club of California is the nation's oldest and largest public affairs forum. As a non-partisan forum, The Club brings to the public airwaves diverse viewpoints on important topics. The Club's weekly radio broadcast - the oldest in the U.S., dating back to 1924 - is carried across the nation on public radio stations and is now podcasting. Our website archive features audio of our recent programs, as well as selected speeches from our long and distinguished history. This podcast feed is usually updated twice a week and is always un-edited.",
"airtime": "THU 10pm, FRI 1am",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/Commonwealth-Club-Podcast-Tile-360x360-1.jpg",
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"meta": {
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"source": "Commonwealth Club of California"
},
"link": "/radio/program/commonwealth-club",
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"google": "https://podcasts.google.com/feed/aHR0cDovL3d3dy5jb21tb253ZWFsdGhjbHViLm9yZy9hdWRpby9wb2RjYXN0L3dlZWtseS54bWw",
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}
},
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"id": "forum",
"title": "Forum",
"tagline": "The conversation starts here",
"info": "KQED’s live call-in program discussing local, state, national and international issues, as well as in-depth interviews.",
"airtime": "MON-FRI 9am-11am, 10pm-11pm",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/Forum-Podcast-Tile-703x703-1.jpg",
"imageAlt": "KQED Forum with Mina Kim and Alexis Madrigal",
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"source": "kqed",
"order": 9
},
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"google": "https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5tZWdhcGhvbmUuZm0vS1FJTkM5NTU3MzgxNjMz",
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},
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"id": "freakonomics-radio",
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"info": "Freakonomics Radio is a one-hour award-winning podcast and public-radio project hosted by Stephen Dubner, with co-author Steve Levitt as a regular guest. It is produced in partnership with WNYC.",
"imageSrc": "https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/freakonomicsRadio.png",
"officialWebsiteLink": "http://freakonomics.com/",
"airtime": "SUN 1am-2am, SAT 3pm-4pm",
"meta": {
"site": "radio",
"source": "WNYC"
},
"link": "/radio/program/freakonomics-radio",
"subscribe": {
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"apple": "https://itunes.apple.com/us/podcast/freakonomics-radio/id354668519",
"tuneIn": "https://tunein.com/podcasts/WNYC-Podcasts/Freakonomics-Radio-p272293/",
"rss": "https://feeds.feedburner.com/freakonomicsradio"
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},
"fresh-air": {
"id": "fresh-air",
"title": "Fresh Air",
"info": "Hosted by Terry Gross, \u003cem>Fresh Air from WHYY\u003c/em> is the Peabody Award-winning weekday magazine of contemporary arts and issues. One of public radio's most popular programs, Fresh Air features intimate conversations with today's biggest luminaries.",
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"link": "/radio/program/fresh-air",
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"apple": "https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewPodcast?s=143441&mt=2&id=214089682&at=11l79Y&ct=nprdirectory",
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"rss": "https://feeds.npr.org/381444908/podcast.xml"
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"here-and-now": {
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"info": "A live production of NPR and WBUR Boston, in collaboration with stations across the country, Here & Now reflects the fluid world of news as it's happening in the middle of the day, with timely, in-depth news, interviews and conversation. Hosted by Robin Young, Jeremy Hobson and Tonya Mosley.",
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"rss": "https://feeds.npr.org/510051/podcast.xml"
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},
"hidden-brain": {
"id": "hidden-brain",
"title": "Hidden Brain",
"info": "Shankar Vedantam uses science and storytelling to reveal the unconscious patterns that drive human behavior, shape our choices and direct our relationships.",
"imageSrc": "https://ww2.kqed.org/radio/wp-content/uploads/sites/50/2018/05/hiddenbrain.jpg",
"officialWebsiteLink": "https://www.npr.org/series/423302056/hidden-brain",
"airtime": "SUN 7pm-8pm",
"meta": {
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"source": "NPR"
},
"link": "/radio/program/hidden-brain",
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"rss": "https://feeds.npr.org/510308/podcast.xml"
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},
"how-i-built-this": {
"id": "how-i-built-this",
"title": "How I Built This with Guy Raz",
"info": "Guy Raz dives into the stories behind some of the world's best known companies. How I Built This weaves a narrative journey about innovators, entrepreneurs and idealists—and the movements they built.",
"imageSrc": "https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/howIBuiltThis.png",
"officialWebsiteLink": "https://www.npr.org/podcasts/510313/how-i-built-this",
"airtime": "SUN 7:30pm-8pm",
"meta": {
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"source": "npr"
},
"link": "/radio/program/how-i-built-this",
"subscribe": {
"npr": "https://rpb3r.app.goo.gl/3zxy",
"apple": "https://itunes.apple.com/us/podcast/how-i-built-this-with-guy-raz/id1150510297?mt=2",
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"rss": "https://feeds.npr.org/510313/podcast.xml"
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},
"hyphenacion": {
"id": "hyphenacion",
"title": "Hyphenación",
"tagline": "Where conversation and cultura meet",
"info": "What kind of no sabo word is Hyphenación? For us, it’s about living within a hyphenation. Like being a third-gen Mexican-American from the Texas border now living that Bay Area Chicano life. Like Xorje! Each week we bring together a couple of hyphenated Latinos to talk all about personal life choices: family, careers, relationships, belonging … everything is on the table. ",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2025/03/Hyphenacion_FinalAssets_PodcastTile.png",
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"officialWebsiteLink": "/podcasts/hyphenacion",
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"order": 15
},
"link": "/podcasts/hyphenacion",
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"spotify": "https://open.spotify.com/show/2p3Fifq96nw9BPcmFdIq0o?si=39209f7b25774f38",
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"amazon": "https://music.amazon.com/podcasts/6c3dd23c-93fb-4aab-97ba-1725fa6315f1/hyphenaci%C3%B3n",
"rss": "https://feeds.megaphone.fm/KQINC2275451163"
}
},
"jerrybrown": {
"id": "jerrybrown",
"title": "The Political Mind of Jerry Brown",
"tagline": "Lessons from a lifetime in politics",
"info": "The Political Mind of Jerry Brown brings listeners the wisdom of the former Governor, Mayor, and presidential candidate. Scott Shafer interviewed Brown for more than 40 hours, covering the former governor's life and half-century in the political game – and Brown has some lessons he'd like to share. ",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/The-Political-Mind-of-Jerry-Brown-Podcast-Tile-703x703-1.jpg",
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"officialWebsiteLink": "/podcasts/jerrybrown",
"meta": {
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"source": "kqed",
"order": 18
},
"link": "/podcasts/jerrybrown",
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"apple": "https://itunes.apple.com/us/podcast/id1492194549",
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}
},
"latino-usa": {
"id": "latino-usa",
"title": "Latino USA",
"airtime": "MON 1am-2am, SUN 6pm-7pm",
"info": "Latino USA, the radio journal of news and culture, is the only national, English-language radio program produced from a Latino perspective.",
"imageSrc": "https://ww2.kqed.org/radio/wp-content/uploads/sites/50/2018/04/latinoUsa.jpg",
"officialWebsiteLink": "http://latinousa.org/",
"meta": {
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"source": "npr"
},
"link": "/radio/program/latino-usa",
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"apple": "https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewPodcast?s=143441&mt=2&id=79681317&at=11l79Y&ct=nprdirectory",
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"rss": "https://feeds.npr.org/510016/podcast.xml"
}
},
"marketplace": {
"id": "marketplace",
"title": "Marketplace",
"info": "Our flagship program, helmed by Kai Ryssdal, examines what the day in money delivered, through stories, conversations, newsworthy numbers and more. Updated Monday through Friday at about 3:30 p.m. PT.",
"airtime": "MON-FRI 4pm-4:30pm, MON-WED 6:30pm-7pm",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/Marketplace-Podcast-Tile-360x360-1.jpg",
"officialWebsiteLink": "https://www.marketplace.org/",
"meta": {
"site": "news",
"source": "American Public Media"
},
"link": "/radio/program/marketplace",
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"rss": "https://feeds.publicradio.org/public_feeds/marketplace-pm/rss/rss"
}
},
"masters-of-scale": {
"id": "masters-of-scale",
"title": "Masters of Scale",
"info": "Masters of Scale is an original podcast in which LinkedIn co-founder and Greylock Partner Reid Hoffman sets out to describe and prove theories that explain how great entrepreneurs take their companies from zero to a gazillion in ingenious fashion.",
"airtime": "Every other Wednesday June 12 through October 16 at 8pm (repeats Thursdays at 2am)",
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"officialWebsiteLink": "https://mastersofscale.com/",
"meta": {
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"source": "WaitWhat"
},
"link": "/radio/program/masters-of-scale",
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"apple": "http://mastersofscale.app.link/",
"rss": "https://rss.art19.com/masters-of-scale"
}
},
"mindshift": {
"id": "mindshift",
"title": "MindShift",
"tagline": "A podcast about the future of learning and how we raise our kids",
"info": "The MindShift podcast explores the innovations in education that are shaping how kids learn. Hosts Ki Sung and Katrina Schwartz introduce listeners to educators, researchers, parents and students who are developing effective ways to improve how kids learn. We cover topics like how fed-up administrators are developing surprising tactics to deal with classroom disruptions; how listening to podcasts are helping kids develop reading skills; the consequences of overparenting; and why interdisciplinary learning can engage students on all ends of the traditional achievement spectrum. This podcast is part of the MindShift education site, a division of KQED News. KQED is an NPR/PBS member station based in San Francisco. You can also visit the MindShift website for episodes and supplemental blog posts or tweet us \u003ca href=\"https://twitter.com/MindShiftKQED\">@MindShiftKQED\u003c/a> or visit us at \u003ca href=\"/mindshift\">MindShift.KQED.org\u003c/a>",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/Mindshift-Podcast-Tile-703x703-1.jpg",
"imageAlt": "KQED MindShift: How We Will Learn",
"officialWebsiteLink": "/mindshift/",
"meta": {
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"source": "kqed",
"order": 12
},
"link": "/podcasts/mindshift",
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"google": "https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5tZWdhcGhvbmUuZm0vS1FJTkM1NzY0NjAwNDI5",
"npr": "https://www.npr.org/podcasts/464615685/mind-shift-podcast",
"stitcher": "https://www.stitcher.com/podcast/kqed/stories-teachers-share",
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}
},
"morning-edition": {
"id": "morning-edition",
"title": "Morning Edition",
"info": "\u003cem>Morning Edition\u003c/em> takes listeners around the country and the world with multi-faceted stories and commentaries every weekday. Hosts Steve Inskeep, David Greene and Rachel Martin bring you the latest breaking news and features to prepare you for the day.",
"airtime": "MON-FRI 3am-9am",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/Morning-Edition-Podcast-Tile-360x360-1.jpg",
"officialWebsiteLink": "https://www.npr.org/programs/morning-edition/",
"meta": {
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"link": "/radio/program/morning-edition"
},
"onourwatch": {
"id": "onourwatch",
"title": "On Our Watch",
"tagline": "Deeply-reported investigative journalism",
"info": "For decades, the process for how police police themselves has been inconsistent – if not opaque. In some states, like California, these proceedings were completely hidden. After a new police transparency law unsealed scores of internal affairs files, our reporters set out to examine these cases and the shadow world of police discipline. On Our Watch brings listeners into the rooms where officers are questioned and witnesses are interrogated to find out who this system is really protecting. Is it the officers, or the public they've sworn to serve?",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/On-Our-Watch-Podcast-Tile-703x703-1.jpg",
"imageAlt": "On Our Watch from NPR and KQED",
"officialWebsiteLink": "/podcasts/onourwatch",
"meta": {
"site": "news",
"source": "kqed",
"order": 11
},
"link": "/podcasts/onourwatch",
"subscribe": {
"apple": "https://podcasts.apple.com/podcast/id1567098962",
"google": "https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5ucHIub3JnLzUxMDM2MC9wb2RjYXN0LnhtbD9zYz1nb29nbGVwb2RjYXN0cw",
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"spotify": "https://open.spotify.com/show/0OLWoyizopu6tY1XiuX70x",
"tuneIn": "https://tunein.com/radio/On-Our-Watch-p1436229/",
"stitcher": "https://www.stitcher.com/show/on-our-watch",
"rss": "https://feeds.npr.org/510360/podcast.xml"
}
},
"on-the-media": {
"id": "on-the-media",
"title": "On The Media",
"info": "Our weekly podcast explores how the media 'sausage' is made, casts an incisive eye on fluctuations in the marketplace of ideas, and examines threats to the freedom of information and expression in America and abroad. For one hour a week, the show tries to lift the veil from the process of \"making media,\" especially news media, because it's through that lens that we see the world and the world sees us",
"airtime": "SUN 2pm-3pm, MON 12am-1am",
"imageSrc": "https://ww2.kqed.org/radio/wp-content/uploads/sites/50/2018/04/onTheMedia.png",
"officialWebsiteLink": "https://www.wnycstudios.org/shows/otm",
"meta": {
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"source": "wnyc"
},
"link": "/radio/program/on-the-media",
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