The Autism News | English


Six days before he died, Van Ingraham was found on the floor of his room. His neck was broken and his spinal cord was crushed and disfigured. The injury was so severe, medical experts said it looked like he’d been put in a headlock or hanged.

But even if Ingraham knew how he’d been injured, his severe autism prevented him from revealing it. He’d never uttered a word in his life – only his injuries could speak for him.

Solving the mystery of Ingraham’s death in the summer of 2007 was left to the detectives at the Fairview Developmental Center, a state-run institution in Costa Mesa where Ingraham lived in a sterile room. A tiny window allowed only a sliver of light into his world.

Ingraham’s family sent him to Fairview when he was just 8 years old. He lived under the care of the state for 42 years. Restless, he would sprint through hallways. He would urinate on himself when upset. At his worst, he would strike at his own face, though never at his three roommates or others around him.

The coarseness of Ingraham’s life at Fairview was matched only by the sloppiness of the investigation into his death.

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

Later, Fairview detectives noted that Ingraham’s caregiver had changed the institution’s log documenting what the patient was doing at the time of the injury. But detectives never pressed the issue.

The lead detective, a former nurse, had minimal police training and no experience investigating suspicious deaths.

In the case file, she left out the opinion from a biomechanical specialist that Ingraham’s death “was likely a homicide” – one of three medical experts to raise alarms about the injury. Two of those experts concluded that Ingraham likely had been put in a headlock.

Fairview detectives eventually focused on another patient without proof he was even near the scene. The key testimony leading detectives down that road came from a blind patient.

The detectives also surmised that Ingraham could have fallen out of bed, which was about two feet off the ground. Medical experts said that scenario was highly unlikely given the force required to produce Ingraham’s injury.

No arrests have been made in the case, and the Fairview caregiver last seen with Ingraham continues to work at the center.

Ingraham’s death illustrates how an ill-equipped, inexperienced and poorly trained police force has dealt with a rising number of unexplained injuries and abuse cases inside state-run facilities managed by the Department of Developmental Services.

The $4.5 billion Department of Developmental Services is responsible for about 1,800 patients with cerebral palsy, mental disabilities and severe autism at five centers in Los Angeles, Orange, Sonoma, Riverside and Tulare counties.

A California Watch investigation has found that detectives and officers working for the agency’s police force, the Office of Protective Services, routinely mishandled reports of abuse at the facilities. Hundreds of cases of reported abuse and unexplained injuries have been documented and then dropped without prosecution or detailed follow-up.

Over the past six months, California Watch has provided state officials with documents, interviews and data from its investigation into Ingraham’s death. But Department of Developmental Services officials declined to comment on the case, citing patient privacy laws.

Terri Delgadillo, director of the department based in Sacramento, said overall, “If there are issues that need to be addressed,” the department is looking into making improvements.

Key players in the case, including Fairview detectives and officials with the Orange County sheriff-coroner’s office, declined to comment or were instructed to remain silent. The circumstances of Ingraham’s death were reconstructed based on interviews, police case files, autopsy examinations and other public records.

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

Fairview police did not secure Ingraham’s room to protect evidence, did not promptly interview witnesses, and failed to respond to the patient’s broken neck as requiring immediate investigation, the detectives said.

“It is my belief that the initial responders did not recognize the scene as a potential crime scene,” Det. Al Cruise of the Seattle Police Department wrote in his review.

Even after the Office of Protective Services learned that Ingraham’s neck had been broken, they waited five days to begin witness interviews. This “gave several people the opportunity to speak about the events,” Det. Mark Czworniak of the Chicago Police Department wrote of the delay, which could have potentially undermined witness statements.

Childhood diagnosis

As a baby, Van Ingraham didn’t respond to voices. His parents feared their youngest son was deaf.

Ingraham’s ears worked. His true disabilities would prove far more challenging. At 18 months, when most children are upwardly mobile, he wasn’t walking. He made sounds, but could not form words.

“Right away, I started noticing things about him as a tiny baby,” said Jane Robert, Van Ingraham’s mother, now 90 years old. “He didn’t want me to hold him and cuddle him. He would stiffen up when I would try to hold him.”

But as he grew, Ingraham was giddy in his love for play.

A black-and-white family picture now fading shows him, about 6 years old, riding piggyback on his older brother’s shoulders in their San Diego neighborhood. Both are smiling, but Van’s mouth is open wide, like a kid screaming joyfully on a roller coaster.

“We had a big family living in a small house,” said Jane, who stayed at home to take care of her two sons and four daughters.

Van Ingraham’s impulses grew more difficult to tame. He suffered severe seizures. When he was 8, Jane took him to a doctor specializing in a relatively new disorder called autism.

The doctor diagnosed him as being on the severe end of the autism spectrum. The conclusion was not so painful as the specialist’s advice, which was “put him away; forget you had him,” said Larry Ingraham, Van’s older brother by six years.

“And that was the beginning of the nightmare,” his mother recalled. “Because my husband said, ‘Never, we’ll never do that!’ And I ran outside of the room. It was the worst day of my life.”

They tried their own methods. When he finally started to walk, and had a tendency to bolt from the house, his family painted the walls of his bedroom yellow, his favorite color, in the hope it might induce him to stay put.

Less than a year after the diagnosis, Ingraham became agitated one day while his mother was caring for him alone. The door to the boy’s bedroom locked only from the outside, so they could contain him. But Ingraham ran out of the room ahead of his mother and slammed the door, locking her in.

Van Ingraham was discovered hours later, naked and running down the middle of the street, following the yellow lane dividers.

It was too much. Jane first tried placing her son in a private group home. That arrangement lasted just 24 hours, as a distraught Van tore down curtains and nearly broke free from the facility.

Life at Fairview

The Fairview Developmental Center was a last resort and a welcome salvation from the stress of caring for a disabled child. A doctor had recommended the facility to Ingraham’s family.

On a clear and cool April 20, 1964, Ingraham’s parents loaded up their car and drove their youngest son to Costa Mesa, the suburban enclave in Orange County where five years earlier the state’s newest institution for the developmentally disabled had been built on 752 acres.

From outside the fenced-in campus, Fairview now looks like a school built for thousands of children, with low-slung buildings painted blue and white. Patients wander the drab halls and common areas, which are serviced by the institution’s own power plant and an industrial kitchen.

Richard “Dick” Ingraham, an executive at the defense contractor General Dynamics for 43 years, and Jane believed their son was safer at Fairview, protected and watched around the clock.

Jane co-founded the parents’ organization – Fairview Family & Friends – that assists the institution to this day and embraces a philosophy that “all people have value as human beings and as members of the human family.”

Over the years, the family would bring their son home on weekends. On one occasion when Ingraham was 9 years old, Jane said she noticed during a bath that he had “bite marks on his little penis.” She said Fairview did not explain the marks.

The toll of institutionalizing the boy was deeply painful to the Ingrahams. Larry Ingraham said he believes it contributed to his parents’ divorce a few years after Van Ingraham first entered Fairview.

Jane Robert said once her son became a teenager, bringing him home on weekends became too stressful for the family.

“Finally there came a day my husband said, ‘Don’t bring him home any more,’ ” Jane said, her voice quivering. “It was just too much for him. You know, he worked hard all week.”

Ingraham grew into a healthy man at the institution. To control his moods, Fairview physicians prescribed him lithium and risperidone. Both medications are used to calm the behaviors of the severely autistic, according to the National Institutes of Health.

He stood 5 feet 9 inches tall, with the lean muscular build of a day laborer and full head of dark brown hair. He was social, though he avoided physical contact with others. This made grooming him a chore. Pictures that Larry Ingraham had taken show his brother with stubble visible along his jaw line and chin.

His tastes and activities changed little, a 2006 assessment by Fairview caregivers shows. Ingraham guzzled soda and generally preferred sweet foods. He “likes hot cereal with LOTS of sugar and cocoa,” the assessment states. Larry Ingraham keeps a photograph of his brother chugging a plastic bottle of Sprite.

His communication skills developed, but they were basic. When Ingraham wanted someone to leave his room, he’d nudge them toward the exit with his elbow. But impulse control would bedevil Ingraham until the day he was paralyzed.

Predawn incident, then injury

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