The killing of a disabled man inside a state-run hospital was the catalyst for two pieces of proposed legislation in California aimed at protecting patients.
Van Ingraham had lived most of his life at the Fairview Developmental Center in Costa Mesa where he was able to receive care for severe autism and retardation.
In June 2007, Van was found in his room with a broken neck and a crushed spine. He died from his injuries six days later.
Workers at the state-run facility said Van's injuries were probably caused by a fall from his bed, which is two feet high.
His brother disputes that theory. An autopsy report suggests Van Ingraham suffered an injury that’s similar to that caused by a motor vehicle accident.
"It was very obvious he didn't slip out of bed," said Larry Ingraham.
Ingraham, a retired San Diego Police officer living in Spring Valley, enlisted help from fellow retired officer Donovan Jacobs and together they say they found major flaws with the investigation.
They also found problems with the state police investigators from the Office of Protective Services.
"I later learned that one was a registered nurse with no police experience whatsoever, and the other one was a security guard," Larry Ingraham said.
"Even someone with common sense could figure out what happened, and these guys were supposed to be trained investigators and they still couldn't figure out what happened,” Jacobs said.
Ingraham and Jacobs say their investigation later determined that a worker at Fairview put Van in a headlock, causing his severe neck injury.
The worker involved still works at Fairview according to Ingraham.
According to Ingraham, they would help protect patients who are being abused by workers and ensure that crimes are properly investigated.
Under the proposed law, local police agencies must be notified if there's any question about an injury at a state run hospital and a written report must be submitted to the local agency within two days.
"It brings in a level of professionalism that you don't have with the hospital police and it brings in street experience," said Jacobs.
The Fairview Developmental Center is one of five centers for the disabled in California and, according to the California Report, the state spends about $300,000 a year on each patient in those centers.