Death Casts Shadow Over State-Run Care Center

Just before dawn last Aug. 7, a severely retarded 31-year-old man died at state-run Lanterman Developmental Center in Pomona. A heart attack, the doctor wrote in the center’s death log. No signs of trauma or foul play.

A few hours later, the man’s parents arrived to say their farewells to the son they called Marky, their youngest, whose difficult life had consumed theirs. He was lying on his bed, his hair neatly combed. It was as though he had died in his sleep.

Two weeks after that, an autopsy determined that Mark Orchen had met a far more brutal end.

By then, blood had pooled into bruises that covered his 4-foot-9-inch frame. They were on his stomach and chest, his arms, right thigh and knee, his left inner ankle, chin and neck and part of his scalp, the autopsy showed. Two quarts of blood -- nearly a third of his body’s total -- filled his abdomen from multiple internal tears.

Someone had kicked Orchen to death at Lanterman, a facility designed to protect and care for more than 600 mentally retarded adults.

Pomona police, after a three-week investigation, settled on one of Orchen’s roommates as a suspect: a 40-year-old autistic man who does not speak.

The Los Angeles County district attorney’s office rejected the case, citing insufficient evidence.

Four months later, in a confidential 1,260-page report obtained by The Times, investigators from the state Department of Developmental Services named another suspect: a Lanterman employee who had tended to Orchen on the night he died.

The prosecutor in charge of the case has not reviewed the state’s report, saying he relies on the police to investigate crimes.

Now, nearly a year after Orchen died, the two suspects continue on at Lanterman -- one as a patient, the other as a staff member. Lanterman is left with a likely killer -- “a frightening thought,” said Sherry Kohler, the center’s acting executive director.

The facility’s failure to protect Orchen is “devastating,” she said. “Nothing like this has ever happened here.”

This week, state health regulators announced they had issued their most severe penalty against Lanterman in Orchen’s death -- an “AA” citation carrying a $25,000 fine. That’s little comfort to Orchen’s parents, who still do not know who killed their son. The possibility of a resolution, let alone justice, now seems remote.

“Marky didn’t have cardiac arrest,” said Helen Orchen, his 70-year-old mother. “Somebody did this to him. Somebody bad hit him, and that’s just not right.”

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Childhood Infection

Life started normally for Mark Orchen.

At two weeks, he lifted his head; at three months he played with his hands and feet -- right on schedule.

Then, when he was nearly 4 months old, he got sick with bacterial meningitis, an infection that causes swelling around the brain. The damage left him severely retarded.

From then on, every step would be a struggle. According to his parents -- Helen, a registered nurse, and Melvin, a hospital pharmacist -- Marky didn’t crawl until he was 3 1/2, didn’t talk until 5, or walk until 6.

By the time he was 7, his parents, with two older children to tend to, could no longer care for him. He was hyperactive and refused to eat.

“Our family was sort of crumbling,” Helen Orchen recalled.

Over the next 24 years, Mark Orchen moved through a series of group homes, state institutions and psychiatric units. At age 21, tests showed that his development had stalled at age 2 1/2. His IQ was about 20, according to records contained in the state’s report.

Though his parents say he could be sweet and impish, he became increasingly aggressive. He lived in four group homes in seven years, often injuring himself or others, the state’s records show. At one point, according to his medical records, he was on nine medications to treat behavioral and health problems.

Lanterman at first seemed to be a good fit. The sprawling 302-acre site, with a swimming pool, equestrian center and ballpark, has housed adults with severe developmental problems since 1927. Residents live in mission-style buildings in rooms decorated in themes such as trains or cowboys. Buffered from the outside world, they learn to socialize, brush their teeth or make items to be sold in the center’s gift shop.

Eighty-five percent of the 640 residents have IQs less than 19. Most have the developmental level of toddlers.

Some of their caretakers have worked at Lanterman for decades, said Kohler, the acting executive director, but attracting new employees is difficult. The residents require constant supervision and can switch from being sweet to aggressive in an instant. The front-line staff -- licensed psychiatric technicians paid about $40,000 a year -- are spit upon, hit, groped and yelled at.

Injuries are not uncommon. Within the last three years, Lanterman has received three Class A citations, the second-most-severe penalty, from the state health department for failing to prevent a wheelchair accident, a possible assault and a self-inflicted head injury.

But Lanterman was “no better or worse” than centers with similar populations -- “probably better than some,” said Paul Hendricks, who oversees the licensing of state facilities for the California Department of Health Services.

For all the challenges of working at Lanterman, Kohler said, employees often find it highly rewarding to nurture those who cannot live on their own.

Melvin Orchen, 72, was initially impressed. “It looked beautiful. The whole picture looked terrific. Look at all these people trying to help Mark,” he said.

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Trouble Early On

Mark Orchen moved into a unit for residents with behavioral problems at Lanterman in February 2002, and doctors began cutting back his medications. But within a month, he ran into trouble.

He still had an impish side: He liked to give hugs, play kickball, sing Christmas songs and run the paper shredder at his on-site job.

But according to the state report, if Orchen didn’t want to do what he was told, he would drop to the floor and refuse to move. He bit staffers and fellow residents. He wet himself during the day and refused to wear underwear at night.

Doctors suggested he might be suffering from medication withdrawal, according to the state report.

About the same time, he began to suffer a series of unexplained injuries, according to incident reports compiled by state investigators. Every month or so, staff members would spot something: a large groin bruise in March; chest bruises in April; a cut lip in May; another groin bruise and a bloody toe in June.

At the end of June, Orchen appeared to suffer a severe beating, leaving him with a bruised left ear and groin, as well as swelling in his eyes, lower lip and left foot.

Two weeks later, three of his fingers were broken. Psychiatric technicians were told not to let Orchen out of their sight during the day and to look in on him every 15 minutes at night.

Orchen’s treatment team -- including a psychologist, a doctor and others -- began pushing for him to be moved to a unit with less-aggressive residents in May, according to state records. But the transfer was never carried out.

Five months after he arrived at Lanterman, Orchen was hurt for the last time.

About 3:45 a.m. on Aug. 7, psychiatric technician Benjamin Goodwin, 27, discovered that Orchen had defecated in his bed, according to an incident report the employee filed.

Goodwin reported bathing Orchen and changing his sheets, then dressing him in underwear and putting him back into bed.

Shortly after that, according to Goodwin, Joel Key, one of Orchen’s roommates, ran down the hall biting his hand and moaning. Goodwin said he stopped Key, who is autistic and does not speak, and returned him to the bedroom.

There he found Orchen slumped on his knees on the floor between his bed and Key’s.

Goodwin and others could not revive him. A Lanterman physician pronounced Orchen dead from a heart attack at 5:06 a.m. On a death report, the doctor listed obesity and an enlarged heart as contributing factors.

Just after 9 a.m., his parents came to say goodbye.

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Investigations Begin

Two weeks after Orchen’s death, a coroner’s investigator called Pomona Police Det. Greg Guenther to report that a Lanterman resident had been killed.

About the same time, investigators were dispatched from a unit of the state Department of Developmental Services that probes serious incidents of abuse.

The two agencies began working together but soon parted ways -- ultimately reaching starkly different conclusions.

Guenther quickly focused on Key, one of Orchen’s three roommates. His 12-page investigative report relied primarily on Lanterman files and information from Goodwin, the psychiatric technician. All told, his report cites interviews with five people.

Goodwin, who has worked at Lanterman for four years, told Guenther that Orchen was known to be combative toward his roommates at night and “normally would target a person that was next to him,” according to Guenther’s report.

Key also could be aggressive. He “grabs and kicks, hits and scratches and/or pushes” and can become “very compulsive and/or explosive,” according to Lanterman documents cited by Guenther.

Probate court records not included in the police report show that the state became Key’s legal conservator around 1995 because, at that time, he was violent and needed to be restrained several times a month. Paul Verke, a spokesman for the state Department of Developmental Services, said he could not comment about clients under the agency’s care.

Guenther concluded that Key had likely retaliated after being attacked by Orchen. But Guenther also noted that, given Key’s mental capacity, he was “incapable of knowingly and willfully inflicting these injuries.”

Guenther, who declined to elaborate on his written findings, took his case to Deputy Dist. Atty. Dennis Ferris in Pomona.

In an interview with The Times, Ferris said there wasn’t enough evidence to proceed. Key, he said, could have become agitated because he killed Orchen -- or because he had seen someone else do it.

“Could have been he saw it. Could have been he did it,” Ferris said.

After the police filed their report, the state’s investigators continued their probe, interviewing more than two dozen Lanterman staffers. They became increasingly skeptical of Guenther’s findings.

There was no evidence of past altercations between Orchen and Key, according to the state report. In addition, it says that several senior staff members described Key as not particularly aggressive.

One staffer said she would be “in shock” if Key was involved in the slaying.

The reference to Key’s “explosive” temperament in his clinical file referred to property destruction, not attacks on people, a residence manager said.

The coroner had determined that whoever killed Orchen probably was wearing shoes. Staff members told investigators Key typically wore socks to bed.

Although Orchen’s two other roommates may have seen what happened, investigators said they were not capable of answering questions, according to the state’s report.

Meanwhile, the investigators were struck by discrepancies in the story of psychiatric technician Goodwin.

Goodwin said he had dressed Orchen in his underwear without any problems, according to the state report. But other staffers said Orchen would have fought efforts to dress him in underwear. Goodwin also said he had put Orchen back in bed after changing his sheets. But the senior psychiatric technician who helped place Orchen’s body in the bed before his parents arrived that morning said the bed appeared never to have been slept in.

When investigators questioned Goodwin about that discrepancy, he couldn’t explain it. “He probably wasn’t in there that long,” he said, according to the state’s transcript of the interview.

Goodwin also told investigators that he did not kick or strike Orchen.

When investigators asked if Orchen was “annoying as heck or what?” Goodwin replied that “to some he might have been,” but he considered Orchen a form of “excitement on my boring night.”

Goodwin declined to speak to The Times. State investigators also declined comment.

According to their report, the investigators considered Goodwin their suspect. They took their findings to the police and the prosecutor -- but neither was interested.

Pomona Det. Guenther told The Times: “My partner and I did the investigation and I’m comfortable with where it took us.”

Ferris, the deputy district attorney, said he didn’t read the state’s report, explaining that the “homicide detective interviewed [Goodwin] and felt there was no deception there at all.”

John Spillane, the deputy district attorney who oversees the Pomona office where Ferris worked, said he did not believe the report had ever been given to his office.

“If the case was presented to our office, we would take a look at it,” Spillane said.

Meanwhile, Orchen’s parents learned of the state’s findings and hired an attorney to obtain the confidential report. On June 23, they sued Lanterman and Goodwin.

“Whether he was killed by another resident or whether he was killed by a staff member at the facility, Lanterman failed in their foremost duty to protect and safeguard Mark Orchen,” said the couple’s attorney, William Berman of San Diego.

After Orchen’s death, Key was supervised closely for six months, especially at night, and Goodwin was removed from working with residents for several days, said Kohler, the acting director.

“There was no way we could validate” the suspicions against either man, she said.

Verke, the Developmental Services Department spokesman, confirmed that civil service rules limit the types of administrative actions that its facilities can take in such cases.

Unable to gain the interest police or prosecutors, state investigators ultimately decided Orchen’s slaying could not be solved: His roommates could not speak for themselves, and there was no one to corroborate or disprove Goodwin’s version of events.

“This case is closed,” the state report concluded.