Marjorie Bittner has no real reason to feel guilty about her son, but that does not matter because she is a mother. To her, there is no getting away from the responsibility, no stopping the sneaky tears that spill without warning, no escape from the nagging questions, the "What if this?" and the "What if that?"
"What if I'd just stayed home that day?" she asks, speaking of that summer day when her 16-year-old son's brain became so badly damaged. "What if I'd been able to get him to the doctor sooner?"
Those questions, as unanswerable as they are agonizing, were only beginning to fade when her youngest son, Mark, died while being restrained in a state facility that was supposed to help him.
Now there is a whole new set of questions. More than a year after the death, though, the state agency responsible for investigating does not seem overly concerned about how or why Mark Bittner died.
That has caused a watchdog group to publicly demand an account of the death and has left the family bewildered over the workings of Maryland health care investigators.
"I loved that boy," says Marjorie Bittner, now 67, sitting in her home in the West Virginia town of Falling Waters, a rolling patch of farmland just across the border of Maryland, where her family once lived in Germantown. "Is it too much to ask for a mother to know why her son died?"
Officials with the state Office of Health Care Quality insist they thoroughly investigated Mark Bittner's death. He died Dec. 21, 2000, at the Rosewood Center, a state-run facility in Owings Mills that treats 222 brain-injured patients.
But all that is clear to health care investigators, at least based on their 2 1/2 -page report, is that Bittner, once a healthy, handsome boy who was in Rosewood as a result of viral encephalitis, died at age 30 while being restrained.
The report is little more than a review of his medical records and a recitation of his autopsy.
Because of privacy laws, the report has never been made public. According to those who have seen it, though, what it fails to address is startling.
The report never mentions the methods used to restrain Bittner - or whether he should have been restrained at all. There is no mention of why defibrillators on hand were not used to shock his heart, no mention that an autopsy indicated he was overmedicated - "intoxicated" - on an antipsychotic drug, no mention of more than 20 cuts and bruises found on his throat and the rest of his body, and no mention that Rosewood's doctors had recommended he be transferred from the facility years before his death.
And there is not a single word concerning this fact: Mark Bittner had stopped breathing at least 14 minutes before any Rosewood employee summoned an ambulance.
The investigators are state employees answerable to the Department of Health and Mental Hygiene. Rosewood is operated by the state's Developmental Disability Administration - another arm of the same department.
The gaps in the report have uncovered a vast void in accountability for state-licensed facilities and exposed a bureaucracy that strives to keep deaths like Bittner's shrouded in secrecy not only from the public but from the families of those who die in state custody.
The Office of Health Care Quality, responsible for both licensing and investigating Maryland institutions, made no findings of fault in his death and made no recommendations in its report about how to avoid deaths in similar circumstances.
For all the investigation lacked, it was more attention than Bittner received from the office in 1993, when an altercation with at least one staff member left his face so bruised it could be called grotesque.
Although his injuries were reported to the office, investigators never issued a report, according to his family.
The findings of health care investigators are important, because state police who investigate injuries and deaths at state facilities try to determine only whether criminal acts were committed, not whether minimal care standards were met.
The Office of Health Care Quality, though, apparently has high tolerance for the facilities it investigates.
Take a case last spring at the Edgemeade School in Prince George's County. Carlton Thomas, 17, a special education student, died there while being restrained.
The administration at Edgemeade insisted that staff members restrained Thomas properly, and health care investigators did not disagree. Their report cited no problems at all.
But the medical examiner did. So did the top prosecutor in Prince George's County. They both ruled Thomas' death a homicide. An Edgemeade employee, charged with manslaughter in the case, is scheduled to stand trial in May.
Nobody, including the medical examiner, is certain why Mark Bittner died. But the autopsy reaches this conclusion, one that the Office of Health Care Quality's report never mentions: The restraint of Bittner contributed to his death.
Mark Douglas Bittner was born healthy, the eighth child of Marjorie and Charles Bittner.
He wrestled and played football, was a fullback and linebacker for the Seneca Valley High School Eagles. He loved the family's camping trips to Rocky Gap State Park in Western Maryland.
"He was always happy," says his brother Bobby Bittner, 36, recalling how the baby of the family was doted on. "I don't want to say he was spoiled - but he was spoiled."
At age 16, Mark Bittner was big and strong, but his mother was concerned when she came home for lunch from her job testing computer systems and found him flat on the couch, not wanting to move.
Marjorie Bittner called the doctor. It was a Friday, no appointments were available until Monday, so the mother told her son she'd stay home the rest of the day. Family has always come first for her and her husband, who was working as an engineering contract analyst.
No, no, Bittner told his mother, she recalls. It was just a headache. He'd be OK. And so she made him some soup, left some aspirin next to him and went to work.
When she returned home about four hours later, she found him on his bedroom floor, between his bed and the wall. He was in convulsions.
"It felt like a lifetime for the ambulance to get here," she says. "Of course, it was about two minutes."
Bittner was airlifted to Children's Hospital in Washington. The convulsions continued for 25 hours. Then, a deep coma.
His family visited him every day, Marjorie Bittner sometimes sitting at his side from 5 in the morning until 11 at night, talking to him, letting him know that everything would be all right.
But it would not. Doctors diagnosed encephalitis, almost certainly transmitted by an infected mosquito. His brain was badly damaged. The coma dragged on three weeks before Bittner slowly started to emerge, with a flicker of his eyes, then a wiggling of his fingers until, finally, he was awake.
He recovered his motor skills relatively quickly. He could walk, which doctors had never guaranteed. He could feed himself. But for a year, he couldn't hear.
It would be years more before he could speak more than a few words, and even longer before he could string together a sentence or two that made sense.
"He was," recalls his mother, "like a little kid in that big body."
Perhaps the most troubling damage was to the part of the brain that controls emotion.
Nearly from the time he emerged from his coma, he displayed flashes of aggressiveness that bordered on violence. He'd get a blank look on his face, as if he were watching a movie flickering inside his head. Then he might shove someone near him and struggle when his arms were grabbed. He was frightening.
His family took him from one rehabilitation center to another, looking for a therapy that might work. In one facility, he was left alone and climbed down seven flights of stairs and out the doors. His family took him to another facility. There, he was sexually molested. They took him to another.
Finally, in 1991, he wound up at Rosewood. Doctors there tried all kinds of medicine with little success. Then, in about 1994, they found one that worked: Clozaril, an antipsychotic drug that was still considered experimental. His outbursts became less frequent.
"You could see his personality wanting to come out," says another brother, Chuck Bittner. "He could remember things from before the accident, like who was married to everyone. But if a new baby came along, he had trouble remembering who it belonged to."
Mark Bittner improved so much, he began making visits home almost every weekend. He'd shoot pool and mow the lawn. He'd sit by his mother's side while the family talked, and he'd toss in remarks - true wit, however slow - that got everybody laughing.
Rosewood, it seemed to his siblings and his father, was working out fine.
They might not have thought that had they known of Marjorie Bittner's deep, deep secret, one she never revealed to her family until after her youngest son's death.
In 1993, Marjorie Bittner arrived at Rosewood and was horrified.
The right side of her son's face was bruised from the top of his eye to more than an inch under it. The left side of his forehead was scraped and cut. The left side of his face was bruised from the top of his eye almost to his jawbone. The purple was almost black.
Marjorie Bittner was told her son was injured during a restraint.
She suspected otherwise. How could the eyes look like that when the nose was uninjured? She did not know then about a letter written by a staff member and provided to Rosewood's investigators. The letter conveys what a patient told the staff member.
Mark Bittner had been held on the ground by three other staff members, the patient said.
"Mark tried to get up and [a staff member] kicked him in the face with the heel of his shoe," according to the letter. "He was shouting at Mark to keep his head down. Mark lifted his head again and [a staff member] kicked him again in the face and again told him to keep his ... head down."
Bittner, with virtually no short-term memory, could not explain what happened to him.
Rosewood investigated and decided the patient had lied, that there was no wrongdoing by staff, according to Marjorie Bittner, who later found out about the letter from a social worker. But she drove home that day with tears on her face, debating whether to tell the family. She decided she would not.
"You have to understand the guilt I had," she explains. "I already felt so responsible for going back to work [when Mark was 16] and then finding him like that. Then we had him in and out of so many places and finally something was working."
Marjorie Bittner decided to bring her son home for longer weekends, three and four days at a time, "to keep him safe," she says. She hoped he'd continue his progress at Rosewood.
He did. As far as any of his family members know, he had his final outburst in 1996. He was so gentle that his brothers and sisters left their babies cradled in his arms.
Slowly, slowly, part of Mark Bittner's brain was returning to life.
Then came Dec. 21, 2000.
Death struggle over jacket
At the time of his death, Bittner had been at Rosewood nine years and was popular with the staff, who were familiar with his habits, good and bad.
About 4 p.m. on a Thursday, he was walking with a new staff member, a "direct care trainee," toward the center's gymnasium.
According to a report by the Maryland State Police, the trainee told Bittner to put on a jacket.
Bittner said no.
Staff members who had experience with him knew this was his initial response to just about everything, that saying "no" was more a reflexive action than any sort of defiance. They'd merely wait a few minutes and ask him again and he'd agree.
According to the trainee's account provided to state police, he kept the pressure on until the situation escalated and Bittner grabbed him by the neck. Other staffers heard the struggle and rushed to help.
Eventually, five of them - including one who weighed 280 pounds - were on top of Bittner, straddled across him and holding down his limbs as he struggled face down on the floor. They tried to put him in a straitjacket.
According to the police report, based on accounts provided by staff members present, Bittner suddenly stopped struggling. The staff members atop him thought he was giving up the fight.
In fact, he had stopped breathing. It was 4:16 p.m. and, according to one report, two minutes had elapsed from the time Bittner had stopped struggling to the time somebody noticed he was turning blue.
There are conflicting reports about when staff members began CPR, ranging from two minutes after Bittner stopped breathing to 10 minutes.
A defibrillator - a machine used to shock hearts back into a normal beat - was on hand. Staff members prepared to shock him, but an auditory signal told them not to.
Still, no ambulance was called. Finally, at least 14 minutes after Bittner stopped breathing, the Rosewood operator called 911. An ambulance arrived seven minutes later, according to Baltimore County emergency records. County emergency workers immediately shocked his heart, but it was too late.
Mark Douglas Bittner was declared dead at 5:01 p.m.
He was 30.
An abnormal heartbeat
The Office of the State Medical Examiner found Bittner died of an "abnormal heartbeat during restraint following a physical altercation and also associated with clozapine intoxication."
The "manner" of death, meaning whether it was natural causes, accidental, suicide or homicide, was ruled "undetermined."
"We know the restraint contributed to his death in some way," the Maryland acting chief medical examiner, Dr. David R. Fowler, said in an interview. "We could not say with certainty to what degree the restraint caused his death - but it was a factor."
When Bittner was being held on the floor, he was face down, according to police reports. That is considered a dangerous position for restraining a person because it can reduce the flow of oxygen.
Yet, the Office of Health Care Quality, in its report on Bittner's death, never remarked on how the restraint was applied. It did not address the medical examiner's finding that he also had bruises all over his body, including his neck, which might or might not have come during attempts to resuscitate him.
The same is true of the report on Carlton Thomas at the Edgemeade School. Health care investigators never mention the type of restraint used on him, which Edgemeade administrators insist was applied correctly.
Together, the cases demonstrate why groups like the Maryland Disability Law Center are sharply critical of the investigators within the Department of Health and Mental Hygiene.
The law center publicly pilloried the Office of Health Care Quality last month for what it sees as cursory investigations that do little more than regurgitate statements made by staff members involved in the deaths.
A thorough investigation into Bittner's death would have sought to determine why nobody called an ambulance until at least 14 minutes after he stopped breathing, said Philip J. Fornaci, executive director of the disability law center.
He wants to know how it is possible that the method of restraint in the Edgemeade case is never discussed in the Office of Health Care Quality's investigative report.
And he is particularly critical of the office because neither report offers suggestions on how to improve restraint training or emergency procedures. In fact, neither report makes a single recommendation of any kind.
"There are serious questions, to say the least, about Mark Bittner's death," Fornaci said, adding that health care investigators have hardly delved into the death of Thomas, either.
"We're not maintaining there's some massive cover-up. What we're upset with is the quality of their investigations."
The office's director, Carol Benner, said her investigators thoroughly examined both cases.
"Everything you need to know about [Mark Bittner's] death is in the autopsy," she said. "We look at systemic problems and, had we found any at Edgemeade or at Rosewood, we would have issued corrective action plans."
She would not comment further on matters such as whether the center's defibrillator was operating properly or about the delay in calling an ambulance because, she said, of privacy concerns.
Those concerns did not stop her last month when, reacting to criticism from the law center, she told reporters that Bittner had a history of aggression. She did not mention the family's claim that he had not been aggressive in six years.
Georges Benjamin, secretary of the Department of Health and Mental Hygiene, said the law forbids him from commenting on specific cases, but he defended the Office of Health Care Quality.
"It does a good review of deaths, from what I've seen," he said in an interview. "If it turns out I'm wrong about something, I have no qualms about going back and looking at things and seeing how we can make them better."
Marjorie and Charles Bittner, along with Mark Bittner's seven siblings, are considering a wrongful death lawsuit. They insist it would have nothing to do with money and everything to do with getting some answers.
Before Mark Bittner died, his doctors, impressed by his progress, suggested he be placed in a much smaller facility, one based in the community. He had been waiting for a placement at least two years.
His family had been anxious to get him into a smaller facility. Their hope was that if he continued his steady progress there, improved on day-to-day skills, he might one day be able to return home.