Mark Bittner died at age 30 just over a year ago while being restrained at Rosewood Center, a state institution for the mentally retarded. That was tragedy enough, his parents said yesterday.
Now their grief has been compounded by a new report that accuses state investigators of "sweeping under the rug" the circumstances surrounding their son's death.
Among the case's unexamined facts, according to the Maryland Disability Law Center report: Workers waited 14 minutes from the time Bittner stopped breathing to call for an ambulance. And, the law center says, he did not require care at Rosewood and should have been discharged to a less-restrictive program years before he died.
In the report scheduled for release today, the law center pillories the Office of Health Care Quality, an arm of Maryland's Department of Mental Health and Hygiene.
The office is a watchdog of sorts and is required to investigate deaths at state-licensed facilities such as Rosewood, which cares for about 250 people in Owings Mills.
"I don't think the office takes the responsibility to investigate very seriously," said Philip J. Fornaci, executive director of the law center. "They don't seem to want a lot of scrutiny about what goes on at some of these institutions."
The law center's report calls the state investigation into Bittner's death "an abysmal failure" and "primarily a cursory review of documents" created by Rosewood.
Carol Benner, director of the health care quality office, said yesterday that her investigators were "thorough," and she questioned the law center's contention that Rosewood staff waited 14 minutes to call an ambulance.
"I think the report is somewhat shrill," she said. "What concerns me is it's written by lawyers."
Benner did not have access to her investigators' report because she was in Annapolis yesterday, she said, and so could not respond further to the law center's findings.
She also said she had to review her investigators' report before releasing it to The Sun, as the newspaper requested.
The law center report focuses on the actions of two groups: employees at Rosewood and the state investigators from Benner's office.
Brain injuries at 16
Bittner died Dec. 21, 2000. He was the youngest of eight children growing up in Germantown, and his parents, Charles and Marjorie Bittner, describe his childhood as normal and healthy.
But in 1986, at age 16, he contracted viral encephalitis and was in a coma for three weeks. Brain injuries left him functionally mentally retarded.
After short stays in at least 14 institutions in seven states, Bittner came to Rosewood in 1991.
"The whole staff loved him; they'd come up to us and tell us so," his mother said. "They never had a problem with Mark in six years or more."
On the day he died, though, Bittner got into an altercation with a staff member. Eventually, according to reports from Rosewood, four or five staff members were restraining him as he lay on his stomach.
During the restraint, he lost consciousness and died.
"There were so many questions," said Charles Bittner. "There are still questions, and it's bad this keeps on getting dragged out, dragged out."
The Office of the State Medical Examiner determined Bittner died of an abnormal heartbeat while being restrained. The law center says the autopsy also found Bittner was over-medicated on Clozapine, an antipsychotic.
"Even a cursory review of the relevant documents raises serious questions about the series of events that led to Mark's death," the law center's report says.
Among the issues that state investigators did not address in their 2 1/2 page report, according to the law center, were the appropriateness of the restraint; the emergency response that led to the delay of a nurse or doctor arriving at the scene and an ambulance being called; the lack of review about the role Bittner's medication may have played in his death; and the appropriateness of his placement at Rosewood.
The law center says Rosewood workers had recommended that Bittner be placed in a community program years earlier.
"It appears that his placement was delayed not due to his readiness but rather because of systemic problems," the report says. "Although the state investigation does not comment on this issue, it is undeniable that, if Mark had not remained at Rosewood, he might still be alive today."
Aiding mentally retarded
Rosewood's legislative mandate is to provide direct service to mentally retarded people while working to integrate them into less restrictive settings in the community.
Rosewood is operated by the Developmental Disabilities Administration and investigated and licensed by the health care quality office - both of which are part of the Department of Mental Health and Hygiene.
The Maryland Disability Law Center is a nonprofit organization established by federal and state law to advocate for the rights of people with disabilities. It is funded through grants from the state and federal governments, and from Maryland Legal Services Corp.