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.