A 63-year-old man who was taken to the Johns Hopkins Hospital in January for a psychiatric evaluation and died days later suffered a severed spine while in the hospital’s care, according to an incident report viewed by The Baltimore Banner.

Baltimore Police disclosed Thursday that the death of Paul Bertonazzi had been ruled a homicide Nov. 1 but have said little else other than he had suffered “trauma to the body.” The Johns Hopkins Hospital said in a statement Thursday night that it was aware of the incident and is cooperating with authorities.

The police incident report reviewed by The Banner provides a fuller picture. In it, police said Bertonazzi had complained about neck pain while in police custody and the autopsy later showed he had a preexisting “curvature” of his spine.

But the evidence, they said, also showed he was moving freely before being taken into the hospital — causing the independent state attorney general’s office’s unit that investigates police custody cases to quickly determine officers were not responsible.

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Steve Markey, an attorney representing Bertonazzi’s family, said he obtained body camera footage and it shows police treated him with “exemplary care.”

“I was extremely impressed with how Baltimore City police officers handled themselves,” Markey said.

Markey, of the law firm Markey & Orsi in Towson, said it remains unclear to the family how Bertonazzi’s fatal injuries occurred. “We don’t know what happened behind the closed doors at Hopkins other than his neck was broken. How that happened when they were clearly advised of his condition and were aware that he could not bend, we don’t know,” Markey said.

The Banner reviewed police body camera video shared by Markey. The videos cover officers responding to the Burger King in the 1200 block of Orleans Street and Bertonazzi’s arrival at the Johns Hopkins Hospital.

Officers were called to the Burger King on the evening of Jan. 5 for a man who was having a behavioral crisis and threatening to hurt himself and others, according to the incident report. Police determined he required an emergency petition, which allows a violent or suicidal person with a mental disorder to be brought to an emergency facility for rapid evaluation.

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Officers placed handcuffs on Bertonazzi and tried to put him into a patrol car; he said his neck hurt and he couldn’t bend it, the report says. Markey, the family attorney, said Bertonazzi was known to have a spinal condition called ankylosing spondylitis, making his spine brittle and unable to bend, and that he made the officers aware.

Police requested medics to the scene, and after their arrival they say Bertonazzi sat down in the car where he continued to resist, including trying to kick an officer. He refused medical treatment, stood up and walked to a police wagon, the report says.

While at the Burger King, one officer called Bertonazzi’s family. The officer can be heard saying Bertonazzi has Alzheimer’s disease and that there’s no one who can or will come to the restaurant to pick him up.

“Nobody wants anything to do with him,” one officer tells another at the scene.

As officers attempt to get Bertonazzi on the wagon, one officer cautions that he’s complaining about being in pain and that “something is wrong with his neck.”

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“He is trying to kick, though,” the officer said.

After the 2015 police custody death of Freddie Gray, who the medical examiner determined suffered a severed spine during a prison wagon transport, police transport wagons were outfitted with cameras. All city patrol officers also now wear body cameras, unlike in 2015.

The report says Bertonazzi was observed hitting his head against the inside of the van but suffered no visible injuries. Bertonazzi was seated and secured by a seat belt in the wagon, and an officer rode in the back with him to the Johns Hopkins Hospital.

Upon arrival, Bertonazzi was assisted out of the vehicle, according to the account, placed into a wheelchair and taken into the emergency room.

Inside the hospital, the officers turned off their body-worn cameras. Police policy instructs that officers “shall be aware of patients’ rights to privacy when in hospital settings” and “shall not record patients during medical or psychological evaluations or treatments.”

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“When recording in hospitals and other medical facilities, members shall avoid recording persons other than the person of interest, or recording medical documents,” the policy states. “However, as in any setting, if confronting a violent or assaultive suspect, or in an anticipated use of force instance, the member shall activate the BWC [body-worn camera] in advance of the encounter or as soon as reasonably practicable.”

Once the wagon arrived at Johns Hopkins, an officer can be seen on the body camera video in the back of the wagon with Bertonazzi, talking to him about getting out of the vehicle.

“I can’t sit. I can turn backwards,” Bertonazzi said.

“Sit on that bumper right here. I can get a better angle,” the officer said.

The body camera video shows Bertonazzi moving his hands and legs while being lifted into a wheelchair by officers. The video turns off after Bertonazzi is wheeled into the hospital. Officers then turned Bertonazzi over to hospital staff.

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The report says Bertonazzi was seen trying to get out of the wheelchair and lifting his legs when people were nearby. He was wheeled into the psychiatric ward by security guards and medical staff. It’s not clear whether the account is based on surveillance video, witness accounts or both.

Police were later told that, in an attempt to remove handcuffs from Bertonazzi, security guards lifted him and put him on a transfer board that was on the floor.

Medical staff told police that, at that point, Bertonazzi was no longer moving any body parts and was deemed to be in critical condition.

Markey, the attorney, said Bertonazzi was reliant on a ventilator. His daughter, Brandy, was given a decision to either allow an operation to be performed on him where he would be a paraplegic with other “significant” medical issues – if he survived – or die, Markey said.

Ultimately, they chose the latter after Bertonazzi was weaned off sedation. Paul Bertonazzi made the decision against the surgery and to be allowed to die, leaving his daughter “extremely distraught,” Markey said.

”And it was very difficult decision,” Markey said. “It was an extremely difficult decision.”

Bertonazzi was pronounced dead Jan. 12. At that time, the medical examiner’s office told police his death was determined to be caused by a break of his spine. Photos and videos of Bertonazzi indicated to the medical examiner that the injury hadn’t occurred prior to his admittance to the psych ward because he had been moving, according to the incident report.

It’s unclear what took the medical examiner’s office more than nine months to determine that the manner of death was a homicide, or the rationale for the ruling.

A classification of homicide is not a legal determination that criminal charges are merited, but it did not rule his death an accident, either.

A much quicker determination in the case came from the attorney general’s office, which in 2021 was given authority to investigate police custody deaths statewide. Baltimore Police referred Bertonazzi’s death to the unit for review.

Thomas Lester, a spokesman for the attorney general’s office, said it was immediately apparent to investigators that the case did not fit their criteria to be investigated by their unit. They declined to pursue the case the day after Bertonazzi’s death: Jan. 13.

“After a review of body-worn camera and surveillance camera footage, our office determined that the decedent was not in police custody when he sustained his injuries,” Lester said. “Based on these factors, the IID is not investigating this incident as a police-involved death.”

Representatives of the Johns Hopkins Hospital responded late Thursday with a statement saying they were “aware” of the information disseminated by police about the January incident. They said they could not discuss any patient’s care due to privacy laws.

“We can assure you that we are committed to providing the safest and highest quality of care for all patients. We will cooperate fully with the authorities as they proceed with their investigation,” the statement said.

Hopkins did not respond to additional questions Friday.

In recent years hospitals in Maryland have seen big increases in patients with mental health and substance-use conditions, and at the same time they have worked to reduce emergency room visits generally. Hospital officials have said they are not equipped to handle the patients beyond their acute medical needs.

Some patients end up facing long waits in the hectic spaces around the emergency bays until there is a bed in the psychiatric wing open or a space in a proper treatment facility.

Hospitals have faced significant staffing shortages at all levels in recent years, with one in four nursing positions vacant, according to the Maryland Hospital Association.

Since 2020, serious events on hospital campuses have been on the rise, jumping 20% from 2021 to 2022, according to the Joint Commission, which accredits hospitals.

They include falls causing severe harm or death, delays in treatment, suicides and a category including assaults and homicides.

Banner reporter Meredith Cohn contributed to this article.


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