Paul Bertonazzi died five days after Baltimore Police took him to Johns Hopkins Hospital in January while he was suffering a mental health crisis. Last week, the state medical examiner called it a homicide.

The investigation is ongoing, but Bertonazzi’s death highlights an issue to which hospitals had already been trying to draw attention: safety.

Much of the concern has been about rising violence against health care workers, but efforts to tackle those problems are tied to safety for patients, too. Hospital officials and regulators say the work to add staff and train workers to handle patients who are aggressive or in a behavioral health crisis will, or should, protect everyone.

“Sadly this isn’t a new issue for health care, but it has definitely increased since the pandemic and, for a variety of reasons, not just behavioral health,” said Colleen Kincaid, a spokeswoman for the American Hospital Association. “The Bureau of Labor statistics had shown that health care is one of the professions most likely to encounter violence for some time.”

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Federal figures show in recent years health care workers were four times more likely to be victims of violence than those in other industries. About three-quarters of nearly 5,000 workplace assaults reported annually happen in health care and social service settings.

The Centers for Medicare and Medicaid Services, which has regulatory authority over hospitals, issued a memo last year saying some threats come from people with a history of aggressive behavior or mental health issues, or those under the influence of drugs.

To protect staff and patients, hospitals should assess patients for risks to themselves or others, ensure there are enough workers and train everyone, the memo said. It cited examples of “systematic failures” when hospitals fall short, including a nurse in an inadequately staffed hospital unit who was sexually assaulted by a behavioral health patient; a patient held down by a custodian with a knee to his back until he stopped breathing and died; and a patient shot in his hospital room by an off-duty police officer after hospital staff failed to perform appropriate patient assessment and de-escalation.

In Bertonazzi’s case, it’s unclear whether or how Hopkins’ care fell short.

Bertonazzi’s condition made him physically fragile

According to Baltimore police, Bertonazzi was picked up Jan. 5 at a fast food restaurant on Orleans Street near Hopkins’ East Baltimore campus while having a behavioral health crisis and threatening to hurt himself and others. Police determined he required an emergency petition allowing a violent or suicidal person to be brought to an emergency facility for rapid evaluation.

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The police report says as he was handcuffed and when officer tried to put him in a police vehicle he complained his neck hurt and he couldn’t bend it. The family attorney later said Bertonazzi had a spinal condition called ankylosing spondylitis, making his spine brittle, and officers were alerted.

The report said he refused medical treatment, was resisting officers and was seen hitting his head in a police wagon. He wasn’t visibly injured before being turned over to Hopkins medical and security staff, who escorted him to the psychiatric ward. It was when security staff sought to remove his handcuffs by lifting and placing him on a board on the floor that he stopped moving and was deemed in critical condition.

The family attorney later said Bertonazzi decided to forgo potentially life-saving surgery that would have left him paralyzed and with other medical conditions. He was pronounced dead Jan. 12, and the medical examiner told police the cause of death was a break in his spine.

Dr. Muhammad Khan, professor emeritus of medicine at Case Western Reserve University in Ohio and the author of numerous books on ankylosing spondylitis, said Bertonazzi’s medical condition made him physically fragile.

Khan said spondylitis causes vertebrae to fuse together over time and become easy to fracture, thus jeopardizing the spine. A fracture could happen when someone is in a car accident, or in Bertonazzi’s case, jolted in the back of a police vehicle. The fracture could remain stable, meaning it’s able to heal without severing the spine. But the spine could be severed by another jolt, Khan said.

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“The story is very typical for a spondylitis patient, having fractures,” said Khan, who also has the condition and is a member of the Spondylitis Association of America medical and scientific advisory board. “If someone says their neck is hurting, the statement should be taken to heart with all the precautions taken, even if the person is having another crisis.”

Hopkins didn’t respond to several questions about the incident, including the status of the security officials.

Liz Vandendriessche, a Hopkins spokeswoman, said in a statement to The Banner on Saturday, “Johns Hopkins Hospital remains committed to providing safe, high quality care for our community. ... We will continue to cooperate fully with the Baltimore Police Department authorities as they proceed with their investigation.”

Tackling complex problems

A classification of homicide is not a legal determination that criminal charges are merited. The attorney general’s office has already said it would not pursue the case as a police-involved death.

“This was a complex case that required many ancillary studies and investigation,” said David McCallister, spokesman for the Maryland Department of Health. The Office of the Chief Medical Examiner is an independent state agency within the department.

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“It is not uncommon for complex cases to take many months before cause and manner of death is determined,” he said. “Once the autopsy report proceeds through our standard finalization procedures, it would then be available for release, provided the state’s attorney does not request it to be held for additional investigation.”

Homicides at hospitals are considered “sentinel,” or significant, events by The Joint Commission, which accredits hospitals. It reported sentinel events jumped 20% in 2022 from the previous year, led by falls causing severe harm or death, but also delays in treatment, suicides and a category including assaults and homicides.

Compounding issues for Maryland hospitals have been increases in patients with mental health and substance use conditions, contributing to longer wait times in chaotic emergency rooms. Often, there isn’t an available psychiatric bed in the hospital or at a community facility.

Advocates say an answer is to prevent behavioral health patients from having crises that end up with them going to often chaotic emergency rooms.

“We need to keep people from going in, keep them from getting to this point,” said Lori Doyle, director of public policy for the Community Behavioral Health Association of Maryland.

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Hospitals also face significant labor shortages at all levels, a situation worsened by the coronavirus pandemic. One in 5 hospital positions in Maryland are vacant, according to the Maryland Hospital Association.

Last year, lawmakers passed legislation creating a work group to prevent violence in health care settings. Hopkins supported the measure that also calls for accommodation of patients with mental health and substance use conditions and disabilities.

Nancy Praglowski, a Hopkins patient safety innovation coordinator, said in testimony at the time that workplace violence has increased by more than 28% and employee injuries increased more than 7% since 2020. She said Hopkins was creating a workplace violence steering committee to tackle such things as crisis-prevention education.

Bob Atlas, the former president and CEO of the Maryland Hospital Association, testified in 2022 that hospital employees are being equipped to avoid confrontations and deploy de-escalation teams led by social workers rather than security personnel.

“Despite these efforts, health care workers continue to report being kicked, bitten, spit at and threatened,” he said.

“These actions — aimed at doctors, nurses, techs, front desk clerks, security guards and others — are simply unacceptable,” he said. “Hospitals should be safe places of health, hope and healing, where staff can focus on delivering care and supporting the needs of patients and their families.”

Banner reporter Justin Fenton contributed to this article.