Dorothy Berry has spent the past year trying to learn more about her son’s death. Her inquiry, however, has been mostly fruitless. With no one appointed the administrator of her son’s estate, neither she nor anyone else was entitled to his medical records. When she went to Georgia Regional looking for answers, she said, the only person who would speak to her was a security guard.
“I don’t know what happened to Matthew,” Berry said recently. “It’s killing me, Lord.”
Officials with the state Department of Behavioral Health and Developmental Disabilities, which runs Georgia Regional, said privacy laws prevented them from commenting on an individual's case. The state's investigation found no fault in how the hospital treated Bohler.
But public records obtained by The Atlanta Journal-Constitution show Bohler's death followed a volatile 5 ½-month stay at Georgia Regional, where investigations a decade ago found numerous suspicious deaths.
Bohler once tried to escape by scaling a fence.
He committed what the records called an “aggressive act” on himself.
He attacked three hospital workers and one other patient.
He experienced neglect by the staff.
And he tried to kill himself.
The state’s investigative report barely addressed those issues. It also failed to reconcile conflicting stories by hospital workers about the morning they discovered Bohler’s body.
The report quoted a psychiatrist as saying Bohler’s condition had improved during the last two weeks of his life. “He had times,” the doctor said, “when he was smiling appropriately.”
But she also said Bohler still repetitively chanted several phrases:
“I’m ready to go back to jail.”
“I wanna go back to jail.”
“I wanna go home.”
Bohler first showed signs of mental illness when he was 20 years old. A DeKalb County woman alleged in court documents that Bohler had stalked her, and a judge issued a protective order. When the police arrested Bohler on a misdemeanor theft charge, another judge ordered him to undergo a psychiatric evaluation. He completed a year of treatment, and the judge dismissed the theft charge.
But the treatment, especially the psychiatric medicines that doctors prescribed, made Bohler feel worse, his mother said. At Berry’s house in Stone Mountain, Bohler regulated his moods by running up and down the street, as fast as he could. Sometimes he lay in bed with his mother so she could massage his head and hands. It was the only way she could calm him.
One day in June 2016, according to hospital records, Bohler became upset at home and broke the windshields on three cars with a baseball. When his stepfather intervened, the records show, Bohler responded with “aggressive gestures.”
“He was laughing like he was having fun,” Berry said, “like it was a game.”
Berry called a mental health crisis hotline. A counselor told her to ask the police to take Bohler to an emergency room for psychiatric treatment. Instead, Berry said, officers took him to jail.
“I wanted him to be seen by a doctor,” she said. “I didn’t know if he was physically sick or mentally sick or altogether.”
Bohler got out of jail 11 days later, only to be arrested again within hours. This time, MARTA police charged him with felony theft and criminal trespass.
His mother asked Bohler's public defender to get the case transferred to DeKalb County's mental health court. It is part of the state's system of so-called accountability courts, intended to direct defendants to treatment rather than jail.
But DeKalb County requires defendants to plead guilty to their criminal charges before they appear in mental health court, said Cheryl Karounos, a spokeswoman for the Georgia Public Defender Council. And Bohler couldn't enter any plea because a judge had declared him incompetent, she said.
“Once they’re deemed incompetent,” Karounos said, “we’re kind of out of the process.”
So on July 14, 2016, the DeKalb County Jail sent Bohler to the forensic unit at Georgia Regional, eight miles away on Panthersville Road. Bohler would return to jail, his doctor said later, once he completed “competency restoration.”
Bohler seemed to be in good physical health when he arrived at Georgia Regional, the doctor who examined him later told a state investigator. But even after several months of treatment, the investigation found, Bohler had made no progress toward restoring his mental competency.
He was “disorganized, confused and unaware of his charges,” a hospital report said. He avoided group therapy sessions and other activities and told nurses he thought he didn’t have a brain.
“I don’t know why I’m here,” he said repeatedly.
Bohler often became violent toward others, the investigator’s report said. One time hospital workers caught him climbing a fence in an escape attempt. At one point, hospital administrators substantiated that the staff had neglected Bohler. But the report gave no details about the neglect. Nor did it elaborate on Bohler’s suicide attempt. It said Bohler was last placed in seclusion on Sept. 22 — but did not say how many times he had been isolated before then, or why.
On New Year’s night, Bohler was one of 21 male patients in the forensic unit at Georgia Regional. Two nurses and seven attendants, known as forensic technicians, worked the overnight shift.
Bohler was assigned to a room with three other patients. His bed was in the corner farthest from the door.
Like most patients, Bohler was supposed to be checked on every 30 minutes during the night. A nursing manager later said the staff merely looked into the room every half-hour and used a flashlight to observe whether his chest rose and fell with each breath. (A hospital official later disputed the nursing manager's description of the observations.)
What happened early the next morning is a matter of disagreement — one that the state investigator seemed to make little effort to resolve.
A nurse from the overnight shift said she twice tried, without success, to awaken Bohler between 6:15 and 7 a.m. When she sent a forensic technician into the room to try a third time by turning on the light, she said, Bohler moved but said nothing. The technician later denied entering Bohler’s room.
Another forensic technician said he made the first contact with Bohler between 8:15 and 8:30. As usual, he said, Bohler had slept with his covers pulled over his head. But on this morning, Bohler was unresponsive, his body cold to the touch — even though he supposedly had been awakened just an hour or so earlier.
The state’s investigative report said the accounts could not be reconciled. The time of Bohler’s death, the report said, was “unclear.” Officials had no more idea of when he died than why.
The morning of Jan. 3, at the Georgia Bureau of Investigation headquarters next door to Georgia Regional, a state medical examiner performed an autopsy on Bohler. A report said Bohler weighed 154 pounds — 27 pounds more than when he entered the hospital less than six months earlier. But at 6-foot-1, Bohler was hardly obese. The autopsy found a minor thickening of Bohler's heart muscle, but apparently not enough to have caused his death. Toxicology results showed only a normal level of an antipsychotic medicine in his system.
“The cause of death for Matthew Bohler is not entirely clear,” Dr. Keith Lehman, an associate state medical examiner, wrote in a report.
But Lehman added: “Patients with schizophrenia who die are reported to have an increased likelihood of having an autopsy that fails to reveal a cause of death, giving evidence that schizophrenia may cause sudden unexpected death in some people.”
Despite the uncertainty, Lehman certified that Bohler died of natural causes.
Researchers have struggled to understand why people with schizophrenia sometimes seem to die for no apparent reason.
In 2010, a study published in the journal Progress in Neuro-Psychopharmacology & Biological Psychiatry suggested that older generations of antipsychotic drugs could interrupt the heart's electrical cycle, sometimes causing cardiac arrest. But modern medicines, the study found, including the one Bohler was taking, seemed less likely to have that effect.
Another study, published in 2014 in the journal Schizophrenia Research, concluded that patients in psychiatric hospitals die of heart failure at a rate well above the general population. The study said an analysis of autopsy reports indicated that brain, heart and lung abnormalities could account for the disproportionate number of deaths.
Dorothy Berry still can’t believe her healthy, 22-year-old son simply died in his sleep. She thinks hospital workers withheld important details about his final hours.
“I just want a little justice,” she said. “I just want to know what happened to my son, my only son. Shouldn’t nobody have to go through this, shouldn’t nobody.”
Last Christmas, after her son called, Berry didn’t tell anyone he was coming home. She was afraid of jinxing the good news. Quietly, though, she began planning a celebration that, as it turned out, would never occur.
She learned the truth only after her son’s death: The hospital had no plans to send him home, after all.