Medical examiner audit reclassifies dozens of police-restraint deaths as homicides

by BRYAN P. SPEARS, Maryland Matters

Dozens of police-custody deaths that were ruled accidental or of unknown causes have been reclassified as homicides after a four-year review of more than 1,300 cases handled by former Maryland State Medical Examiner Dr. David Fowler.

The results of that review, announced Thursday, also highlighted potential racial and pro-police biases in the medical examiner’s office at the time that may have contributed to the mischaracterizations.

The audit, led by Towson University psychology professor Jeff Kukucka, looked at roughly 1,300 in-custody deaths between 2003 and 2019 — a period corresponding with Fowler’s time leading the Office of the Chief Medical Examiner (OCME). Attorney General Anthony Brown (D), who announced the findings with Kukucka and Gov. Wes Moore (D), said the report raises “profound concerns, and they are well founded in the audit.”

“The audit report’s findings reveal significant discrepancies that demand our attention and response,” Brown said.

“Our research has determined that OCME was especially unlikely to classify death as a homicide if the decedent was Black or if they died after being restrained by police,” Brown said. “These findings have profound implications across our justice system. They speak to systemic issues rather than individual conduct.”

The audit, released Thursday afternoon, will be presented Friday to the National Academy of Sciences, Engineering and Medicine.

“The findings of this audit are deeply concerning,” Moore said. “It’s going to take time to digest a report prepared over the course of four years and two different administrations.

“But if there’s one takeaway that we’ve already drawn at this very early stage is this: We have to make sure we are continuing to make Maryland a model for public safety and transparency and equal justice under the law, and one is not more important than the other,” he said.

Moore said the audit is the first of its kind in the nation, and should set “the standard for what this type of investigation can, and what this type of investigation should, look like” in other states.

“Blazing new trails is never easy,” Kukucka said, “but someone has to lead the way, and we believe that Maryland can and will be that leader in terms of strengthening death investigations across the country.

“We hope that our rigorous audit procedure will provide a blueprint for other states to conduct similar audits, and that implementing our recommendations will establish Maryland’s OCME as a gold standard to which other agencies can aspire,” he said.

Police-custody deaths get a second look

The audit released by the Office of the Attorney General included the names of 41 people who died soon after being restrained by police. The majority included an “undetermined” cause of death ruling. As a result of the audit, all 41 are reclassified as homicides.

The review began in 2021, sparked by an outcry over Fowler’s testimony in the trial of Minneapolis Police Officer Derek Chauvin, who was convicted of murder in the 2020 death of George Floyd during an arrest. As part of that arrest, Chauvin knelt for up to nine minutes on the neck of Floyd, who said repeatedly that he could not breathe.

Fowler, who resigned as the chief medical examiner in 2019, was called as an expert witness for Chauvin. He testified that Floyd’s death was caused by “excited delirium,” rather than police actions.

Excited delirium was a catchall term used to describe aggressive behaviors related to mental health or substance abuse issues. It has been disavowed by the American Medical Association and the National Association of Medical Examiners.

Fowler came under fire for his testimony in the highly publicized case. The audit was triggered by a 2021 letter from 450 medical experts, who called on Maryland officials to investigate deaths in police custody and practices in the medical examiner’s office under Fowler.

“These members of the medical community were concerned that our state’s death determination has been tainted by racial or pro law enforcement bias, or were otherwise inconsistent with the standard practices for investigating and certifying in custody deaths,” Brown said.

Among the report’s findings: Excited delirium or the synonymous agitated delirium was cited in the death statements made by Fowler’s office in 42 of the more than 80 in-custody deaths that came shortly after an episode of police restraint.

Researchers reviewing the initial 1,300 in-custody deaths focused on 84 cases of individuals who died soon after being restrained by police. Those cases were reviewed by 12 forensic pathologists, randomly divided into three-member panels. Sensitive and identifying information about the dead, including race, was redacted from reports reviewed by the teams.

In all, the teams disagreed with 41 cause-of-death determinations issued by Fowler’s office. In 36 of those cases, all three panel members determined the cause of death to be homicide; in the remaining five, two of the three experts called the death a homicide.

In 34 of those cases, the medical examiner’s office reported that the cause and manner of death was undetermined. Five were ruled accidental and another two were ruled death by natural causes.

“Those discrepancies suggest that OCME practices during the audits time frame were out of step with national standards for death certification, namely the ‘but for’ standard, which states that any death resulting from the actions of another person, regardless of that person’s intent, should be classified as a homicide,” Kukucka said.

“As a result, it appears that OCME undercounted restraint-related homicides during the audit time frame,” he said.  “We also found that they undercounted homicides even more in cases where the decedent was Black or was restrained by police, which raises the possibility of racial and pro-police bias.”

Those deaths have now been reclassified as homicides. Of the 41 cases, 14 occurred in Baltimore City and five each were in Baltimore, Montgomery and Prince George’s counties.

Officials cautioned that the reclassifications do not equal a finding of criminal activity or culpability. Instead, it means that the deaths occurred as the result of the action of another person.

“There’s no suggestion that anyone is currently culpable, but it’s our responsibility to go through these files, beyond the OCME report, beyond the medical and the original forensic examination, look at the entire file, which means engaging law enforcement as well to make determination,” Brown said.

Kukucka stressed the report comes with two caveats.

First, the review is retrospective, looking at a specific period of time. The most recent case reviewed is six years old. Kukucka said that “makes it impossible to know whether racial or pro-police biases truly affected OCME determinations. Those disparities could instead reflect factors other than bias.”

And he repeated Brown’s caution that the findings do not imply criminal wrongdoing or liability.

In addition to the release of the report and broader review of the deaths at the county level, officials announced a series of reforms meant to improve death investigations within the Office of the Chief Medical Examiner.

Moore, prior to the release of the report, signed an executive order directing Brown’s office to work with state’s attorneys to review each case. Those reviews could potentially lead to reopening investigations.

Moore also ordered the Maryland Department of Health to work with the medical examiner’s office to implement best-practice investigation policies. The department is ordered to report on its progress by Dec. 31, 2026.

Finally, Moore’s order creates a new task force to work on policies to reduce in-custody police restraint deaths. That panel will include health and legal experts, law enforcement and community members

“Maryland was the first state in the nation to launch a comprehensive audit on the office of chief medical examiner, and today, we are proud that we’ll also become the first state in the nation to respond to such an audit with swift and targeted action,” Moore said.

“I hope that our work will inspire others around the country to take similar steps as we work together to strengthen our system of justice,” he said

Republished from Maryland Matters, which  is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Maryland Matters maintains editorial independence. Contact Editor Steve Crane for questions: editor@marylandmatters.org.

Streetcar Suburbs previously reported on the deaths in Hyattsville police custody of Edwin Morales (2020) and Leonard Shand (2019).