Maryland Audit Uncovers Widespread Misclassification of In-Custody Deaths

An independent audit of the Maryland Office of the Chief Medical Examiner (OCME) has revealed systemic issues in the classification of in-custody deaths, with over half of reviewed cases found to have potentially inaccurate determinations. The report, released by Attorney General Anthony G. Brown, has prompted calls for immediate reform and a full review of dozens of past cases. The findings are expected to inform national discussions about forensic standards and equity in death investigations.

The audit examined 87 in-custody deaths handled by the OCME between 2003 and 2019. Independent forensic reviewers—blinded to original conclusions and racial information—found that in 44 cases, the OCME’s determination of the manner of death was incorrect. Thirty-six of those deaths were unanimously deemed homicides by all three independent reviewers, while five additional cases had a 2-to-1 majority agreement that the deaths should be classified as homicides. Many of the cases originally listed the manner of death as undetermined, accidental, or natural.

Patterns suggesting racial disparities were also uncovered. Deaths involving Black individuals or occurring during law enforcement restraint were significantly less likely to be ruled homicides. Additionally, nearly half of the cases cited the now-rejected diagnosis of “excited delirium,” a term medical organizations have deemed scientifically invalid and associated with biased or unsupported conclusions. The audit also identified repeated documentation failures, including missing body camera footage and incomplete autopsy records.

The audit was initiated following controversy over former OCME Chief Dr. David Fowler’s 2021 testimony in the Derek Chauvin trial, which drew national scrutiny and led to a demand for a review of death determinations during his tenure. The audit, overseen by an international panel of experts, was described as the first of its kind in the nation. From a pool of more than 1,300 deaths, 87 were selected for thorough review, with three independent forensic pathologists assigned to each case. In total, 41 deaths were determined by a majority or unanimous panel to warrant reclassification as homicides.

In response to the audit, Governor Wes Moore issued an executive order authorizing the Attorney General to conduct a comprehensive review of the 36 unanimously identified cases. He also announced the formation of the Maryland Task Force on In-Custody Restraint-Related Death Investigations. The task force, led by the Governor’s Office of Crime Prevention and Policy, will evaluate and implement the audit’s recommendations.

Recommendations from the audit include clearer standards for determining the cause and manner of death, eliminating use of the “excited delirium” diagnosis, improving autopsy documentation, and requiring external peer reviews. Law enforcement agencies are urged to ensure full documentation of restraint incidents, enhance officer training, and integrate mental health professionals in crisis responses. The audit also called for systemic reforms to improve transparency and prevent similar issues in the future.

Article by multiple RFHC contributors, based upon information from a press release issued by the Maryland Office of the Attorney General.

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