Maryland Attorney General Anthony G. Brown has released the findings of a 70-page independent audit of the Maryland Office of the Chief Medical Examiner (OCME), revealing significant discrepancies in how the state classified deaths during or following law enforcement restraint.
Out of 87 cases reviewed by independent forensic experts, 44—more than half—had manner-of-death determinations that disagreed with the original OCME findings. In 36 of those cases, all three independent reviewers concluded the deaths should have been classified as homicides. In five additional cases, two out of three reviewers reached the same conclusion.
The audit also identified systemic racial disparities, with deaths involving Black individuals and law enforcement restraint significantly less likely to be ruled homicides. Nearly half of the reviewed cases cited “excited delirium” as a cause of death, a now-discredited diagnosis rejected by leading medical organizations.
The audit found widespread documentation issues, including missing photographs, incomplete incident details, and insufficient acknowledgment of injuries related to restraint. These shortcomings were consistent across multiple counties.
The audit stemmed from controversy surrounding former Chief Medical Examiner Dr. David Fowler’s testimony in the 2021 trial of former Minneapolis police officer Derek Chauvin, where Fowler classified George Floyd’s death as “undetermined.” In response, over 450 medical professionals called for a review of OCME practices under Fowler’s tenure (2003–2019).
The Attorney General’s Office launched the audit in 2021, forming a team of forensic pathologists, psychologists, and scientists to conduct a review using internationally accepted scientific standards. Reviewers were blinded to the decedents’ race and OCME’s original conclusions.
From a pool of more than 1,300 in-custody deaths, 87 cases were selected. The reviewers made their own independent assessments. Where there was no unanimous agreement, cases were discussed to reach consensus.
Key audit recommendations for OCME include:
- Establishing clear standards for determining cause and manner of death
- Eliminating use of “excited delirium”
- Improving autopsy documentation
- Standardizing investigations of restraint-related deaths
- Requiring peer review and ongoing examiner education
Recommendations for law enforcement include:
- Mandatory use of body cameras during restraints
- Better training on restraint risks
- Involving mental health professionals in crisis responses
- Comprehensive documentation of witness statements
For accountability, the audit calls for:
- Reviewing all 41 cases flagged as potential homicides
- Periodic audits of OCME operations
- Systems to detect and correct problematic patterns early
In response, Governor Wes Moore issued executive actions granting the Attorney General’s Office authority to review the 36 unanimously identified homicide cases. He also created the Maryland Task Force on In-Custody Restraint-Related Death Investigations to assess the audit’s recommendations and oversee implementation.
Maryland is the first state in the nation to conduct and act upon a scientific audit of in-custody death determinations by a medical examiner’s office. The audit’s findings will be presented May 16 to a National Academies of Sciences, Engineering, and Medicine committee studying national medicolegal death investigation practices.
Families who believe a loved one may have been affected can contact the OCME Audit Hotline at 833-282-0961 or email OCMEAuditHotline@oag.state.md.us.
