An independent audit of Maryland’s Office of the Chief Medical Examiner found three dozen deaths in police custody that should have been ruled homicides during the nearly 20-year tenure of Dr. David Fowler — including the high-profile deaths of Tyrone West and Anton Black in police custody.
The Maryland Attorney General’s Office plans to review with each jurisidiction’s state’s attorney’s office all of the cases that reviewers say should have been identified as homicides, though the report’s findings do not automatically mean there will be criminal charges or that police will face discipline.
The first-in-the-nation audit report also found that deaths involving Black people and those involving law enforcement restraint were less likely to be ruled homicides compared to other cases, and that “excited delirium” was cited as the cause of death in nearly half of the reviewed cases.
The first-in-the-nation audit report also found that deaths involving Black people and those involving law enforcement restraint were less likely to be ruled homicides compared to other cases, and that “excited delirium” was cited as the cause of death in nearly half of the reviewed cases. The term “excited delirium” has been widely discredited as a medical diagnosis because of its roots in racism and frequent use to justify deaths in police custody. A quarter of the cases examined took place in Baltimore.
“Marylanders deserve a justice system built on transparency, accountability, and equity. This audit’s findings pave the way for meaningful reform in how medical examiners approach death investigations and propose changes that could address systemic inequities that have persisted for too long,” Attorney General Anthony Brown said in a news release.
The audit began in 2021 after Fowler testified for the defense during the murder trial of former Minneapolis police officer Derek Chauvin and said that the death of George Floyd should have been classified as having an “undetermined” cause. Video of Floyd’s arrest showed Chauvin pressing his knee against Floyd’s neck for more than nine minutes, and Chauvin was ultimately convicted of murder.
More than 450 medical experts signed a letter to then-Attorney General Brian Frosh calling for an independent review of the Office of the Chief Medical Examiner’s practices during Fowler’s tenure leading the office from 2003 until 2019.
The audit team selected 87 cases to review out of more than 1,300 in-custody deaths investigated by OCME during that period and hired 12 independent forensic pathologists to examine the cases. Three reviewers were assigned to independently review each case and make their own determinations of the manner of death. In 36 cases, all three reviewers agreed the death should have been ruled a homicide. In another five cases, two out of the three reviewers found the manner of death should have been homicide.
The audit report recommended that the OCME stop using “excited delirium” as a diagnosis, improve documentation for deaths in custody, create standardized procedures for investigating restraint-related deaths and implement external peer review. It also recommends that law enforcement require the use of body cameras in all restraint situations, provide better training on the dangers of improper restraint techniques and include mental health professionals in crisis responses.
Gov. Wes Moore on Thursday also announced several executive actions in response to the audit results, including granting the Attorney General’s Office the authority to review the 36 cases where reviewers unanimously agreed a death should have been ruled a homicide. Moore also established a task force on in-custody restraint-related death investigations.
The Attorney General’s Office also launched an OCME audit hotline for families who believe their deceased loved one’s case may have been covered under the audit. You can email OCMEAuditHotline@oag.state.md.us or call 833-282-0961 to reach the hotline.
At a press conference announcing the audit results Thursday, Moore said the pain that families of the deceased are feeling is “very real,” and that some spent years “screaming for this type of analysis” only to be met with silence. Tawanda Jones, the sister of Tyrone West, has spent every Wednesday since West’s death calling for accountability for her brother’s death and all victims of police brutality.
Jones raised concerns about the medical examiner’s office beginning in 2013 when the office ruled her brother’s death “undetermined.” She could not immediately be reached for comment Thursday.
The audit also examined the death of Anton Black, an Eastern Shore teenager who died in 2018 after being chased and pinned down by police officers. His death was originally ruled an accident, but the new audit found it should have been classified as a homicide. Black’s death helped inspire major police reform legislation in Maryland, including “Anton’s Law,” which made police disciplinary records available to the public for the first time.
“We still have a lot to process for this report, and I’m not sure if that processing of what this report unveils will ever be fully settled,” Moore said. “But I know this is the start of the conversation.