BALTIMORE, Md., May 15, 2025 — An independent audit of the Maryland Office of the Chief Medical Examiner (OCME), announced by Attorney General Anthony G. Brown, revealed significant errors in death classifications, with over half of the 87 reviewed cases showing discrepancies. The 70-page report identified 36 deaths originally ruled as undetermined, accidental, or natural that independent reviewers unanimously classified as homicides. The audit, initiated in 2021, also uncovered racial disparities, reliance on discredited diagnoses like “excited delirium,” and systemic deficiencies in autopsy documentation.
In 44 of the 87 cases, independent forensic reviewers disagreed with OCME’s original manner of death determinations. Among these, 36 cases were unanimously deemed homicides by all three reviewers, while in five additional cases, two of three reviewers reached the same conclusion. The audit highlighted patterns where deaths involving Black individuals or law enforcement restraint were less likely to be classified as homicides. Nearly half of the cases cited “excited delirium,” a diagnosis rejected by major medical organizations, contributing to misclassifications.
“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,” Brown said at a news conference. He emphasized that Maryland’s audit, the first of its kind nationwide, offers a model for other states to enhance death investigation standards.
The audit was prompted by concerns over former Chief Medical Examiner Dr. David Fowler’s testimony in the 2021 trial of Derek Chauvin, convicted for George Floyd’s murder. Fowler, who served from 2003 to 2019, classified Floyd’s death as “undetermined,” citing heart issues despite video evidence of Chauvin’s restraint. This led over 450 medical experts to demand a review of OCME’s practices under Fowler, suspecting bias in in-custody death rulings.
The audit focused on 87 in-custody deaths involving restraint, selected from over 1,300 cases. An international Audit Design Team, including forensic pathologists and social scientists, oversaw the process. Twelve independent reviewers, blinded to race and OCME’s original findings, assessed each case. “This audit is a groundbreaking collaboration between social scientists and forensic medical experts who carefully designed and executed it in line with sound research principles, including best practices for protecting against bias,” said Dr. Jeff Kukucka, who managed the audit.
Key cases included Shawn Floyd (2018, Anne Arundel County), originally ruled undetermined but deemed a homicide, and Tawon Boyd (2016, Baltimore County), reclassified from accidental to homicide. Other examples, like Anton Black (2018, Talbot County) and Tyrone West (2013, Baltimore City), underscored issues with restraint-related deaths. Black’s death, captured on video showing police holding him down, was ruled a cardiac event, while West’s was attributed to natural causes despite a violent struggle.
Systemic issues included incomplete autopsy documentation, such as missing photographs, unnoted body camera footage, and inconsistent reporting of restraint injuries. The report recommends that OCME adopt clear standards for death determinations, cease using “excited delirium,” improve autopsy documentation, and implement external peer reviews. For law enforcement, it suggests mandatory body cameras, better restraint training, and inclusion of mental health professionals in crises.
Governor Wes Moore announced executive actions, including authorizing the Attorney General to review the 36 unanimous homicide cases and forming the Maryland Task Force on In-Custody Restraint-Related Death Investigations. “Maryland will continue to be a national leader in accountability, action, and equal justice under law,” Moore said. “This executive order takes us one step closer to a more just and transparent system.”
The audit’s findings will be presented on May 16 to the National Academies of Sciences, Engineering, and Medicine, which is studying improvements to the nation’s death investigation system. A hotline (833-282-0961) and email were established for families affected by the audit.
The audit’s scope included high-profile cases like Freddie Gray’s 2015 death, ruled a homicide due to spinal injuries from police transport, though no officers were convicted. The report clarifies that a homicide classification indicates someone’s actions contributed to the death but does not imply police misconduct or criminal culpability, necessitating further investigation.
