Thirty-six deaths in police custody in Maryland should have been ruled homicides, according to an independent audit released Thursday of the Maryland Office of the Chief Medical Examiner.
The Maryland Office of the Attorney General launched the audit after former Maryland Chief Medical Examiner David Fowler testified in 2021 that the cause of George Floyd’s death should be classified as “undetermined.” Minneapolis Police Officer Derek Chauvin was later convicted of Floyd’s murder.
The investigation by a team of independent forensic pathologists reviewed 87 cases from 2003 through 2019 — the period when Fowler served as chief medical examiner — in which someone died while or shortly after being restrained, and in which the medical examiner said the cause of death was undetermined, accidental or natural.
Those 87 cases included 22 from Baltimore City. The rest span 12 of Maryland’s counties. Roughly 70% of the deceased were people of color.
Three independent forensic pathologists reviewed each case. In 36 cases — including 12 from Baltimore City — the reviewers unanimously said the deaths should have been classified as homicides, and in another five cases, two of the three reviewers said the deaths should have been classified as homicides.
“These 41 combined cases show a failure to apply the standard practices of certifying homicides and reveal patterns that are consistent with the possibility of both racial bias and pro-police bias,” Maryland Attorney General Anthony Brown said Thursday. “Our research has determined that OCME was especially unlikely to classify a death as a homicide if the decedent was Black or if they died after restrained by police.”
Jeff Kukucka, the case manager for the audit and a psychology professor at Towson University, echoed Brown’s sentiment but added a caveat.
“The retrospective nature of the audit makes it impossible to know whether racial or pro-police biases truly affected OCME determinations,” Kukucka said. “Those disparities could instead reflect factors other than bias, which is something we make very clear in our report.”
But the data does suggest, Kukucka said, that OCME under-counted restraint-related homicides at a higher rate when the person who died was Black or was restrained by police, rather than by someone outside of law enforcement.
The report says the medical examiner’s cause-of-death statements often failed to acknowledge that being restrained may have contributed to the individual’s death. And in some cases where the medical examiner did acknowledge that being restrained likely contributed to a person’s death, they still did not classify the death as a homicide.
“In my experience, if an inflicted injury contributes to causing death, the ‘relative’ contribution in comparison to underlying drugs and/or natural disease is irrelevant,” one reviewer wrote about one of the cases they reviewed.
Brown said his next steps include working with state’s attorneys to review each case and determine if an investigation needs to be reopened.
Maryland State’s Attorneys’ Association President Richard Gibson issued a statement declining to “support or oppose the analysis or conclusions” in the audit report.
“Our shared commitment is to ensure justice is served, and that any and all people affected by the report are treated with dignity and respect, a priority they rightfully deserve,” Gibson said in the statement.
The report includes a list of recommendations not just for the Office of the Chief Medical Examiner, but also for law enforcement. For example, it recommends the use of body cameras in all situations involving restraint and thorough documentation of witness testimony surrounding in-custody deaths.
The Attorney General’s Office has also launched a hotline for people who believe one of their loved ones is affected by the audit’s findings.
And Gov. Wes Moore announced a new Maryland Task Force on In-Custody, Restraint-Related Death Investigations. The entity will be tasked with making recommendations for long-term oversight of these sorts of manner-of-death investigations, and with developing ways to reduce in-custody, restraint-related deaths.
Moore acknowledged that the conversations prompted by this audit won’t be easy.
“The pain that these families are feeling, it is real, and for many, this is years, years in the making, some of whom have been screaming for this type of analysis and have been met with silence,” Moore said. “We're talking about families that are still grieving.”
