This spring, an independent audit reached a stunning conclusion: Dozens of deaths in police custody reviewed by Maryland’s medical examiner should have been ruled homicides but weren’t.

For its principal author, the audit was years in the making.

Jeff Kukucka, a psychology professor from Towson University with no medical training, had spent his career toiling to shine new light on how the criminal justice system suffers from bias, including racial bias, that can affect the integrity of its work.

When he and his colleagues published research four years earlier suggesting the work of medical examiners was racially biased, it upended the world of forensic medicine and infuriated some of its biggest names.

Nearly 90 of its professionals from across the nation issued a rebuttal, accusing Kukucka’s study of “egregious” errors and insisting the paper should be retracted because it was an “abject failure” of the academic process. Charges of racial bias, they concluded, were “absurd.”

The explosive but largely insider debate might have ended there — if not for a remarkable turn.

In 2021, hundreds of miles from Maryland, the state’s former chief medical examiner, Dr. David Fowler, took the witness stand in a high-profile case on behalf of a Minnesota police officer charged with killing a Black man. A viral video showed George Floyd handcuffed and face down on the street as the white officer knelt on Floyd’s neck for more than nine minutes.

Shocking many, Fowler testified Floyd’s death should not have been ruled a homicide.

The backlash was swift, prompting state officials in Maryland to launch a sweeping review of Fowler’s own past work, looking particularly at police-involved deaths ruled as something other than murder.

The person placed in charge of the effort? Kukucka.

The work took months, and then years. The final product released last month by Kukucka and his team of experts found 36 people who died in law enforcement custody had their causes of death misclassified as accidents, natural causes or “undetermined” instead of homicide.

For the families of those who died, the findings confirmed what many said they always believed: Their loved ones didn’t just die — they were killed. Several wonder now if real justice is still possible. Reactions inside the broader forensic science community, however, have been largely muted, adopting a wait-and-see approach.

In Maryland, Attorney General Anthony Brown is reviewing the audit’s findings and considering whether stronger oversight of the autopsy process would help.

The first step, however, still rests with the state’s current medical examiner, who has the power to decide whether to act on the audit so critical of her predecessor’s work.

“We are still learning,” Dr. Stephanie Dean said in a recent interview when asked if she would reclassify any of the deaths as homicide. “That’s part of the challenge. There’s still a lot to learn, to unpack, to process.”

The first big test of the new lens on police-custody deaths may already be before them. After more than three weeks, police have yet to issue a cause of death for Dontae Melton Jr., who died while being restrained by Baltimore officers in the midst of Melton’s behavioral crisis June 25.

The challenger

Kukucka has never stood over a dead body, sliced it open, cradled its organs. He’s never tested lungs for water or soot, or looked for a crushed hyoid bone in a victim’s neck for evidence of strangulation.

Instead, the 38-year-old works out of a small office on the third floor of Towson University’s liberal arts building. There’s a “Black Lives Matter” sticker on his door and a Grateful Dead tattoo on his calf.

Kukucka’s career has been spent evaluating the human mind and how it plays out in the criminal justice system. He grew up in Baltimore County’s Jacksonville, the son of a teacher and an accountant, believing he’d become a therapist.

Instead, in college, he participated in a research study on the fallibilities of eyewitness memories of crimes. After the subjects watched a jewel heist from the movie “Return of the Pink Panther,” the researchers planted information to reveal how people could adopt false memories of things they had never witnessed.

The findings were a revelation for Kukucka, who said he never considered how the crucial witness accounts could be so easily influenced and consequentially wrong.

“From there, it really snowballed into learning about the fallibilities of memory and, more broadly, wrongful convictions,” Kukucka said. “That’s where I really kicked things into high gear like, oh damn, the legal system gets it wrong an alarming amount of time.”

At John Jay College of Criminal Justice in New York, he studied with pioneers in the scientific examination of false confessions. And he linked up with Dr. Itiel Dror, a University College London professor who has found cognitive bias across many professions that affected the integrity of their work.

In one study, they looked at forensic examiners who had become privy to confessions in criminal cases, finding their medical conclusions had been unduly swayed by that knowledge.

For the Maryland audit years later, Kukucka set out to recruit a dozen pathologists to review autopsies independently, a task that proved much more difficult.

So many U.S. experts declined that five slots went to professionals outside the country. And even they were unwilling to be publicly associated with the work, fearing backlash from their own profession.

The incumbent

For decades, Fowler‘s work examining how people died drew little controversy.

Fowler, who did not respond to requests for comment, grew up in apartheid South Africa, earning his medical degree from the University of Cape Town in 1983. By the 1990s, he had moved to the U.S. and joined the Maryland medical examiner’s office, first as an assistant in 1994 and then as its chief in 2002. He became a well-regarded leader of one of the country’s preeminent offices.

Many states rely on untrained coroners or a patchwork of officials by county. But Fowler oversaw a team of highly trained forensic pathologists performing thousands of autopsies a year.

Fowler wasn’t one for the spotlight, calling press conferences or granting interviews. But young medical examiners and forensic pathology students were eager to work for him.

A surge of deaths beginning a decade ago from opioid overdoses statewide and homicides in Baltimore upended the West Baltimore office. Medical examiners fled, leaving it with the bruising prospect of losing accreditation, an official stamp giving the office credibility in court. In an interview with the Baltimore Sun, Fowler himself cited the overload as a reason for retiring in 2019.

It was a stark turn for Fowler, known for teaching at universities locally and overseas, traveling for industry speeches and serving as a past president of the National Association of Medical Examiners.

NAME honored him for outstanding service, including in 2021 — the same year he testified in the George Floyd case, the group’s records show.

Fowler is also credited in more than 160 research papers, including one in 2017 examining in-custody deaths. It concluded cases ought to be sampled continually to “minimize bias” and strengthen the validity of results.

In an interview, his former longtime assistant, Bruce Goldfarb, said he respects Fowler, adding that his old boss didn’t deserve the public backlash.

Goldfarb even wrote a 2023 memoir about his experience, describing how Fowler signed off on all autopsies but did not lead the office with a heavy hand, a leadership style that earned him loyalty among staff. According to Goldfarb, Fowler never argued with medical examiners over their determinations about the causes of deaths.

”The conclusion of an autopsy report is labeled ‘opinion’ for a reason. That’s their opinion, and I’ll back them up,’" Fowler said, according to Goldfarb’s book.

Fowler told others he was unbothered by outside criticism.

“It doesn’t matter what people say,” Fowler said, according to Goldfarb. “We’ll still be in business tomorrow.”

The industry’s unease

Rooting out bias in the medical examiner profession won’t be swift.

“The medical examiners were the toughest and most recalcitrant and defensive,“ said Dan Simon, a professor of law and psychology at the University of Southern California’s Gould School of Law.

Simon served on a panel for six years at the National Institute of Standards and Technology aiming to develop better guidelines for all forensic sciences.

”It’s a pity because they are fighting a losing battle,” he added about the profession’s reluctance to address allegations of bias.

In his own search to identify the problem of bias, Kukucka started his original research with a test.

Medical examiners were presented with the same facts about two children taken to a hospital with fatal injuries. But one was a white child taken by her grandmother, the other a Black child taken by her mother’s boyfriend.

The examiners, according to the findings of Kukucka’s research team, were more likely to rule the Black child died by homicide.

Dr. Jonathan Arden, a former chief medical examiner in Washington, D.C., who worked on the research, said it “demonstrated something that should not have been surprising: that cognitive bias exists in almost every you look for it, even when it is intentional or not knowing.

But Arden said the medical examiner community responded “very badly.”

After being a member of NAME for 35 years, Arden said, he resigned over the issue.

Dror, the British expert on cognitive bias, told a podcaster last year that complaining by the examiners “was and still is a very organized campaign.”

There are, however, some signs of change. In 2023, NAME joined medical groups to banish the charged term “excited delirium” as a scientifically valid diagnosis or cause of death.

Medical experts had concluded that the symptoms for excited delirium — elevated temperature, disorientation and aggression — had become a rationale for law enforcement to use restraint, sometimes excessively and often in cases where the suspect was Black. Fowler had used excited delirium in part to explain George Floyd’s death.

The association also called for examiners to consider labeling any case a “homicide” if it was “at the hands of another,” which could include law enforcement officers. That applied even if there was no harm intended and didn’t necessarily mean a crime was committed.

In an interview, Quinton A. Reade, the current president of NAME, said the change had been years in the making because the term had been used “as a diagnosis rather than a description of symptoms.”

The court where it happened

George Floyd’s death in 2020 landed in the social media age, as bystanders captured videos of Chauvin kneeling on Floyd’s neck, ultimately for 9 minutes and 29 seconds, while Floyd uttered a phrase later adopted as a Black Lives Matters slogan: “I can’t breathe.”

After the videos pinged around the globe, the trial’s outcome seemed assured.

Then Fowler took the stand.

Fowler had made a career of cautious calls when he saw multiple factors at play in someone’s death, including in those involving police. He considered them more “intellectually honest,” according to Goldfarb’s book.

Fowler appeared to see this case no differently. And he wasn’t alone.

Chauvin’s defense attorney enlisted an organization called The Forensics Panel, with 14 experts in various disciplines to review records and conduct for what’s known as a morbidity conference.

They all signed off on the final report. But it was Fowler who testified in a trial broadcast nationally and bore the brunt of the backlash.

That was “unconscionable,” said Chauvin’s defense attorney, Eric Nelson, who said he found more than two dozen pathologists professing sympathies but “not one was willing to testify for fear of exactly such reprisal.”

Those with medical authority who did speak out were calling for a review of autopsies during Fowler’s tenure. Former Washington, D.C., medical examiner Dr. Roger Mitchell circulated a letter and got more than 400 of their signatures.

Brian Frosh, Maryland’s attorney general at the time, agreed. He sought a team of pathologists and psychologists, including Dror, to develop a review framework. Dror later was replaced by Kukucka, who struggled to recruit the pathologists.

Those such as Dwayne A. Wolf, a deputy county coroner in Ohio, balked at participating. He said he and many other colleagues took a dim view of evaluating past cases “in light of today’s political and social climate.”

“I think most of us could’ve predicted the outcome of the survey before it was done, which was why most people walked away from it,” Wolf said.

Families of those named in the audit, however, welcomed the eventual findings, even if they opened old wounds.

Jennell Black is the mother of Anton Black, a 19-year-old who died while being restrained by police officers on the Eastern Shore in 2018.

The cause of death had been ruled accidental due to Black’s congenital heart condition, a history of mental illness and alleged stress from the struggle with police at the scene.

Black’s mother said her son had been healthy, clearing twice-a-year physicals for football and track.

“I’m so glad it finally happened. It’s what we’ve been waiting on,” she said. “I always said it was murder.”

The path forward

So far, not much has changed.

The president of the medical examiners association said in a statement after the Maryland audit that it could convene independent reviews, similar to those often used after the death of a child, for wider reviews. And the group could provide more training to recognize “unconscious bias.”

Dr. Gregory Schmunk, a past president of NAME, declined to comment in part because of how he views the public’s treatment of Fowler.

“And honestly, public/media comments are simply asking to have a target put on your back, as he [Fowler] has found out,” he said.

Supporters of Kukucka’s findings such as Dr. Michael D. Freeman, a consultant in forensic medicine and forensic epidemiology who worked on the Maryland audit, said it was unfortunate that the nation’s medical examiner association declined to aid the audit’s work.

“All other aspects of the judicial system are subject to constant scrutiny in lower and upper courts, and there is no reason that methods used to investigate the cause and manner of death should be any different,” Freeman said.

In late June, Brown, the attorney general, downplayed the possibility of reopening cases during a state legislative hearing. Any new charges based on the reclassification of a police-involved death would likely face steeper odds in court.

But there are signs of reform. The governor formed a multidisciplinary panel to formulate ways to improve death investigations for those in police custody.

At the Office of the Chief Medical Examiner, Dean, who has been in charge for the last two years, said she’s “worked to build on the foundation laid before us,” adding she expects her work to evolve as her profession reviews allegations of bias and decides how to address them.

For his part, Kukucka said he understands that medical examiners chafe at the word bias, believing they’re being accusing of fraud, laziness or even incompetence.

But that’s wrong, he said.

“All we’re accusing you of is being human,” Kukucka said, “and being subject to the same limitations of decision-making that plague us in our everyday lives.”