Maryland officials on Thursday released a wide-ranging independent audit of nearly 90 in-custody deaths spanning 2003 to 2019, finding that three dozen cases should have been classified as homicides but were not.
The unprecedented review was sparked by a highly critical letter from more than 400 medical professionals raising questions about the tenure of Maryland’s former chief medical examiner. The experts said they were alarmed by the controversial testimony from Dr. David Fowler for the defense at the trial of Derek Chauvin, the Minneapolis police officer convicted of murdering George Floyd.
Here are key takeaways from the 56-page audit, as well as what happens next.
The audit ‘validated concerns’ of racial, pro-police bias in death investigations
Well before Floyd’s 2020 murder, victims of police violence and their families have claimed that medical examiner investigations were biased against Black people and skewed in favor of police.
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Family members of Tyrone West, who died after Baltimore Police officers pepper-sprayed and beat him with batons following a traffic stop in 2013, commissioned an independent autopsy that cast doubt on the official medical examiner’s ruling. And a settlement in the wrongful death lawsuit brought by the family of Anton Black, a 19-year-old who died in police custody in 2018, led to sweeping changes to try to improve how Maryland conducts autopsies of deaths in police custody.
Still, in a letter accompanying the audit, Attorney General Anthony Brown wrote that the in-depth examination of 87 police-involved deaths “validated concerns that bias may have affected death investigations in Maryland.”
The audit was somewhat limited in its ability to prove pro-police or racial bias, but found “patterns consistent with the possibility” of them.
For example, in cases where reviewers unanimously agreed a death should have been ruled a homicide, the Office of the Chief Medical Examiner “rarely certified the manner as homicide, and they did so even less if the decedent was Black.”
Additionally, the state’s medical examiners “more often failed to acknowledge restraint as a potential contributing factor if the decedent had been restrained by police rather than by others.”
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Dozens of deaths will be reexamined
For the audited cases in which experts said the deaths should have been classified as homicides, Gov. Wes Moore directed the Maryland Office of Attorney General to look into potentially reopening the investigations to determine whether criminal charges are appropriate.
The cases — 12 of which are listed in Baltimore — often involved police officers restraining people during arrests or shocking them with Tasers.
The audit did not immediately change the official manner of death. And even if the medical examiner changes the ruling to homicide, it would not necessarily mean a crime was committed, only that the actions of the officer caused the death.
Prosecutors determine whether an officer’s actions merit criminal charges when someone dies in custody. But the medical examiner’s rulings in these cases are critical starting points for any potential prosecutions.
Maryland was a hub for ‘excited delirium’ deaths. That era is over.
The audit found that in nearly half of its now-disputed cases, the medical examiner’s cause of death cited the “discredited concept of ‘excited delirium.’”
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The term has its origins in the review of a string of police-custody deaths that happened in Florida in the mid-1980s. The phrase has been used to describe someone in a “potentially fatal state of extreme agitation and delirium, often combined with aggressive behavior, heightened pain tolerance and extreme physical strength.”
The theory later took root in Maryland, where Fowler, the state’s chief medical examiner, and his eventual replacement, Dr. Pamela Southall, endorsed the concept in two publications on the topic in the late 2000s, according to the audit.
Though the concept was widespread among medical examiners at the time, it has “never been accepted in the broader medical community,” the audit noted.
The premise has since come under heavy scrutiny, including by the American Medical Association, whose Council on Science and Public Health “concluded that current scientific evidence does not support the use of excited delirium as a valid medical diagnosis.”
The audit all started with George Floyd
In 2021, Fowler testified as an expert witness in a Minnesota courtroom on behalf of Chauvin, one of the four officers involved in Floyd’s death in police custody.
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Chauvin, who is white, pressed his knee into Floyd’s neck while he was handcuffed for about 9 1/2 minutes as Floyd repeatedly cried out, “I can’t breathe.”
But Fowler concluded that Floyd’s cause of death was heart problems. Maryland’s former chief medical officer also opined that fentanyl and methamphetamine, and possibly car exhaust, were contributing factors in Floyd’s death. Fowler testified that he would have classified the manner of death as undetermined, not homicide.
His testimony created shockwaves and prompted more than 400 medical professionals to pen an open letter calling for Maryland to conduct an independent investigation into police-involved deaths that Fowler’s office handled.
“Our disagreement with Dr. Fowler is not a matter of opinion,” the letter stated. “Our disagreement with Dr. Fowler is a matter of ethics.”
Former Attorney General Brian Frosh announced in 2021 that his office, in consultation with the governor’s chief legal counsel, would create a way to audit the bulk of cases during Fowler’s tenure.
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The Banner reached out to Fowler on Thursday, but he did not immediately return a request for comment.
Body cameras have reshaped in-custody death investigations
The forensic pathologists who helped complete the audit lamented in the report the lack of body camera video, dash camera video and surveillance video to aid their review of death cases.
That’s because many of the deaths under review preceded widespread use of police body-worn cameras.
Moving ahead, the audit noted, such footage will be especially important when trying to understand what happened.
What happens next?
Moore has already signed an executive order authorizing the attorney general, in consultation with state’s attorney’s offices, to review each disputed case and decide whether they should be reopened. He also directed the Maryland State Police to help with any investigations.
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In addition, Moore created a state task force on the investigations of police-involved deaths. The report released Thursday recommended the state commission issue a follow-up independent audit in five years.
“As a final point, we hope that state officials in other jurisdictions will consider undertaking similar audits to better understand the extent to which the concerning issues that were uncovered in the course of this audit are also present in other US medical examiner/coroner systems,” the report‘s authors said.
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