Attorney General Anthony G. Brown announced an independent audit of Maryland’s Office of the Chief Medical Examiner, finding that more than half of reviewed cases had differing determinations of manner of death, including several from Montgomery County that were reclassified as homicides.
The audit identified racial disparities, use of discredited diagnoses, and documentation issues, prompting recommendations for reform and executive actions by Governor Wes Moore to improve accountability and death investigations statewide.
Per the news release distributed on Thursday, May 15: “Attorney General Anthony G. Brown today announced the findings of the Office of the Attorney General’s independent audit of the Maryland Office of the Chief Medical Examiner (OCME). The 70-page report found that in more than half of the cases reviewed, the case reviewers disagreed with the OCME’s original determination of manner of death. The audit identified 36 deaths originally classified as undetermined, accidental, or natural that the panel concluded should have been ruled homicides, found patterns consistent with racial disparities in death classifications, and documented the use of discredited diagnoses such as “excited delirium.”
Key findings include:
• In 44 out of 87 cases, independent forensic reviewers disagreed with OCME’s original manner of death determination.
• In 36 cases, all three reviewers unanimously concluded the death should be classified as homicide.
• In 5 cases, two out of three reviewers concluded the death should be classified as homicide.
• Deaths involving Black individuals and those involving law enforcement restraint were less likely to be ruled homicides.
• The discredited diagnosis of “excited delirium” was cited in nearly half of reviewed cases, contributing to misclassification.
• Systemic deficiencies were found in autopsy documentation, including missing photographs and incomplete incident details.
Attorney General Brown stated that Marylanders deserve a justice system built on transparency, accountability, and equity. He emphasized that the audit paves the way for meaningful reforms and serves as a national model for safeguarding death investigations against bias and ensuring fairness in cases involving law enforcement custody.
The audit began in 2021 after concerns arose from testimony by Maryland’s former Chief Medical Examiner, Dr. David Fowler, in the Derek Chauvin trial, which led over 450 medical experts to call for an independent review of OCME practices during Dr. Fowler’s tenure. An international Audit Design Team of forensic experts conducted the independent, scientific examination of deaths occurring during or shortly after restraint, using blinded reviewers with no ties to OCME.
From over 1,300 in-custody deaths, 87 cases were selected for detailed review. Each case was independently reviewed by three forensic pathologists who initially did not know the decedent’s race or OCME’s original conclusions. When reviewers disagreed, they discussed the cases to reach consensus.
The audit report included a list of 41 decedents whose manner of death should be reconsidered as homicide, based on unanimous or majority reviewer conclusions. It is important to note that a “homicide” classification means someone’s actions contributed to the death but does not imply automatic police misconduct or criminal culpability. It signals the need for further investigation.
Recommendations from the audit for the OCME include adopting clear standards for death determinations, ceasing use of “excited delirium” as a diagnosis, improving autopsy documentation, standardizing investigations of restraint-related deaths, and implementing external peer review and education.
Recommendations for law enforcement include mandatory body camera use during restraints, improved training on restraint risks, inclusion of mental health professionals in crisis response, and thorough documentation of witness statements.
For accountability, the report urges review of all 41 cases flagged by the panel, regular audits to ensure improvements, and systems to identify systemic issues early.
In response, Governor Wes Moore announced executive actions including granting the Attorney General’s office authority to review the 36 cases unanimously deemed homicides by reviewers. He also established the Maryland Task Force on In-Custody Restraint-Related Death Investigations to evaluate the audit’s policy recommendations and plan implementation.
Governor Moore emphasized Maryland’s commitment to accountability and justice, noting the state’s pioneering role in both conducting the audit and acting on its findings.
To assist affected families, the Office of the Attorney General has launched a hotline and email for those who believe their loved one’s case was impacted by the audit: [email protected] and 833-282-0961.
Maryland is the first state to conduct an independent scientific audit of in-custody death determinations by a state medical examiner’s office. The audit findings will be presented to a National Academies of Sciences, Engineering, and Medicine study committee on May 16, which is examining the national medicolegal death investigation system to improve standards, reduce bias, and strengthen public trust in forensic pathology.”