Autopsies misclassified deaths in police custody that were homicides,
Maryland officials say
[May 16, 2025]
By BRIAN WITTE and LEA SKENE
ANNAPOLIS, Md. (AP) — An audit of Maryland autopsies has uncovered at
least 36 deaths in police custody that should have been considered
homicides, state officials announced Thursday following a comprehensive
review of such cases spurred by widespread concerns about the former
state medical examiner’s testimony in the death of George Floyd.
Medical examiners under Dr. David Fowler displayed racial and pro-police
bias, according to the review. They were “especially unlikely to
classify a death as a homicide if the decedent was Black, or if they
died after being restrained by police,” Attorney General Anthony Brown
said during a news conference.
“These findings have profound implications across our justice system,”
Brown said. “They speak to systemic issues rather than individual
conduct.”
The auditors reviewed 87 in-custody death cases after medical experts
called Fowler’s work into question because he testified that police
weren’t responsible for Floyd’s death. The Maryland team focused on
cases in which people died suddenly after being restrained, often by
police, officials said.
Three-person panels evaluated each autopsy and, in 36 cases, they
unanimously concluded that the deaths should have been classified as
homicides but were not. In five more cases, two of the three reviewers
came to that conclusion.
Fowler didn’t immediately respond to messages seeking comment.
State officials could reopen death investigations
Democratic Gov. Wes Moore said he has signed an executive order
directing Brown to review the 41 cases and determine if any should be
reopened for investigation.
oore acknowledged the families whose loved ones have died in police
custody, some of whom have been “screaming for this type of analysis —
and have been met with silence.” He also acknowledged the many members
of law enforcement who do their jobs honorably and protect the public.
Moore said he has also created a statewide task force to study the
deaths of people restrained in law enforcement custody. He said the
state won’t shy away from rooting out misconduct and working to create a
more equitable justice system.
Among a list of recommendations, the review suggested better training
for law enforcement officers on the dangers of improper restraint
techniques. It also directed the Office of the Chief Medical Examiner to
create standardized procedures for investigating restraint-related
deaths.
The governor described the review as the first of its kind in the
nation, saying he hopes it will provide a model for similar
investigations elsewhere.
In a national investigation published last year, The Associated Press
and its reporting partners found that medical examiners and coroners,
whose rulings have huge consequences in the courts, can face pressure
from law enforcement to exonerate officers. Some medical officials based
their decisions not on physical evidence, but instead on whether they
believed police intended to kill.
When deaths are ruled accidental, prosecutions of officers are
exceedingly rare — of 443 cases that were ruled accidental, just two
resulted in criminal charges. A family’s chances of winning a wrongful
death lawsuit also become much tougher.
While the audit findings are troubling, Maryland officials said they
don’t suggest intentional or malicious conduct. They emphasized that a
homicide classification simply means someone died because of another
person’s action, not necessarily that the officers involved should be
prosecuted.
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Family members of Anton Black, from left, LaToya Holley; father,
Antone Black, and mother, Jennell Black, speak during a news
conference Thursday, Sept. 30, 2021, in Baltimore. (AP Photo/Gail
Burton, File)
Fowler was criticized for embracing a widely rejected theory
Fowler, who testified for the defense at the 2021 murder trial of
former Minneapolis police Officer Derek Chauvin, attributed Floyd’s
death to a sudden heart rhythm disturbance as a result of his heart
disease — a widely rejected theory that did little to persuade the
jury. Chauvin was ultimately convicted of murder and manslaughter
for kneeling on Floyd’s neck for more than nine minutes.
After his conviction, 400 medical experts signed a letter to the
Maryland attorney general asserting that Fowler’s testimony deviated
way outside the bounds of accepted forensic practice. In addition to
citing heart problems, he classified the manner of death as
“undetermined” rather than “homicide.”
The letter called for an investigation to determine whether the
office’s in-custody death determinations under Fowler’s leadership
exhibited certain bias, among other potential issues.
Officials said Thursday that their audit found a troubling systemic
pattern.
Nearly half of the reviewed cases cited “excited delirium” as a
cause of death, a diagnosis that has been debunked by medical
experts in recent years. Critics say it was often used to justify
excessive force by police. The report recommended that medical
examiners stop using the term altogether.
Fowler was Maryland’s chief medical examiner from 2002 to 2019.
Two high-profile deaths are among the 41 cases highlighted
In 2023, state officials approved a settlement agreement that
reformed the process for conducting autopsies on people killed in
police custody.
That change came in response to the 2018 death of Anton Black, who
died in police custody on Maryland’s Eastern Shore. His death was
captured on video, which showed police in rural Greensboro holding
the unarmed teenager down for more than six minutes. Fowler ruled
that Black died because of a sudden cardiac event while struggling
with police — not because they pinned him in a prone position. His
death was declared an accident.
Fowler similarly ruled that Tyrone West died of natural causes after
struggling with Baltimore police following a traffic stop in 2013.
Witnesses and the officers themselves said there was a violent
struggle between the officers and West. His manner of death was
undetermined, according to the autopsy.
Both Black and West are now included on the list of cases that
should have been ruled homicides.
Tawanda Jones, West’s sister who has held weekly rallies for 616
weeks to highlight his case, said she feels something positive will
come from the investigation. “They’re finally listening to me now,”
Jones said. “It feels good that finally they’re listening.”
Fowler’s tenure also included the death of Freddie Gray 10 years
ago. The autopsy concluded Gray died from spinal injuries sustained
during transport in a Baltimore police van. It also classified his
death as a homicide because officers repeatedly failed to seek
medical attention while he was in distress. Prosecutors filed
charges against six officers, but none were convicted.
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