The results of a four-year audit into the practices of Maryland’s Office of the Chief Medical Examiner (OCME) will set a precedent for comprehensive reform on how deaths are determined. Findings from the first-of-its-kind review were announced Thursday (May 15), during a press conference led by Governor Wes Moore, Attorney General Anthony Brown, and Dr. Jeff Kukucka, a Towson University professor and decision scientist who served as an audit case manager.

A team of forensic pathologists and social scientists was appointed to the task in 2021. At that time, Larry Hogan, who served two consecutive terms beginning in 2015, was governor. Moore was sworn into office in January 2023. The team of researchers began assessing more than 1,300 deaths that were examined under then-Chief Medical Examiner Dr. David Fowler’s tenure. They studied case files from 2003 to 2019. Deaths for 87 of those were of individuals who passed away around the time they were restrained, oftentimes by police. The outcome of the research suggests that those deaths were wrongly misclassified as something other than homicide. Nearly all of the subjects were male, and 75 percent were Black.

The audit shares a connection to the 2021 Derek Chauvin murder trial for the death George Floyd

“This audit began after Dr. David Fowler, then-Maryland’s chief medical examiner… who provided testimony in the murder trial of Derek Chauvin. Dr. Fowler’s testimony raised profound concerns within the medical community about the independence and objectivity of death determinations made by OCME,” said Brown.

Fowler drew criticism and concern when he testified on behalf of the defense that Floyd’s death could not be determined. Chauvin, a Minneapolis police officer, was recorded kneeling on the handcuffed man’s neck for over nine minutes. Floyd uttered, "I can't breathe" multiple times before he died at the scene of his arrest.

Brown said more than 450 medical professionals signed a letter asking the Office of the Attorney to review Fowler and his team’s cases. “These members of the medical community were concerned our state’s death determination had been tainted by racial or pro-law enforcement bias or were otherwise inconsistent with the standard practices for investigation and certifying in-custody deaths,” he said.

Furthermore, the attorney general said, “I want to be clear, labeling a death a homicide by the OCME means the decedent died because of another person’s actions. It does not mean those actions rose the level of criminal liability or culpability for those involved in the decedent's death. It does not mean the officers involved can or should be prosecuted... This report does not suggest intentional or malicious conduct on the part of any Maryland medical examiner. Implicit biases run throughout our system of justice, not just in Maryland but across the United States.”

Key findings in the audit:

1. Medical examiners consistently misclassified restraint-related homicides that occurred in police custody.

2. 41 cases show a failure to apply stands practices of certifying homicides and reveal patterns consistent with the possibility of racial and pro-law enforcement bias.

3. OCME was unlikely to classify a death as homicide if the victim was Black or died after being restrained by police.

Gov. Wes Moore announces executive actions in response to the report

Speaking of the significant role medical examiners hold, he said, “Their difficult work helps inform legal proceedings and it lends clarity to the families of those who’ve lost a loved one, including those whose death occurred under unexplained or suspicious circumstance.” The elected official also noted, “The audit was designed to study the accuracy and the integrity and the precision of determinations made by the chief medical examiner's office in the state of Maryland.”

In response, he signed an executive order that:

1. Directs the attorney general to work with the state attorney to review every case in the audit and to determine if they should be reopened.

2. The Maryland Department of Health will review audit recommendations and conduct an analysis to determine how to implement the suggestions.

3. The Department of Health will work with the Medical Examiner’s Office to ensure compliance with national standards and practices. Both departments will report their progress by December 31, 2026.

4. A new task force overseeing restraint-related death investigations will be formed.