Annapolis · Maryland · May 15, 2025 | ForensicTimes.com | Police Accountability · Forensic Science · Racial Justice
Table of Contents
- The Audit and What It Found
- Dr. David Fowler: The Man Whose Testimony Started the Review
- Excited Delirium: A Diagnosis That Protected Officers and Buried Victims
- The Racial Bias Pattern: Black Lives, Accidental Deaths
- Anton Black and Freddie Gray: The Cases That Frame the Crisis
- Forensic Analysis: How Homicide Classification Works — and Why It Matters
- Criminal Psychology: Institutional Bias in the Forensic Suite
- Law and Legal Implications: Accidental vs. Homicide and the Prosecution Gap
- Global Context: Medical Examiners, Police Pressure and the Accountability Deficit
- Investigation: What Remains Unknown
- The Classification That Changed Everything — and Changed Nothing
The Audit and What It Found
On May 15, 2025, Maryland Governor Wes Moore and Attorney General Anthony Brown stood before cameras in Annapolis and announced the results of a four-year forensic audit that described, in systematic and documented detail, how the state’s chief medical examiner’s office had spent seventeen years misclassifying the deaths of people who died in police custody.
The audit, led by Towson University psychology professor Jeff Kukucka, began by reviewing roughly 1,300 in-custody deaths that occurred between 2003 and 2019 — the full span of Dr. David Fowler’s tenure as Maryland’s chief medical examiner. From that population, Kukucka’s team identified 87 cases in which people had died suddenly after being restrained by police. Three-person expert panels then reviewed each of those 87 autopsies. In 36 cases, the panels unanimously concluded that the deaths should have been classified as homicides but were not. In five additional cases, two of the three reviewers reached the same conclusion. In total, 41 deaths that had been certified as accidental or of undetermined cause were found to be homicides by the independent review.
The findings were accompanied by a statistical pattern that Attorney General Brown described as among the most troubling dimensions of the report. Medical examiners under Fowler were, the audit found, “especially unlikely to classify a death as a homicide if the decedent was Black, or if they died after being restrained by police.” The racial disparity in classification rates was not a marginal anomaly — it was a documented pattern across seventeen years of cases. “These findings have profound implications across our justice system,” Brown said. “They speak to systemic issues rather than individual conduct.”
Governor Moore signed an executive order directing Brown to review all 41 misclassified cases and determine whether any should be reopened for criminal investigation. Moore also created a statewide task force to study deaths of people restrained in law enforcement custody and directed the Office of the Chief Medical Examiner to develop standardised procedures for restraint-related death investigations. He described the audit as the first of its kind in the nation and called on other states to conduct similar reviews.
Dr. David Fowler: The Man Whose Testimony Started the Review
The audit exists because of a courtroom in Minneapolis. In April 2021, Dr. David Fowler — by then retired from Maryland, where he had served as chief medical examiner from 2002 to 2019 — took the witness stand as a defence expert in the murder trial of former Minneapolis police officer Derek Chauvin. Chauvin had knelt on George Floyd’s neck for more than nine minutes on May 25, 2020, while Floyd repeatedly stated he could not breathe and eventually lost consciousness and died. The Hennepin County medical examiner had ruled Floyd’s death a homicide caused by law enforcement subdual, restraint, and neck compression.
Fowler disagreed. He testified that Floyd’s death was attributable to a sudden heart rhythm disturbance caused by his existing heart disease — that the restraint was not the cause of death, and that police were not responsible. He also cited carbon monoxide from a vehicle’s exhaust pipe as a possible contributing factor. The theory was dismissed by every medical expert who reviewed it and did nothing to prevent Chauvin’s conviction on murder and manslaughter charges. But Fowler’s testimony did something that the verdict did not undo: it raised public awareness of his specific analytical approach and prompted 450 medical experts to sign a letter in 2021 calling on Maryland officials to investigate whether the death determinations made by Fowler’s office had been tainted by racial or pro-law enforcement bias.
That letter triggered the audit. Fowler served as Maryland’s chief medical examiner for seventeen years, during which time every in-custody death in the state passed through an office he led. The question the audit was designed to answer was whether the same analytical approach that produced his George Floyd testimony had been applied to Maryland’s own cases — and whether the deaths of people who died in Maryland police custody had been systematically misclassified as a result.
The answer, after four years of review, was yes. Fowler did not immediately respond to requests for comment when the audit was released.
Excited Delirium: A Diagnosis That Protected Officers and Buried Victims
In 42 of the more than 80 in-custody deaths that occurred shortly after an episode of police restraint — nearly half — the death statements issued by Fowler’s office cited “excited delirium” or the synonymous “agitated delirium” as a cause or contributing factor in the death. The audit’s report recommended that medical examiners stop using the term altogether. That recommendation reflects a consensus that had been building for years before the audit was published.
“Excited delirium” is not recognised as a valid medical diagnosis by the American Medical Association, the American Psychiatric Association, the World Health Organization, or the Diagnostic and Statistical Manual of Mental Disorders. The concept — which describes a syndrome of extreme agitation, unusual strength, insensitivity to pain, and sudden death — emerged from forensic pathology contexts in the 1980s and 1990s and was heavily promoted by TASER International (now Axon), the manufacturer of conducted energy weapons. Its critics argue, with substantial evidentiary support, that the “syndrome” functioned primarily as a post-hoc explanation for deaths that occurred during or immediately after police restraint, attributing the death to the person’s psychological state rather than to the physical stress of the restraint itself.
The diagnosis carried enormous legal weight precisely because of its forensic framing. A death certified as caused by “excited delirium” — rather than by positional asphyxia, mechanical asphyxia, or compression of the neck or chest during restraint — shifts the cause of death away from the actions of officers and toward an internal medical event in the decedent. That shift has direct legal consequences: when a death is classified as accidental rather than homicide, prosecutions of officers become extraordinarily rare, civil wrongful death suits become substantially harder to win, and the families of those who died receive no formal acknowledgment that a human action — rather than their loved one’s own body — was responsible for the death.
The National Association of Medical Examiners, the professional body that accredits forensic pathology offices, has issued guidance advising its members that “excited delirium” should not be used as a sole or primary cause of death. Several major metropolitan medical examiner offices have formally retired the diagnosis. Maryland’s audit represents the most systematic public accounting of what happens to a state’s death record when the diagnosis is applied at scale across 17 years of in-custody deaths.
The Racial Bias Pattern: Black Lives, Accidental Deaths
The racial dimension of the audit’s findings is documented statistically and deserves precise examination. The audit found that medical examiners under Fowler were significantly less likely to classify a death as a homicide when the deceased person was Black. The pattern held independently of other variables — it was not explained by differences in the circumstances of the deaths or the severity of the restraint. It reflected, in the auditors’ assessment, a systemic bias in how the racial identity of the deceased person interacted with the determination of cause and manner of death.
This finding sits within a broader documented pattern in American forensic pathology. The Associated Press and its reporting partners, in a national investigation published in 2024, found that medical examiners and coroners across the United States can face pressure from law enforcement to exonerate officers — and that some medical officials based their death determinations not on physical evidence but on whether they believed police had intended to kill. The Maryland audit makes that general finding specific and quantifiable: in this office, under this leadership, over this period, Black people who died in police custody were systematically less likely to be classified as homicide victims.
The consequences of that disparity are not abstract. A misclassification from homicide to accidental death affects whether a district attorney opens a criminal investigation, whether a grand jury hears evidence, whether a family can pursue civil remedies, and whether the public record of a person’s death accurately reflects what happened to them. In 36 unanimously confirmed cases, the public record did not accurately reflect what happened. Those 36 cases represent 36 families who were told their loved one’s death was an accident when the forensic evidence, evaluated by independent experts, supported a finding of homicide.
Anton Black and Freddie Gray: The Cases That Frame the Crisis
Two high-profile deaths are specifically identified among the 41 cases that the audit flagged, though the full list has not been publicly released.
Anton Black was 19 years old when he died in police custody on Maryland’s Eastern Shore in September 2018. Video captured officers in rural Greensboro holding the unarmed teenager down for more than six minutes. He lost consciousness and died. The case became a flashpoint for community organisations and civil rights advocates who challenged the medical examiner’s determination and argued that Black’s death was the result of positional asphyxia — a condition in which the physical position forced on a restrained person, combined with the weight applied by officers, prevents adequate breathing. In 2023, state officials approved a settlement agreement that reformed the process for conducting autopsies on people killed in police custody — a direct consequence of the Black case and the community pressure it generated.
Freddie Gray died in April 2015 from spinal injuries sustained while being transported in a Baltimore police van, handcuffed, with his feet shackled, and without a seatbelt. Fowler’s office classified Gray’s death as a homicide — correctly, in the sense that the audit’s framework defines homicide as death caused by another person’s action — because officers had repeatedly failed to seek medical attention while Gray was visibly in distress. Prosecutors filed charges against six officers. None were convicted. The Gray case illustrates a specific dimension of the legal implication of homicide classification: a homicide determination does not guarantee prosecution, and prosecution does not guarantee conviction. The classification opens the door. What walks through that door depends on everything else in the system.
Forensic Analysis: How Homicide Classification Works — and Why It Matters
The distinction between accidental death and homicide in a medical examiner’s determination is often misunderstood in public discourse, and the Maryland audit has surfaced that misunderstanding in consequential ways. Maryland officials were explicit in their press conference: a homicide classification by a medical examiner is not an accusation of criminal wrongdoing. It is a forensic statement that a person’s death was caused by the actions of another human being, as opposed to by natural causes, accident, or suicide. Homicide, in the medical sense, is descriptive. Whether those actions constitute a crime is a separate determination made by prosecutors, not medical examiners.
This distinction matters enormously for the downstream legal consequences of the classification. When a medical examiner certifies a death as accidental, the investigation that would otherwise follow a homicide determination typically does not occur. Prosecutors who might have convened a grand jury do not have a forensic foundation to do so. Civil attorneys who might have built a wrongful death case on the authority of a homicide determination must instead overcome the official finding that the death was accidental — a significantly higher evidentiary burden. Of 443 cases nationally that were ruled accidental after deaths in police custody, just two resulted in criminal charges, according to the AP investigation.
The methodology of the Maryland audit was specifically designed to produce forensically defensible findings. Each of the 87 case files was reviewed by a three-person panel of independent forensic experts who examined the original autopsy findings, the scene investigation records, and the death certificates. Unanimous agreement among all three panelists — the threshold for the 36 confirmed misclassifications — represents a high standard of consensus. The additional five cases where two of three reviewers found misclassification reflect cases where the evidence was somewhat more complex but still supported a majority conclusion of improper classification.
The audit’s leadership — Towson University professor Jeff Kukucka, a psychology researcher whose work focuses on forensic decision-making and bias — brought a specifically behavioural science lens to the analysis. The combination of forensic pathology expertise (the three-person panels) and behavioural analysis of patterns across the full dataset produced an unusually comprehensive account of how bias operates not just in individual cases but systemically across an institution over time.
Criminal Psychology: Institutional Bias in the Forensic Suite
The Maryland audit’s findings raise a question that is as much psychological as forensic: how does bias operate inside an institution that is explicitly charged with objectivity, and what conditions allow it to persist for seventeen years undetected?
Forensic psychology research on cognitive bias in expert decision-making is extensive and consistently finds that experts are not immune to the contextual pressures that affect lay judgment. Medical examiners work in institutional relationships with law enforcement — they receive scene reports from police, they rely on law enforcement cooperation to do their work, and in smaller jurisdictions, they may have personal relationships with the officers whose cases they review. That relational context creates conditions for what researchers call contextual bias: the tendency for background information about a case to influence evaluations that should, in principle, be based solely on physical evidence.
The “exciting delirium” diagnosis is itself a product of this dynamic — a concept that emerged from, and was primarily deployed in, contexts where law enforcement-adjacent forensic experts needed a medically-sounding explanation for deaths that occurred during police restraint. Its widespread adoption by medical examiners, documented across multiple jurisdictions, reflects not scientific consensus but institutional contagion: a concept that served the needs of law enforcement organisations spread through professional networks that had structural incentives to adopt it.
The racial dimension adds a further layer of psychological complexity. Research on implicit bias in legal and medical decision-making consistently finds that racial identity of a subject affects evaluations in contexts where it should be irrelevant. The specific finding that Black decedents were less likely to be classified as homicide victims — independent of case circumstances — is consistent with a large body of research on how racial bias operates in high-stakes forensic and judicial contexts. It is not a finding that requires the attribution of conscious prejudice to individual medical examiners. It is a finding that documents the output of a system in which bias operated, whatever its source, with measurable and consequential results.
Law and Legal Implications: Accidental vs. Homicide and the Prosecution Gap
Governor Moore’s executive order directing the attorney general to review all 41 misclassified cases creates a formal legal process with a specific mandate: determine whether any of those cases should be reopened for criminal investigation. The scope of what that review can achieve is legally complex and practically constrained in ways that the press conference did not fully address.
The most significant constraint is the statute of limitations. In Maryland, the general statute of limitations for most felonies is three years, with no limitation for murder. If the misclassified deaths were caused by officer conduct that constitutes criminal homicide — manslaughter, reckless homicide, or second-degree murder — there is no time bar to prosecution. However, the evidentiary challenges of prosecuting cases from 2003 to 2019 are substantial: physical evidence may no longer be available in the form required for trial; witnesses’ memories have faded; officers who may have been involved have retired, moved, or died; and the criminal standard of proof — beyond reasonable doubt — is significantly higher than the civil standard that produced most of the legal accountability in these cases to date.
The civil litigation landscape is also shaped by the misclassifications in ways that may produce new legal proceedings. Families who pursued wrongful death claims and were denied or settled for reduced amounts on the basis of accidental death determinations now have a basis for arguing that the foundational forensic determination in their case was incorrect. Whether existing settlements and judgments can be reopened, and whether new claims can be filed within applicable limitation periods, will depend on individual case facts and state law provisions regarding fraud on the court and newly discovered evidence.
The audit’s findings also have implications for ongoing civil rights litigation. The pattern of racial bias documented across seventeen years is exactly the kind of systemic evidence that supports claims under the Equal Protection Clause and civil rights statutes. The Maryland Attorney General’s office, which both conducted the audit and is charged with reviewing the cases, will need to navigate the structural complexity of being the same institutional actor in both roles.
Global Context: Medical Examiners, Police Pressure and the Accountability Deficit
Maryland’s audit is the most systematic public accounting of medical examiner bias in police custody deaths in American history, but it did not emerge from a vacuum. The conditions it documents — institutional relationships between forensic offices and law enforcement, the use of contested diagnoses to reclassify restraint-related deaths, racial disparities in cause-of-death determinations — are present in varying degrees across the United States and in international forensic systems as well.
The AP’s 2024 national investigation found that the pressure on medical examiners to produce determinations favourable to law enforcement was documented in jurisdictions across the country, with some medical officials explicitly describing the relational dynamics that influenced their findings. The investigation found that the classification of in-custody deaths as accidental rather than homicide was strikingly common nationally, and that the prosecutorial consequences of accidental classification were nearly nil: two criminal charges out of 443 accidental rulings.
In the United Kingdom, the Independent Office for Police Conduct has jurisdiction over deaths following police contact and operates with greater institutional separation from the agencies it reviews than most American coroner and medical examiner systems. The IOPC’s investigations consistently find a higher rate of systemic concern in restraint-related deaths than equivalent American findings — a difference that may reflect genuine investigative independence rather than a genuine difference in the underlying rate of problematic conduct.
In Australia, the Royal Commission into Aboriginal Deaths in Custody — concluded in 1991 but whose recommendations remain substantially unimplemented — documented a systematic pattern of deaths in police custody that were attributed to causes other than the conditions of custody itself. The Royal Commission’s central findings — that Aboriginal people were dying in custody at rates disproportionate to their share of the incarcerated population, and that the deaths were associated with failures of duty of care — are directly analogous to what Maryland’s audit has documented in the American context.
The governor’s description of the Maryland audit as the “first of its kind in the nation” is accurate in a specific sense: no other US state has conducted a similarly systematic, independent, multi-year review of its medical examiner office’s classifications of police custody deaths. Whether other states will follow Maryland’s lead — and whether federal oversight can produce similar reviews in jurisdictions unwilling to initiate them voluntarily — are questions with direct implications for thousands of families across the country who received accidental death determinations for loved ones who died in police custody.
Investigation: What Remains Unknown
The full list of the 41 cases in which the audit found misclassification has not been publicly released, consistent with the attorney general’s ongoing review of whether those cases should be reopened for criminal investigation. The identities of the deceased in each case, the specific cause of death certified in the original autopsy, and the specific forensic basis for the independent panels’ reclassification remain unknown to the public.
Whether any of the 41 misclassified cases will result in criminal charges against law enforcement officers has not been determined. The attorney general’s review is ongoing, and no timeline for its completion has been publicly established. The statute of limitations analysis for each individual case — which depends on the specific circumstances, the conduct alleged, and the available evidence — has not been publicly addressed.
The two high-profile deaths specifically identified among the 41 flagged cases have been described only in general terms. Whether Anton Black’s death is among the 36 unanimously confirmed misclassifications or among the five cases with majority agreement — and what the specific forensic basis for reclassification is in each named case — has not been disclosed.
David Fowler has not publicly responded to the audit’s findings. Whether he faces any professional or legal consequences — including potential review of his expert witness qualifications in cases where he testified outside Maryland — is not addressed in the current proceedings. His testimony in the Chauvin trial, while not directly adjudicated by the Maryland audit, may be subject to renewed scrutiny in any subsequent proceedings that reference his professional credibility.
The extent to which the bias patterns documented in Maryland are present in other states’ medical examiner and coroner systems has not been studied. Governor Moore’s call for other states to conduct similar audits has not, as of this report, produced any announced commitments from other jurisdictions.
The Classification That Changed Everything — and Changed Nothing
Thirty-six people died in police custody in Maryland between 2003 and 2019 and were told — through the official record of their death — that what happened to them was an accident. Their families were told the same. Prosecutors who might have opened investigations were not given the forensic foundation to do so. Officers who may have used restraint techniques that caused those deaths were not investigated. The official record of those 36 lives ended with a classification that said: no one is responsible for this.
The audit does not restore those lives. It does not automatically reopen those cases. It does not guarantee that any officer will face criminal charges or that any family will receive additional legal remedy. What it does — and what Governor Moore described as its irreducible achievement — is change the official record. Thirty-six deaths that were certified as accidents are now, in the independent assessment of qualified forensic experts, homicides. The classification has been changed. What follows from that change depends on decisions being made in the Maryland Attorney General’s office, in prosecutors’ offices, and in courtrooms that do not yet exist.
Some of the families affected have been, as Moore said, “screaming for this type of analysis — and have been met with silence.” The audit is an end to the silence. Whether it is also the beginning of something more — accountability, prosecution, reform that prevents the next seventeen years from looking like the last seventeen — is a question that Maryland’s institutions, and those watching from other states, are only beginning to answer.
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