In the wake of the 2021 Minneapolis trial of police officer Derek Chauvin for the 2020 murder of George Floyd, Maryland’s Office of Chief Medical Examiner (OCME) came under scrutiny due to a former Maryland chief examiner’s testimony at the trial that the cause of death in the case, should have been called “undetermined.” This seemed like a dubious proposition, given taped video showing the police officer’s knee pressed against Floyd’s neck for nearly ten minutes.

While this testimony did not affect the outcome of the trial, in which the jury found Chauvin guilty of murder, it provoked the start of a first-of-its kind audit in 2021 by then Maryland Attorney General Brian Frosh to examine bias in past death determinations during the tenure of the Maryland’s former medical chief examiner. According to an executive summary, the audit started with a review of more than 1,300 cases of death in custody from 2003 through 2019, with 87 cases identified as involving an unexpected death during or soon after restraint.

The results, which were released in a May report provided dramatic evidence that this state methodically identified 36 deaths as accidental, undetermined or natural which should have been classified as homicides during that period. 

In the audit, the Maryland AG brought together a team of pathologists, psychologists and research scientists to comb through OCME’s determinations of cause of death that occurred during or soon after restraint by law enforcement authorities.

Some of the outstanding findings:

• “In 44 out of 87 cases (more than half), independent forensic reviewers disagreed with OCME’s original determination of the manner of death.”

• “Deaths involving Black individuals and deaths involving law enforcement restraint were significantly less likely to be ruled homicides compared to others.

• “Excited delirium” – a diagnosis now rejected by leading medical organizations – was cited as a cause of death in nearly half of the reviewed cases, contributing to misclassification.”

• “Auditors found systemic deficiencies in autopsy documentation, including missing photographs, incomplete incident information such as the absence of available body camera footage, and inconsistent acknowledgment of restraint-related injuries.”

Current Maryland Attorney General Anthony Brown stated in a press release, “Marylanders deserve a justice system built on transparency, accountability, and equity. This audit’s findings pave the way for meaningful reform in how medical examiners approach death investigations and propose changes that could address systemic inequities that have persisted for too long.”

 Continuing his comments, AG Brown said the audit “gives other states a blueprint on how to safeguard their death investigations against bias, ensure accountability across our legal institutions, and guarantee that when someone dies in law enforcement custody, the case is handled according to the highest professional standards of fairness and impartiality.”

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