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FORENSIC FAILURES: 36 POLICE-CUSTODY DEATHS SHOULD HAVE BEEN RULED A
HOMICIDE, AUDIT FINDS  
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Justin Fenton, Ben Conarck and Pamela Wood
May 15, 2025
Baltimore Banner
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_ The audit found that the state’s medical examiners “often
failed to acknowledge restraint as a potential contributing factor”
when restrained by police and "often failed to appropriately classify
homicides” when the people who died were non-white. _

Pictures of Anton Black in a collage in his family’s home in
Greensboro in 2019. Black died after a struggle with three officers
and a civilian outside the home in September 2018, (Patrick
Semansky/AP).

 

An unprecedented independent audit found that 36 deaths in police
custody over a two-decade span in Maryland should have been ruled
homicides by the state’s top medical examiner, a stinging rebuke of
Maryland‘s past efforts to investigate the deaths of those once held
by law enforcement.

The yearslong audit, shared exclusively with The Baltimore Banner
ahead of Thursday’s release, cited a likely reason behind the
massive failure: racial and pro-police bias in the work of the
state’s Office of the Chief Medical Examiner, which had been led for
nearly 20 years by Dr. David Fowler.

Before the audit, the deaths had been classified as accidents, natural
causes or simply undetermined. But many of them involved police
restraining people during arrests or shocking them with Tasers. The
affected cases were spread across the state with the most — 12 —
connected to Baltimore.

The recommended reversals include some of the state’s most
controversial and high-profile in-custody deaths. Anton Black, 19,
died while being restrained by officers on the Eastern Shore in 2018.
Tyrone West, 44, died after struggling with Baltimore Police in 2013.
And Dondi Johnson, 43, was paralyzed in 2005 and later died after what
he described as what’s known as a “rough ride” in a Baltimore
Police transport van.

After reviewing the audit, Gov. Wes Moore ordered the state, led by
Attorney General Anthony Brown, to reinvestigate the 36 cases plus
five others flagged by the audit and explore whether criminal charges
were now warranted.

Moore and Brown, both somber and serious, announced the findings
during a State House news conference Thursday afternoon.

They underscored that they believe this is the first audit of its kind
in the nation, and that the review was necessary after Fowler’s
credibility was called into question.

“I do want to say at the top: The findings of this audit are deeply
concerning,” said Moore, a Democrat.

The audit grew out of widespread concerns about the past work by
Fowler and his team once he appeared on the national stage.

In a stunning fall from grace four years ago, more than 400 medical
professionals lambasted Fowler for his high-profile testimony for the
defense at the trial of Derek Chauvin, the Minneapolis officer
convicted of murdering George Floyd in 2020.

Fowler, who served as Maryland‘s top forensic pathologist from 2003
to 2019, testified that he would not have ruled Floyd‘s death a
homicide. Instead, according to Fowler, it was the result of heart
problems with drug use and possibly car exhaust as contributing
factors and that he would have classified the case as
“undetermined.”

Outrage over video showing Chauvin pinning his knee on Floyd‘s neck
spurred law enforcement reform across the country. And outrage over
Fowler’s testimony in 2021 gave rise to the audit released Thursday,
which called into question his office’s ability to rule
appropriately on cases involving law enforcement.

The Banner reached out to Fowler on Thursday, but he did not
immediately return a request for comment.

The audit released Thursday found that in nearly half of its
now-disputed cases, the medical examiner’s cause of death cited the
“discredited concept of ‘excited delirium,’” a term long
debunked by many experts but heartily embraced by Fowler and his team
that avoided a homicide ruling.

The term “excited delirium” has its origins in the review of a
string of police-custody deaths that happened in Florida in the
mid-1980s. The controversial phrase — now discontinued for use in
Maryland — has been used to describe someone in a “potentially
fatal state of extreme agitation and delirium, often combined with
aggressive behavior, heightened pain tolerance and extreme physical
strength.”

The impact of the audit’s findings could be substantial, further
changing the way law enforcement and prosecutors investigate the
deaths of those in custody.

Officials in the Moore administration also say that the audit and
upcoming reforms could serve as a possible blueprint for other states,
a reform model that could offer new hope for victims’ families and
advocates who have long complained about a death review process that
they say unfairly tilts towards those in uniform.

The audit will not immediately reclassify the deaths, or lead
immediately to criminal charges against law enforcement personnel
involved in those cases, if at all. A medical determination of
homicide means that someone caused the death, and not that a crime was
committed. Some of the cases have already been extensively reviewed
and litigated.

The audit found that medical examiners “persistently
misclassified” the manner of death for people who had been
restrained by police, said Brown, a Democrat. And the audit identified
“patterns that are consistent with the possibility of both racial
bias and pro-police bias,” Brown said.

Brown was clear, however, that the bias may not have been intentional.

“These findings are troubling, but this report does not suggest
intentional or malicious conduct on the part of any Maryland medical
examiner,” Brown said. “Implicit biases run throughout our system
of justice, not just in Maryland, but across the United States.”

In a letter as part of the report, Brown also commented on the audit
results and the role of law enforcement officers.

“Addressing these concerns benefits everyone in our system of
justice — including the vast majority of law enforcement
professionals who perform their duties with integrity and deserve
clear, consistent standards,” Brown said.

The audit involved three experts separately evaluating cases then
comparing findings. In 36 cases, they unanimously agreed that deaths
had been misclassified or downgraded — and should be ruled
homicides.

In five additional deaths, two out of the three expert forensic
pathologist said they should be ruled homicides. Those cases will also
be rereviewed in an effort led by the attorney general.

After Fowler’s testimony in the Chauvin case, then-Attorney General
Brian Frosh stood up a panel of experts to comb through more than
1,300 deaths that occurred in police custody across the state during
Fowler’s 17-year tenure. By 2022, they had zeroed in on 87 cases for
a closer look.

In most cases flagged in the audit, the medical examiner’s office
had ruled the manner of death to be “undetermined.” That was a
ruling Fowler favored when he believed there was not enough
information to make a firm conclusion. Other cases questioned by
auditors were labeled accidental or natural deaths.

The audit found that the state’s medical examiners had “more often
failed to acknowledge restraint as a potential contributing factor”
when restrained by police and “more often failed to appropriately
classify homicides” when the people who died were non-white.

“These findings are of great concern and demand further review,”
Moore said in a letter accompanying the report.

Prosecutors, not medical examiners, determine whether officers’
actions were legally justified or whether they merit criminal charges.
But it’s the medical examiner’s ruling that sets the stage.
Without a homicide classification, it is almost impossible to bring
criminal charges.

All of the deaths auditors found to be misclassified occurred prior to
2023. That was the year lawmakers gave Maryland‘s attorney general
exclusive jurisdiction to investigate police custody deaths, rather
than local state’s attorneys in each jurisdiction.

Since then, the attorney general’s office has brought charges
in two cases
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fatal vehicle pursuits in Anne Arundel County.

In addition to the 12 cases listed in Baltimore, five cases have been
flagged for further review in Baltimore and Montgomery counties, four
in Prince George’s County, and three in Frederick County. There were
additional cases from Anne Arundel, Carroll, Talbot, Washington (2)
and Wicomico (2) counties.

The report released Thursday did not detail deficiencies in individual
cases, and it stops short of calling for cases to be formally
reclassified. But it is likely to boost hopes for the dozens of
families who have been demanding more scrutiny for their loved ones’
deaths.

Deputy Attorney General Zenita Wickham Hurley said officials have
tried to temper expectations with families.

“We hope we’ve earned families’ trust — that knowing someone
is taking a serious, honest look at the facts will be meaningful to
them, even if there’s no guarantee we’ll find criminal wrongdoing
or decide that further investigation or prosecution is warranted,”
she said in an interview.

State officials told The Banner that reforms at the medical
examiner’s office have been underway for years, largely prompted by
a settlement with the family of Anton Black. The 19-year-old with
severe bipolar disorder was chased by officers who then tried to
restrain him outside his family’s home in rural Greensboro,
Maryland, in 2018.

Officers handcuffed Black and shackled his legs before he stopped
breathing. The medical examiner’s autopsy report listed Black’s
death as accidental and said a congenital heart condition, mental
illness and stress from the struggle likely contributed to his death.

As part of the lawsuit, a cardiologist at Johns Hopkins University
concluded that asphyxiation was the cause of Black’s death. The
family reached a $5 million settlement in August 2022 with three
Eastern Shore municipalities.

In a separate settlement with the state 
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officials agreed to institute new policies requiring impartial
investigations. Anyone outside of the medical examiner’s office was
prohibited from providing input about an autopsy.

The National Association of Medical Examiners guidelines were adopted
for determining how such deaths are investigated and how examiners
determine cause.

The standards are clear: If a person would not have died “but for”
the intentional conduct of another, that death is a homicide, the ACLU
said.

Prior to that, in 2020, the medical examiner’s office had updated
its standards of practice and discontinued use of the term “excited
delirium,” five years before the national medical examiner’s
association disavowed the term, state officials said.

During a briefing with Banner reporters on Wednesday, Jeff Kukucka, a
Towson University professor who helped facilitate the audit and legal
psychologist who specializes in wrongful convictions, said he believes
the Maryland audit likely points to systemic problems that could be
uncovered in other states.

“No one has undertaken a project of this scope of this rigor, and we
developed the methodology in a way that we knew that we were providing
a blueprint for other states to hopefully follow so that in the
future, states will look back at Maryland and say we are we are
emulating their example,” Kukucka said.

_JUSTIN FENTON is an investigative reporter for the Baltimore Banner.
He previously spent 17 years at the Baltimore Sun, covering the
criminal justice system. His book, “We Own This City: A True Story
of Crime, Cops and Corruption,” was released by Random House in 2021
and became an HBO miniseries. He was part of the Pulitzer Prize
finalist team for coverage of the death of Freddie Gray, and was a
two-time finalist for the national Livingston Award for Young
Journalists for an investigation showing how police were discarding
rape complaints at the highest rate in the country as well as a
five-part narrative series inside a homicide investigation. He is an
Anne Arundel County native, a graduate of the University of Maryland,
College Park and lives in Baltimore._

_BEN CONARCK joined The Baltimore Banner as a criminal justice
reporter in July 2022. Previously, he worked for the Miami Herald as a
healthcare reporter and led the newspaper’s award-winning coverage
on the coronavirus pandemic. He was a member of the investigative team
studying the forensics of Surfside’s Champlain Towers South
collapse, work that was recognized with a staff Pulitzer Prize for
breaking news. Prior to his time in Miami, Conarck was an
investigative reporter covering criminal justice at the Florida
Times-Union, where he received the Paul Tobenkin Memorial Award and
the Al Nakkula Award for Police Reporting for his series with
ProPublica on racial profiling by the Jacksonville Sheriff’s
Office._

_PAMELA WOOD covers Maryland politics and government, focusing on how
powerful people make decisions that affect daily life for people
living and working in and around Baltimore. She previously reported
for The Baltimore Sun, The Capital and other Maryland newspapers on
topics as varied as politics, local government, the environment,
healthcare and breaking news. Though not a Maryland native, she’s
spent most of her life here, graduating from Howard High School and
earning a degree in journalism from the University of Maryland,
College Park. She now calls Anne Arundel County home._

_BALTIMORE BANNER MISSION: To be the most essential and compelling
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inspire the communities we serve by providing trusted local journalism
that tells people’s stories, holds leaders accountable, and delivers
news on a wide range of topics that readers and partners are eager to
support. As a nonprofit founded by The Venetoulis Institute for Local
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independent and we do not endorse leaders or political candidates._

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