BALTIMORE, MD—Maryland’s Attorney General Anthony G. Brown announced the findings of an independent audit of the state’s Office of the Chief Medical Examiner (OCME) on Thursday, revealing significant discrepancies in death classifications and systemic deficiencies in autopsy documentation.

The 70-page report (PDF), initiated in 2021, examined 87 deaths that occurred during or shortly after restraint. In a shocking finding, the audit revealed that in more than half of these cases (44 out of 87), independent forensic reviewers disagreed with the OCME’s original determination of the manner of death. In 36 of those cases, the reviewers unanimously concluded that the death should have been ruled a homicide, while in five additional cases, two out of three reviewers agreed.

The audit found that the discredited diagnosis of “excited delirium” was cited as a cause of death in nearly half of the reviewed cases, contributing to misclassifications.

The audit, conducted by an international team of leading forensic pathologists, psychologists, and research scientists, employed internationally recognized scientific methods to ensure impartiality. The team, selected from a pool of over 1,300 in-custody deaths investigated by OCME between 2003 and 2019, used a blind review process to eliminate bias. The audit found systemic deficiencies in autopsy documentation, including missing photographs, incomplete incident information, and inconsistent acknowledgment of restraint-related injuries.

Attorney General Brown emphasized the importance of transparency and accountability in the justice system, stating, “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.”

Several key recommendations have emerged from the audit, including the adoption of clear standards for determining cause and manner of death, the discontinuation of using “excited delirium” as a diagnosis, and the implementation of external peer review and ongoing education for medical examiners. The report also calls for law enforcement reforms, such as mandatory body cameras to document all restraint situations and improved training on the dangers of improper restraint techniques.

The following table lists the 41 decedents, 36 whose cases were – unanimously – deemed as homicides by all 3 independent case reviewers assigned to those cases as well as 5 cases in which 2 out of 3 reviewers concluded that the manner of death should have been determined as a homicide.

Governor Wes Moore announced immediate executive actions in response to the audit, granting the Attorney General’s Office the authority to review the 36 cases that reviewers unanimously concluded should have been ruled homicides. Governor Moore also established the Maryland Task Force on In-Custody Restraint-Related Death Investigations to evaluate the audit’s recommendations and develop an implementation plan.

This article was written with the assistance of AI and reviewed by a human editor.

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