Attorney General Brown Releases Results of Independent Review of Maryland's Office of the Chief Medical Examiner, Revealing Significant Misclassifications of Deaths and Recommending Case Reviews and Systemic Reforms

Authorities today announced the summary of the recently released independent audit conducted by the Office of the Attorney General regarding the Maryland Office of the Chief Medical Examiner (OCME). The 70-page report outlines significant concerns pertaining to the OCME's death classifications.

A central finding of the audit indicates a disagreement by independent forensic experts in over half of the reviewed cases, specifically 44 out of 87. The audit concluded that 36 deaths, initially classified as undetermined, accidental, or natural, should have been categorized as homicides, a determination reached with unanimous agreement among the three independent reviewers for each of these cases. Furthermore, in an additional 5 cases, two out of three reviewers supported a classification of homicide.

The audit also brought to light potential racial disparities in death classifications and noted the application of "excited delirium," a diagnosis that has been discredited, in nearly half of the reviewed cases, which contributed to classification errors. Moreover, the report identified systemic deficiencies in autopsy documentation, including missing photographic evidence, incomplete incident details such as the absence of available body camera footage, and inconsistent recording of injuries related to restraint.

According to Attorney General Brown, this audit offers a pathway for substantial reform in the methodologies employed by medical examiners in death investigations, with the aim of addressing long-standing systemic inequities. He emphasized that Maryland's leadership in undertaking this audit provides a model for other states to enhance the impartiality and accountability of their death investigations, particularly in cases involving deaths occurring in law enforcement custody.

The audit, initiated in 2021, was prompted by concerns arising from the testimony of former OCME Chief Medical Examiner Dr. David Fowler in the Derek Chauvin trial. Dr. Fowler's suggestion that George Floyd’s death was "undetermined" led to a call from over 450 medical experts for a review of OCME practices during his tenure from 2003 to 2019. The Attorney General’s Office, in collaboration with the Governor’s Office of Legal Counsel, formed an international Audit Design Team comprising experts to conduct a thorough and unbiased examination of OCME determinations in deaths that occurred during or shortly after restraint. The audit utilized internationally recognized scientific methods, and the case reviewers were experienced, credentialed experts with no prior affiliations with the OCME.

Dr. Jeff Kukucka, who managed the audit, highlighted the collaborative and rigorous nature of the process, involving social scientists and forensic medical experts. He expressed strong confidence that the audit's findings will lead to improvements in the quality of medicolegal death investigations, the advancement of social justice, and a reduction in preventable deaths.

For the purpose of the audit, the Audit Design Team selected 87 in-custody death cases from over 1,300 investigated by the OCME. Twelve independent forensic pathologists, who were initially unaware of the decedent’s race and the OCME’s original conclusions, reviewed these cases. Each case was independently assessed by three randomly assigned pathologists who determined the manner of death. Disagreements among the reviewers were discussed to seek a consensus where possible.

The subsequent table lists the 41 decedents whose cases were reviewed, including the 36 cases unanimously deemed homicides by all three independent reviewers and the 5 cases where two out of three reviewers concluded that the manner of death should have been homicide:

| Name | Year of Death | \*County | OCME MOD | Audit MOD |
| :---------------- | :------------ | :-------------- | :----------- | :------------------------------------------------- |
| Shawn Floyd | 2018 | Anne Arundel | Undetermined | Homicide |
| Gregory Williams | 2003 | Baltimore City | Undetermined | No Consensus (2 out of 3 reviewers determined Homicide) |
| Shawn Bryant | 2004 | Baltimore City | Undetermined | No Consensus (2 out of 3 reviewers determined Homicide) |
| Rodney Wilson | 2005 | Baltimore City | Undetermined | Homicide |
| Dondi Johnson | 2005 | Baltimore City | Accident | Homicide |
| William Washington| 2006 | Baltimore City | Undetermined | Homicide |
| Carlos Branch | 2007 | Baltimore City | Undetermined | Homicide |
| Thomas Campbell | 2007 | Baltimore City | Undetermined | Homicide |
| Eric Dorsey | 2011 | Baltimore City | Natural | Homicide |
| Don Thomas | 2011 | Baltimore City | Undetermined | Homicide |
| Jontae Daughtry | 2011 | Baltimore City | Undetermined | Homicide |

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