On Thursday, Governor Wes Moore, along with the Attorney General and the Office of the Chief Medical Examiner, released the results of an independent audit of 87 in-custody death investigations.
The audit started following the conviction of Derek Chauvin for the murder of George Floyd.
During the trial, Dr. David Fowler, a former Maryland Chief OCME, had testified that Floyd's death was due to undetermined causes, not homicide.
Hundreds of medical experts signed a letter condemning that conclusion and demanded that then-AG Brian Frosh conduct a review of the in-custody deaths investigated by the Maryland OCME during Fowler's term.
An audit team found 87 cases to include from more than 1,300 in-custody death cases between 2003 and 2019.
"This audit marks the beginning of a long conversation - one that must be handled with honesty, delicacy, resolve, and deep consideration," says Gov. Wes Moore in a letter introducing the audit.
Three of 12 reviewers looked at each of these 87 cases and came to independent findings on cause and manner of death.
In 36 cases, all three reviewers looking at the case made the determination of homicide. In these cases, 29 had been ruled undetermined by the OCME. Five cases had been ruled accidental, and two cases had been ruled natural deaths.
"In nearly half (42) of the 87 audit cases, OCME’s cause-of-death statement referenced “excited" or "agitated" delirium, which has been widely rejected as a valid cause of death. In those cases, OCME almost always certified the manner of death as ‘undetermined’ (93%), with only one case (2%) ruled a homicide. In contrast, case reviewers deemed 25 of those same 42 deaths (56%) to be homicides."
- Audit Report
Twelve of the 36 cases that reviewers found to be homicides that weren't ruled murders by the Medical Examiner were in Baltimore City.
Five were in Baltimore County, one was in Anne Arundel, and one was in Carroll.
"Marylanders deserve a justice system built on transparency, accountability, and equity," says Attorney General Anthony Brown. "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."
Below is the list of the 36 individuals for whom all three reviewers concluded the manner of death was homicide, plus an additional 5 individuals whom two out of three of the audit reviewers concluded the death was homicide.
*County, as listed above and in the report, is the jurisdiction that OCME listed on the cover page of the decedent’s autopsy report, which may differ from the county in which the decedent died or where the restraint occurred.
"It's important to note," says Brown, "that a homicide determination is a medical classification, not a judgment of criminal wrongdoing or police misconduct."
Today, Governor Moore also signed an executive order in support of the audit findings.
"Maryland will continue to be a national leader in accountability, action, and equal justice under law," said Moore.
The Executive Order also directs the Attorney General's Office to work with local State's Attorneys' Offices to look into each of these cases to see if an investigation needs to be reopened.
The audit team made several recommendations, including that the OCME takes steps to improve its documentation of post-mortem examinations, specifically for cases involving in-custody deaths, and that the office review the 36 cases that were unanimously found to be considered homicides by reviewers.
We reached out to the Baltimore City and Baltimore County Police Departments for statements on this release.
A spokesperson for BPD in the City said, "The Baltimore Police Department is aware of the recent audit findings. We are committed to full transparency and we will fully cooperate with the State in its ongoing investigation and findings."
The President of the Maryland State's Attorney's Association, Richard H. Gibson, Jr. also released a statement on the release of the audit findings.
"While the Office of the Attorney General did brief prosecutorial offices as to aspects on the forthcoming report, neither the report itself nor the full details of its findings, methodologies, or conclusions were shared with Maryland's State's Attorneys in advance of its public release," Gibson said as part of his statement. "As such, at this time, we are not in a position to support or oppose the analysis or conclusions contained within the document until we conduct our own independent due diligence."
He added, "Our shared commitment is to ensure justice is served and that any and all people affected by the report are treated with dignity and respect, a priority they rightfully deserve."
This story is developing and will be updated.