BALTIMORE, MD – An explosive independent audit of the Maryland Office of the Chief Medical Examiner (OCME) has confirmed what Black families and communities have said for decades: the OCME has been systemically misclassifying police-involved deaths, concealing the role of law enforcement and violating professional standards.
Commissioned by the Maryland Attorney General, the 70-page report released on May 15 concluded that at least 36 deaths that occurred in police custody between 2003 and 2019 were wrongly classified as “undetermined”, “accidental”, or “natural”—despite clear evidence they were homicides. Conducted by a panel of more than a dozen independent forensic reviewers, the audit documented patterns of pro-police bias and racial disparities. The reviewers also issued recommendations for preventing such abuses and ensuring compliance with national standards going forward.
“The report validates years of advocacy by family members, communities, and survivors,” said Sonia Kumar, Senior Staff Attorney with the ACLU of Maryland. “Maryland’s official records have long protected police from accountability while families begged for the truth about what happened to their loved ones. That ends now.”
In 2022, a lawsuit filed by the family of Anton Black charged that the Office of the Chief Medical Examiner—led by Dr. David Fowler, who served as an expert witness in defense of Derek Chauvin’s murder of George Floyd—engaged in a pattern of misrepresenting facts, medical evidence, and basic principles of the profession to conceal the truth about police-involved deaths. Nearly a decade earlier, the family of Tyrone West had similarly urged government officials to acknowledge the causal connection between West’s violent encounter with police and his death. The family of Jarrel Gray had filed a suit five years prior to that when Gray died after being tased by police—something that the OCME failed to acknowledge in its findings.
“It should never have taken this much work to get to the truth,” Kumar added. “For decades, the state misled Marylanders by claiming police were not responsible for the deaths of people in their custody, perpetuating the lie that we could not save lives like Anton’s. Now that the truth is out, the state owes it to these families – and all Marylanders – to ensure it never happens again. That starts with really listening to and working alongside those who have lived with the consequences of this injustice.”
In response to the audit, Governor Wes Moore issued an executive order that includes three key directives:
- Case Review: The Attorney General is directed to review each of the 36 cases in which auditors unanimously disagreed with the OCME’s original determination.
- Policy Reform: The Maryland Department of Health is tasked with reviewing current OCME policies and practices to ensure they align with national and professional standards.
- Task Force Creation: The order directs the Governor’s Office of Crime Prevention and Policy to lead a new “Maryland Task Force on In-Custody Restraint-Related Death Investigations” comprised of state officials to review audit findings and guide implementation of its recommendations.
While these steps move in the right direction, surviving families and the ACLU of Maryland urge the Governor to ensure that those most affected by OCME’s failures—and those who helped bring these failures to light—are actively involved in shaping the state’s response. We urge inclusion of family members, community leaders, and advocates in implementing all aspects of the executive order, including formal participation on the task force. Their representation and participation are essential to building a process that is not only fair, but truly effective.
“We need accountability now at this very moment! No one's family deserves to ever go through this nightmare and pain,” said Tawanda Jones, sister of Tyrone West and convener of West Wednesdays. “The real change begins when we get accountability for our loved ones. We are more than hash tags and body bags. More than being six feet in the dirt and—more than pictures on buttons and t-shirts. Their lives matter. We deserve a non-bias, diverse and community-based task force to investigate these findings.”
Audit recommendations mirror the relief sought by Anton Black’s family and the Coalition for Justice for Anton Black in their case: that the OCME tell the truth and adhere to the standards of the profession in all cases, including those of people who die in police custody; that the state rely on the best evidence to make its determinations; and that it correct the record in the cases it got wrong. A after years of litigation, the state has made some changes, but resisted commitment to the full relief then sought and now echoed as necessary by the audit.
“Our family to ensure the government tells the truth about how my brother died,” said LaToya Holley, sister of Anton Black and police reform advocate. “The audit’s findings matter so much to our family and our ongoing struggle to ensure accountability for the police who murdered Anton, all those who covered it up, and for the Medical Examiner’s Office who tried to justify it. This audit gives us some hope in our hearts that accountability will come, and that our efforts will ultimately help other families in Maryland and across the country to avoid the heartbreak and struggle for justice our family has endured.”
“The recently released audit of restraint-related deaths has profound implications for our justice system,” said Reverend Marguerite Morris, Founder of For Kathy's Sake and the C.A.S.T. of Anne Arundel County. “It confirms not only individual misconduct, but systemic issues that are deeply embedded, affecting its multiple parts and causing widespread negative consequences. That misconduct is far reaching and sadly not just resulting in in-custody misconduct. The results of these systemic issues impact how other types of cases that flow between the OCME, and law enforcement are handled, categorized, and responded to. The people of Maryland are the ones who are impacted by these structures, policies and practices – and it must be addressed and corrected immediately.”
The ACLU of Maryland urges the Moore administration to act swiftly and collaboratively to ensure that this moment leads not only to real reform, but to healing and justice for the families who have borne the weight of state-sanctioned silence.
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