On May 30, 2020, citizens gathered to protest the murder of George Floyd by Minneapolis, Minnesota police officers. The officers placed Floyd in a prone position that restricted his ability to breath. Maryland is now reviewing other in-custody deaths and autopsies that may be similar.
Maryland will review about 100 autopsies of people who died in police custody involving physical restraint because of concerns about the state’s former medical examiner’s testimony in the death of George Floyd.
An independent audit team of forensic pathologists and behavioral experts convened in September 2021 narrowed down the scope of the review after looking at about 1,300 autopsies conducted during the tenure of David Fowler, who testified for the defense at the 2021 murder trial of former Minneapolis police officer Derek Chauvin.
Fowler, who was Maryland’s chief medical examiner from 2002 to 2019, testified that the primary cause of Floyd’s death was a sudden heart rhythm disturbance during police restraint due to underlying heart disease—not a lack of oxygen.
Just a couple weeks later, after Chauvin was convicted of murder, over 400 doctors from around the country sent a letter to Maryland Attorney General Brian Frosh outlining concerns with Fowler’s conclusions and, subsequently, his previous casework.
“Dr. Fowler’s stated opinion that George Floyd’s death during active police restraint should be certified with an ‘undetermined’ manner is outside the standard practice and conventions for investigating and certification of in-custody deaths. This stated opinion raises significant concerns for his previous practice and management,” the letter stated. “There is a genuine concern that there may be an inappropriate classification of deaths in custody by the Maryland OCME as either Accident or Undetermined to purposefully usurp a manner of death classification of Homicide.”
The letter requested an immediate review of all in-custody deaths investigated by the Maryland Office of the Medical Examiner (OCE) during Fowler’s tenure—and Frosh agreed.
Now, a little over a year after it was convened, the 7-member Audit Design Team (ADT) has released their report with the recommendation to re-review 100 in-custody deaths and autopsies.
The report details key factors and questions that need be to addressed by the next audit, including:
- whether the cases were adequately investigated,
- whether OCME’s operations and investigative protocols were consistent with best practices,
- what role restraint played in each death,
- whether the OCME’s determinations were correct,
- whether the determinations were affected by bias,
- and where determinations were incorrect, what significance the reviewers attach to such errors, including whether they reflect bias.
The report proposes conducting the audit in two phases. In the first phase, reviewers will be given access to OCME case files and asked to give their own initial opinion about each case. In the second phase, the reviewers will meet to discuss each case and attempt to reach a consensus on key questions like the quality of the investigation and case workup by the OCME, and its conclusions regarding cause and manner of death.
AG Frosh said his office will now recruit additional independent forensic pathologists and other experts to perform the review of the 100 cases, as recommended by the ADT.
Frosh nor the ADT has released the names of the descendants of the 100 cases that are to be reviewed. But, looking at the appropriate years, at least two very well-known cases could be included.
In 2013, Tyrone West, a 44-year-old Black male, died after running from Baltimore police during a traffic stop. Witnesses and police officers say there was a violent struggle, but accounts vary. During the autopsy, Fowler determined that West died of cardiac arrhythmia when his heart suddenly stopped beating, exacerbated by dehydration, a heart condition and excessively high temperatures. The medical examiner said neither asphyxia nor trauma from the fight contributed to West’s death.
In 2018, 19-year-old Anton Black also died in police custody. Black ran from police after they approached him on the street in response to a 911 call. Once police caught Black, they tased him and then pinned him down for more than five minutes as they handcuffed him and shackled his legs. During the autopsy, Fowler ruled that Black died because of a sudden cardiac event while struggling with police, and not because they pinned him in a prone position.
As a result of his in-custody death, Black’s family sued the state of Maryland, the police officers involved and Fowler, who they claim “improperly concealing police wrongdoing.” The case again Fowler is ongoing, while Maryland agreed to pay the Black family $5 million and institute changes in policing policy, including a ban of placing suspects in the prone position.
The ADT comprised the following experts: Stephen Cordner; Jack Crane; Deborah Davis; Itiel Dror; Michael Freeman; William Thompson; and Alfredo Walker.