A blistering state audit has found that Maryland’s Office of the Chief Medical Examiner (OCME) misclassified dozens of deaths in police custody — many of which independent experts unanimously deemed homicides.
The review, ordered after former OCME Chief Dr. David Fowler testified in defense of George Floyd’s killer, revealed that during Fowler’s 17-year tenure, the office frequently downplayed police involvement and used discredited medical theories to avoid ruling deaths as homicides.
Of 87 in-custody deaths reviewed from 2003 to 2019, independent forensic pathologists found that 48 should have been classified as homicides. The OCME, under Fowler, had labeled only 12 that way.
In 36 of those cases, the office labeled deaths as accidents, natural causes, or undetermined — even when all three outside reviewers agreed they were homicides.
“This audit confirms what many feared — that Maryland’s death investigations during that time were compromised by systemic bias and flawed procedures,” said Attorney General Anthony Brown. “These findings demand urgent accountability.”
The report comes after a national backlash over Fowler’s testimony in the 2021 trial of former Minneapolis police officer Derek Chauvin. Fowler claimed that Floyd’s death was “undetermined,” not a homicide. The jury rejected that conclusion, convicting Chauvin of murder. In the aftermath, over 450 medical professionals signed a letter calling for a full investigation into Fowler’s record.
“This moment demands truth. The findings in this audit make clear that too many families were denied that truth,” Maryland Gov. Wes Moore said in a statement accompanying the report.
The audit found that the OCME often relied on the widely discredited theory of “excited delirium” to explain in-custody deaths — using the term in nearly half the cases reviewed.
The phrase has been denounced by the American Medical Association, the American Psychiatric Association, and numerous human rights groups, who warn that it’s disproportionately applied to Black victims and used to shield law enforcement from scrutiny.
In cases where “excited delirium” was listed as the cause, OCME almost always labeled the manner of death as “undetermined.” Independent reviewers found that over half of those deaths were homicides.
The audit also raised concerns about systemic racial bias. Black people comprised over 70% of the decedents in the reviewed cases. OCME was significantly less likely to rule those deaths as homicides compared to similar cases involving white decedents.
Experts said the office repeatedly failed to acknowledge restraint — particularly prone positioning and police pressure on the neck and back — as a contributing factor. In many cases, OCME’s findings violated the “but-for” standard, which requires classifying a death as a homicide if it would not have happened but for another person’s actions, regardless of intent.
“This is not just about medical errors — it’s about denying families justice and hiding the role of police in preventable deaths,” said Dr. Alfredo Walker, co-chair of the audit’s design team.
The report calls for an end to the use of “excited delirium,” reforms to classification standards, better documentation and transparency, and the inclusion of mental health professionals in crisis responses.
“We can’t change what happened,” Moore stated, “but we can make sure it never happens again.”