FILE – In this image from video, Dr. David Fowler, a retired forensic pathologist and former chief medical examiner for the state of Maryland testifies as Hennepin County Judge Peter Cahill presides, on April 14, 2021, in the trial of former Minneapolis police Officer Derek Chauvin at the Hennepin County Courthouse in Minneapolis, Minn. Chauvin is charged in the May 25, 2020 death of George Floyd. (Court TV via AP, Pool, File) 
Maryland Gov. Wes Moore speaks at a news conference on Thursday, May 15, 2025 in Annapolis, Md. (AP Photo/Brian Witte) 
Maryland Gov. Wes Moore speaks at a news conference on Thursday, May 15, 2025 in Annapolis, Md., Maryland Attorney General Anthony Brown is standing right. (AP Photo/Brian Witte) 
FILE – Tawanda Jones leads a vigil outside of Baltimore City Hall on Oct. 21, 2015, for her brother, Tyrone West, who died during an encounter with police. (AP Photo/Patrick Semansky, File) 
FILE – Family members of Anton Black, from left, LaToya Holley; father, Antone Black, and mother, Jennell Black, speak during a news conference Thursday, Sept. 30, 2021, in Baltimore. (AP Photo/Gail Burton, File)
ANNAPOLIS, Md. | An audit of Maryland autopsies has uncovered at least 36 deaths in police custody that should have been considered homicides, state officials announced Thursday following a comprehensive review of such cases spurred by widespread concerns about the former state medical examiner’s testimony in the death of George Floyd
Medical examiners under Dr. David Fowler displayed racial and pro-police bias, according to the review. They were “especially unlikely to classify a death as a homicide if the decedent was Black, or if they died after being restrained by police,” Attorney General Anthony Brown said during a news conference.
“These findings have profound implications across our justice system,” Brown said. “They speak to systemic issues rather than individual conduct.”
The auditors reviewed 87 in-custody death cases after medical experts called Fowler’s work into question because he testified that police weren’t responsible for Floyd’s death. The Maryland team focused on cases in which people died suddenly after being restrained, often by police, officials said.
Three-person panels evaluated each autopsy and, in 36 cases, they unanimously concluded that the deaths should have been classified as homicides but were not. In five more cases, two of the three reviewers came to that conclusion.
Fowler didn’t immediately respond to messages seeking comment.
State officials could reopen death investigations
Democratic Gov. Wes Moore said he has signed an executive order directing Brown to review the 41 cases and determine if any should be reopened for investigation.
Moore acknowledged the families whose loved ones have died in police custody, some of whom have been “screaming for this type of analysis — and have been met with silence.” He also acknowledged the many members of law enforcement who do their jobs honorably and protect the public.
Moore said he has also created a statewide task force to study the deaths of people restrained in law enforcement custody. He said the state won’t shy away from rooting out misconduct and working to create a more equitable justice system.
Among a list of recommendations, the review suggested better training for law enforcement officers on the dangers of improper restraint techniques. It also directed the Office of the Chief Medical Examiner to create standardized procedures for investigating restraint-related deaths.
The governor described the review as the first of its kind in the nation, saying he hopes it will provide a model for similar investigations elsewhere.
In a national investigation published last year, The Associated Press and its reporting partners found that medical examiners and coroners, whose rulings have huge consequences in the courts, can face pressure from law enforcement to exonerate officers. Some medical officials based their decisions not on physical evidence, but instead on whether they believed police intended to kill.
When deaths are ruled accidental, prosecutions of officers are exceedingly rare — of 443 cases that were ruled accidental, just two resulted in criminal charges. A family’s chances of winning a wrongful death lawsuit also become much tougher.
While the audit findings are troubling, Maryland officials said they don’t suggest intentional or malicious conduct. They emphasized that a homicide classification simply means someone died because of another person’s action, not necessarily that the officers involved should be prosecuted.
Fowler was criticized for embracing a widely rejected theory
Fowler, who testified for the defense at the 2021 murder trial of former Minneapolis police Officer Derek Chauvin, attributed Floyd’s death to a sudden heart rhythm disturbance as a result of his heart disease — a widely rejected theory that did little to persuade the jury. Chauvin was ultimately convicted of murder and manslaughter for kneeling on Floyd’s neck for more than nine minutes.
After his conviction, 400 medical experts signed a letter to the Maryland attorney general asserting that Fowler’s testimony deviated way outside the bounds of accepted forensic practice. In addition to citing heart problems, he classified the manner of death as “undetermined” rather than “homicide.”
The letter called for an investigation to determine whether the office’s in-custody death determinations under Fowler’s leadership exhibited certain bias, among other potential issues.
Officials said Thursday that their audit found a troubling systemic pattern.
Nearly half of the reviewed cases cited “excited delirium” as a cause of death, a diagnosis that has been debunked by medical experts in recent years. Critics say it was often used to justify excessive force by police. The report recommended that medical examiners stop using the term altogether.
Fowler was Maryland’s chief medical examiner from 2002 to 2019.
Two high-profile deaths are among the 41 cases highlighted
In 2023, state officials approved a settlement agreement that reformed the process for conducting autopsies on people killed in police custody.
That change came in response to the 2018 death of Anton Black, who died in police custody on Maryland’s Eastern Shore. His death was captured on video, which showed police in rural Greensboro holding the unarmed teenager down for more than six minutes. Fowler ruled that Black died because of a sudden cardiac event while struggling with police — not because they pinned him in a prone position. His death was declared an accident.
Fowler similarly ruled that Tyrone West died of natural causes after struggling with Baltimore police following a traffic stop in 2013. Witnesses and the officers themselves said there was a violent struggle between the officers and West. His manner of death was undetermined, according to the autopsy.
Both Black and West are now included on the list of cases that should have been ruled homicides.
Tawanda Jones, West’s sister who has held weekly rallies for 616 weeks to highlight his case, said she feels something positive will come from the investigation. “They’re finally listening to me now,” Jones said. “It feels good that finally they’re listening.”
Fowler’s tenure also included the death of Freddie Gray 10 years ago. The autopsy concluded Gray died from spinal injuries sustained during transport in a Baltimore police van. It also classified his death as a homicide because officers repeatedly failed to seek medical attention while he was in distress. Prosecutors filed charges against six officers, but none were convicted.
This is a dangerous and misleading leap that will help to further cripple law enforcement. Suspects have been dying this way for a long time. It caused the coining of the term “sudden in custody death” to identify these cases. It will continue to happen. Suspects don’t take care of themselves, abuse drugs, are often mentally unstable, and fight past their physical ability. To automatically blame the police will create even more of an atmosphere where the police cannot do the job and you will have little reason to call the police. The Colorado legislature has already crippled the police to a large extent with vague guidelines that leave the police hesitant to get involved at all. The definition of the chokehold is worded in such a way that it indicates that an officer is at fault if he/she interferes with a suspect’s ability to breathe in any way. Let me explain something. It is not possible to fight with a suspect and consistently avoid going to the ground. It is in fact, usually necessary to take them to the ground to get control. Often, everyone falls to the ground in the struggle. Given the poor, inadequate, and inconsistent training given to officers, it is often impossible not to put weight on the suspect. By the nature of that, it means the suspect’s ability to breathe is affected. Contrary to popular belief, that is actually desirable. In wrestling and judo, putting weight on the opponent to make breathing difficult is part of the game. If they are having trouble breathing, they can’t resist as well. The key is that as soon as they quit resisting on the street or when significant control has been gained, the officers have to transition to insuring that the person can breathe. I can’t fight with you and at the same time insure that you are breathing fine. We must begin to realize that the person fighting has some responsibility in the whole matter. If we just want to say that it is fine to fight the police and the police are solely responsible, then we may as well have the police stay home except when necessary to shoot someone.
I am not saying that the police should be excused for poor tactics or excessive force. Proper training in control technique should be constantly conducted and reviewed and each incident should be reviewed for misconduct and areas needing more and better training. But the public and the legislature are not experts. They should be allowed complete disclosure. Someone with expertise, not the chief, should go over the incident with them.
In addition the legislature has determined in their knee jerk legislation that the police should use minimal force. “Minimal force” is a vague and dangerous concept. First, what is that? The legislature has given officers a vague definition of force. So, now everything is a use of force. Just touching you to get you to move out of the way of the fire engine is a use of force. In order to overcome the suspect’s use of force, the officer’s force has to be greater. Otherwise, it is a tie. The officer has to win, not tie. Further, minimal force often means that the officer uses force that is not enough to control the situation. That means the suspect breaks free and gets a weapon. Now, the officers or the suspect are killed since no adequate control was established. So, something that should have been a minor fight becomes deadly. The Supreme Court has said that the use of force should be reasonable when viewed from the prospective of a reasonable officer at the scene. The Supreme Court has said that the force should be reasonable but not necessarily the best use. Our legislature wants to sit back and view the videos and decide that the officers could have done this or that with no knowledge of what it is like to actually struggle with suspects repeatedly over many years.
If we return to the determination of death then we should consider a number of things. First, the term “excited delirium’ was coined by the medical profession. Suspects were dying after exhibiting the same symptoms repeatedly. The medical people could not clearly establish why. Now the medical profession wants to do an about face and hang everything on the officers. Does your doctor know what is wrong with you every time and diagnose everything correctly? Mine can’t figure out why I always have some congestion. There are thousands of deaths due to medical errors yearly. There are far more deadly medical errors than there are police deadly errors. But now, they can clearly tell us that the officers caused the death of the overweight drug addict who struggled mightily against efforts by citizens, security, and the police. What kind of stress do emotions put on your body? Clearly, when the suspect is extremely afraid, very angry, or affected by some other extreme emotion, their body is affected. After the fight begins, there is a limited amount an office can do to change that emotion. The physical stress, coupled with the emotional stress, add to any physical problems the suspect may have. Right now, the officers understand that they should take a hands off approach with people of color or people who appear unstable. That means that you don’t need to call the police. You are on your own. Do you see a problem?
Let me be clear. I have taught police officers for many years. The focus has been on fair and respectful treatment of all citizens and suspects. In the process, I, like most police trainers, have come to understand where the real problem lies. Police administrators ( I won’t call them leaders), have neglected training for as long as I can remember. When you combine that with an inability to lead, you have a recipe for poor performance. The average recruit receives between one third and one half of the hours of training that they should get in physical skills before they hit the street. After they hit the street, they receive only a smattering of training through very occasional inservice training. Poorly trained officers become poorly trained supervisors who are hesitant to teach or correct their officers’ skills. Poorly trained superiors become poorly trained chiefs. Poorly trained chiefs make decisions on what training their officers receive. Ever wonder why your city gets sued because crowd control situations were so poorly handled? The cycle repeats constantly. That shiny, smooth talking chief often knows virtually nothing about proper use of force. It used to be that chiefs felt that they had to support their officers. Now, with the George Floyd hysteria, they know it is desirable to immediately condemn the officers. Such was the case with the notorious pistol whipping case in Aurora a few years ago. Chief Vanessa Wilson charged the officers involved and called their actions criminal before they even picked up the business videos that would have cleared the officers. The city paid the felony suspect (supposed victim) over $800,000 for trying to take an officer’s gun during a lawful arrest on a felony warrant. After Detective Ethan Snow obtained the videos, he showed them to no one. Divison Chief Juul chaired a Force Review Board that did not view the videos and condemned the officers actions in a report that is full of untrue and misleading statements. The department never showed the videos to their own people. The videos were buried in the police records. When I found the videos and they were shown to a jury, the main officer was acquitted of all charges. A female officer was convicted of failure to intervene because her attorney never viewed the videos that were buried in the mass of investigative material. So, two officers’ lives and careers were shattered behind the politically correct motives of a few dishonest police administrators. The department directives are clear about unsatisfactory performance and any kind of untrue or misleading statements in reports. I made an Internal Affairs complaint against Chief Juul and Detective Snow (now sergeant) about a year ago. No response of any kind. So, Aurora PD still has questionable
ethical standards. Further, I am told that the training has slipped greatly and token training has become the standard.
If we look at the problem objectively, then we should understand that most of the problems come from a lack of competent leadership. As a former military officer, I was taught that the first requirement was to be technically proficient. Police chiefs are usually not technically proficient in the area of use of force. Yet, they make the decisions on training and discipline. But worse than this incompetence is the lack of ethical backbone. Understand that most of them are just police politicians. Police officers have no voice. They can’t tell you what is happening. It is up to the police leaders to speak out and to fix things. The failure to speak out on the problems with SB217 passed by our liberal legislature speaks volumes. That bill drove thousands of good and experienced officers out of law enforcement. Now the legislature and the governor talk about how they are concerned about public safety and the need to hire more officers. The lack of moral courage and personal responsibility extends from the chiefs and sheriffs to the police unions. They should be screaming about the stupidity of SB217. They are not. They have abdicated their responsibility to their officers and to the public.
DONT GET ME STARTED