Md. to review 100 in-custody deaths as audit into former medical examiner continues

Maryland’s attorney general says a team of experts will conduct a detailed review of some 100 autopsies of people who died in police custody during the tenure of the state’s former chief medical examiner.

Attorney General Brian Frosh announced details of the review Wednesday in a news release.

Dr. David Fowler, who led the state’s Office of the Chief Medical Examiner between 2002 and 2019, came under scrutiny after he testified for the defense during the 2020 murder trial of Derek Chauvin, the Minneapolis police officer who was charged with murder in the killing of George Floyd.

In contrast to multiple experts who said Floyd died due to a lack of oxygen, Fowler attributed Floyd’s death to heart disease; and he said that fentanyl and possibly carbon monoxide poisoning from car exhaust fumes were also contributing factors. Fowler also testified that he would classify Floyd’s manner of death as “undetermined” rather than as a homicide.

After Fowler’s testimony, Frosh announced his office would conduct an independent audit of Fowler’s office.

An initial panel of experts conducted a first look into about 1,300 in-custody deaths and recommended that about 100 cases — involving people who died after they were physically restrained — should get a deeper look by forensic pathology experts.

The next step in the audit will examine whether those cases were adequately investigated by Fowler’s office, whether the office’s operations and protocols followed the best practices, and whether the office’s determinations regarding cause and manner of death were correct.

The experts are expected to render their own conclusions on the cases they examine.

The review will focus specifically on deaths that “occurred during or shortly after the decedent was physically restrained, and for which no obvious medical cause of death, such as a knife wound, was discerned during the autopsy,” according to the plan for conducting the review from the initial panel of experts.

Frosh launched the audit last May after more than 400 medical experts signed an open letter arguing Fowler deviated from standard medical practice in classifying Floyd’s death as “undetermined” rather than homicide, and calling on Frosh to investigate whether Fowler exhibited racial or pro-law enforcement bias in his work.

The open letter said Maryland’s OCME may have used the classifications of “accident” or “undetermined” in order to avoid labeling the deaths of individuals in police custody as homicides.

In a statement, Fowler said, “As I have said, since this effort was announced in May of 2021, I am proud of my seventeen years of service as Maryland’s Chief Medical Examiner, and I am confident that any fair review will confirm that the Office met or exceeded all applicable professional standards. I have offered my full cooperation with the audit, and that remains the case today.”

Fowler is also named as a defendant in a lawsuit filed by the family of Anton Black, who died after being handcuffed and manhandled in 2018 in rural Greensboro, Maryland. Part of the family’s wrongful death lawsuit was settled in August for $5 million and a promise by three Maryland towns to make improvements in police training.

However, the settlement did not resolve the claims against Fowler and the state medical examiner’s office, The Associated Press reported. The 2018 autopsy said Black’s death was “accidental” and that a combination of his congenital heart condition, mental illness and stress from the struggle with police likely contributed to his death.

A cardiologist from Johns Hopkins University, hired as an expert by Black’s family, concluded asphyxiation was the cause of his death, according to AP.

The Associated Press contributed to this report.

Jack Moore

Jack Moore joined as a digital writer/editor in July 2016. Previous to his current role, he covered federal government management and technology as the news editor at, part of Government Executive Media Group.

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