WJZ Investigates is following the fallout from a bombshell audit that revealed dozens of cases where people died after police restrained them, which should have been classified as homicides. 

Baltimore City had the most cases under review of any jurisdiction, 22 of the 87 autopsies.

Some autopsies used the discredited diagnosis of "excited delirium," and reviewers found pro-police and racial biases.

For years, families have been telling WJZ the autopsy findings were incorrect. Now, because of this audit, the state is taking another look. 

Anton Black 

On September 15th, 2018, police arrested and then tackled 19-year-old Anton Black on his front porch in the small town of Greensboro on the Eastern Shore.

The medical examiner called his death accidental, blaming his heart.

From the start, his family told WJZ Investigator Mike Hellgren that Black died because he was unable to breathe after being pinned by police.

"He shouldn't have died like that," the teen's mother, Jennell Black, said at the time. "Those officers need to pay. I need to make sure that they pay, and that's what I want. I want justice for my son."

In 2023, the family settled for $5 million, and as part of that settlement, the state instituted reforms in how the medical examiner reviews cases where people die in police custody. 

"The autopsy mischaracterized Anton's death as accidental. There was nothing accidental about it," family attorney René Swafford said in 2022.

An independent panel unanimously found Anton Black's case should have been ruled a homicide as part of the audit released this week.

Tyrone West 

The panel's finding was the same in the 2013 death of Tyrone West in Northeast Baltimore: Homicide. 

West's sister, Tawanda Jones, told anyone who would listen in weekly protests for more than a decade that the initial autopsy came to an incorrect conclusion. 

She said she even spent $50,000 of her own money to exhume her brother's body. 

Finally, someone in power did listen. 

"They threw my family a flimsy seven-page report and said my brother died from a heart attack and dehydration, and that broke my heart—and I died again that day!" Jones told WJZ Investigates. 

Criticism of the medical examiner 

The common thread in all the cases: Dr. David Fowler, Maryland's chief medical examiner from 2003 to 2019. 

His testimony on behalf of Minneapolis police officer Derek Chauvin, later convicted of murdering George Floyd, drew widespread criticism. 

Fowler testified he would have classified Floyd's death as undetermined, citing past heart problems, drug use, and even car exhaust. 

"It was the 450 members of the medical community, as well as the world, who saw that testimony and gasped. You didn't have to be a medical professional to be in disbelief of that testimony," said Maryland Attorney General Anthony Brown Thursday. 

That testimony led the prior attorney general, Brian Frosh, to launch the review, as he explained to WJZ Investigates in 2022.

"I hope that the ultimate results will give them solace, either that their loved one was treated appropriately by the office of the medical examiner or validate their concern that he or she wasn't," Frosh said.

Maryland's audit found some autopsy findings during Fowler's tenure may have been tainted by racial and law enforcement biases, with this caution from Dr. Jeff Kukucka, who managed it: 

"The retrospective nature of the audit makes it impossible to know whether racial or pro-police biases truly affected OCME's determinations," Dr. Kukucka said. 

Attorney General Brown cautioned families that just because their loved ones' cases are being reviewed, it does not mean there will be any criminal charges or any findings that officers who applied restraint are liable for these deaths. 

"Some cases may be clear that there is no criminal culpability. Other cases may require a little more digging. Others may require even more," Brown said. 

He also promised, "What we assure them of is that we will look at these cases to assure them that justice is done."

For Tyrone West's sister, the fight has lasted 12 years, and she has no intention of stopping. 

"They tortured my family. David Fowler needs to be in jail. Forget a report, he needs to be in jail," Tawanda Jones said. 

"They didn't just do this to the West family. They did this to many families!" she told WJZ. "All I kept doing is exposing them whether they wanted to listen or not. I'm going to keep standing ten toes down on the truth."

WJZ Investigates did reach out to Dr. Fowler to get his perspective through multiple phone calls and emails, but did not get an immediate response. 

Read the audit

You can .

To support families, the attorney general has launched a hotline. 

They wrote in a news release, "If you believe your loved one is a decedent whose case was impacted by the OCME audit, please e-mail OCMEAuditHotline@oag.state.md.us."

People may also call 833-282-0961.

Here is how the attorney general's office summarized the audit:

• In 44 out of 87 cases (more than half), independent forensic reviewers disagreed with OCME's original determination of the manner of death.

• In 36 cases, the reviewers unanimously, 3 out of 3, concluded that the death should have been classified as a homicide.

• In 5 additional cases, 2 out of 3 reviewers concluded the death should have been classified as a homicide.

• Deaths involving Black individuals and deaths involving law enforcement restraint were significantly less likely to be ruled homicides compared to others.

• "Excited delirium" – a diagnosis now rejected by leading medical organizations – was cited as a cause of death in nearly half of the reviewed cases, contributing to misclassification.

• Auditors found systemic deficiencies in autopsy documentation, including missing photographs, incomplete incident information such as the absence of available body camera footage, and inconsistent acknowledgment of restraint-related injuries.