An independent review has uncovered widespread misclassifications of deaths involving people in police custody in Maryland, with racial implications. 

The 70-page audit of Maryland's Office of the Chief Medical Examiner (OCME), announced Thursday by Attorney General Anthony Brown and Gov. Wes Moore, reviewed 87 cases. Outside reviewers disagreed with the then-Chief Medical Examiner Dr. David Fowler's original determination of the manner of death in more than half of those cases.

The review found that dozens of cases involving in-custody police deaths should have been ruled homicides.

"The findings of this audit are deeply concerning," Moore said.    

Audit reveals inconsistencies, racial disparities

The report flagged serious inconsistencies in how deaths were categorized. 

Reviewers found that 36 cases initially labeled as undetermined, accidental, or natural should have been classified as homicides. 

The audit also pointed to patterns that suggest racial disparities, according to Brown. Deaths involving Black individuals or those involving police restraint were significantly less likely to be classified as homicides.

Out of 87 cases reviewed, independent experts disagreed with the original conclusions in 44, Brown said. 

"These findings highlight the need for real reform," Attorney General Brown said. "Marylanders deserve a system rooted in fairness, transparency, and accountability."

In addition, the audit revealed that reports on many cases lacked full incident details, such as missing body cam footage or photographs. It also showed inconsistencies in documenting injuries linked to police restraints.

Baltimore man who died in police custody named in audit

Tyrone West died while in the custody of Baltimore police in 2013. For years, his sister Tawanda Jones has proclaimed her brother did not die of natural causes, as initially reported.

West's death was mentioned in the audit.

"I still have never changed the truth," Jones said. "Always said my brother was brutally murdered."

For 12 years, Jones has spoken publicly about her brother's death.

At 44 years old, he was arrested in Northwest Baltimore after fleeing a traffic stop, and he died while in police custody.

"It's always been, when are they going to know it, when are they going to expose it?" Jones said. 

West's cause of death was listed as natural causes, but his sister argued it was homicide.

"The coverup was far worse than my brother's execution, and my brother's execution was horrible, being pepper-sprayed, tased, kicked, stomped, tortured, and you want to come back and say he died of a bad heart," Jones said.

Jones says she's not going to rest until there's accountability.

"I've been standing 10 toes down on truth, but I'm not going to be completely happy until we get a thorough investigation into my brother's murder," Jones said.

Moore supports further investigations 

In response to the audit, Gov. Moore signed an executive order creating the Maryland Task Force on In-Custody Restraint-Related Death Investigations. The group includes government officials, forensic experts, legal professionals, law enforcement, and community advocates.

The task force is responsible for improving how these deaths are investigated, recommending oversight processes for future cases, and suggesting changes to training and collaboration with mental health and substance use professionals. The task force will also consider whether further audits are needed.

"This executive order takes us one step closer to a more just and transparent system and was crafted with the same values that have guided our approach to public safety since Day One - true partnership with both law enforcement and the communities they protect; a close, objective examination of the facts; and an abiding commitment to making Maryland safer and uplifting the brave public servants who keep us safe," said Gov. Moore.

The executive order also requires the Department of Health and the OCME to share a report on their progress in implementing recommended changes.  

Autopsy concerns raised in 2022 

In 2022, WJZ reported that 100 death investigations involving physical restraint were recommended for review after an audit of the state medical examiner's office. 

The audit was carried out by a team that was tasked with reviewing former Chief Medical Examiner Dr. David Fowler's cases after he testified that Minnesota Police Officer Derek Chauvin did not kill George Floyd. The case gained national attention in 2020 and sparked protests across the world, some of which turned violent. 

Fowler was Maryland's chief medical examiner between 2002 and 2019. 

The audit analyzed whether Fowler's cases were adequately investigated, if best practices were used, and if reviewers agreed with the manner of death that was determined. 

"It appears OCME undercounted restraint-related homicides during the audit's time frame," Dr. Jeff Kukucka, who managed the audit. "We also found that they undercounted homicides even more in cases where the decedent was black or was restrained by police."

Attorney General Brown said these findings speak to systemic issues across our justice system.

"We recognize both the gravity of these findings for affected families and communities, and the importance of surrounding law enforcement or supporting law enforcement officers who navigate difficult situations," Brown said.