House Judiciary Committee Grapples With Response To Medical Examiner Audit

By William J. Ford, Maryland Matters

June 26, 2025

House lawmakers grappled Wednesday to find a path forward on a report that dozens of police-custody deaths previously ruled accidental or of unknown causes by the Office of the Chief Medical Examiner have been reclassified as homicides.

The report, the result of a four-year review of 1,300 cases between 2003 and 2019, was presented to the House Judiciary Committee by Attorney General Anthony Brown (D) and Towson University psychology professor Jeff Kukucka, who led the audit.

It revealed the potential of racial and pro-police biases in the office led by former Medical Examiner David Fowler that led to the incorrect characterization of some deaths as accidental. The report, originally released last month, included several recommendations, most of which are administrative, Brown said.

“None of the recommendations require legislation,” Brown said. But, “they all could be done by legislation. If you’re going that path, we respectfully ask that we’d be involved to help shape that.”

Judiciary Committee Chair Luke Clippinger (D-Baltimore City) said the committee would likely meet again to discuss the issues, if not before the start of the 2026 General Assembly session, then shortly thereafter.

The hearing was the latest in the sudden unraveling of the legacy of the office under Fowler, who led it form 2003 to 2019, when he resigned.

Questions arouse after Fowler was called as an expert witness in the trial of Minneapolis Police Officer Derek Chauvin, a white police officer who was ultimately convicted of murder in the May 2020 death of George Floyd, a Black man, while in police custody. As part of Floyd’s arrest, Chauvin knelt for up to nine minutes on the neck of Floyd, who said repeatedly that he could not breathe.

Medical examiner audit reclassifies dozens of police-restraint deaths as homicides

Local autopsies determined that Floyd’s death — captured by witnesses on cellphone video that went viral — was a homicide.But Fowler testified that he would have ruled Floyd’s death caused by “excited delirium” rather than police actions.

Excited delirium was a catchall term used to describe aggressive behaviors related to mental health or substance abuse issues. It has been disavowed by the American Medical Association and the National Association of Medical Examiners, and Kukucka said Wednesday that it has since been abandoned by Maryland’s medical examiner’s office.

Fowler’s testimony triggered outrage, and a 2021 letter signed by 450 medical experts called on Maryland officials to reexamine deaths in police custody and medical examiner’s office practices under Fowler.

That audit involved independent review of Maryland cases by a dozen forensic pathologists around the globe, who determined that 48 police-custody deaths during Fowler’s tenure should be reclassified as homicides. The audit said 32 of the 48 cases reclassified as homicides involved victims who were Black, the other 16 were white.

The reviewers determined that the office was more likely to determine a death was homicide if the victim was white, at 44%, but only 16% if the person who died was Black.

“As AG Brown mentioned, it’s a pattern that is consistent with the possibility of racial bias,” Kukucka said. “That homicides are being under-counted in general, but they’re being under-counted even more dramatically if the decedent is Black.”

Kukucka also said the medical examiner’s office certified 14% of restraint deaths as homicides when police were involved, but that nearly quadrupled, to 54%, if the restraint was applied by a security guard, emergency medical personnel, or some other individual who was not a police officer.

Kukucka and Brown reiterated the findings do not imply criminal wrongdoing or liability. But an executive order issued by Gov. Wes Moore (D) directed the attorney general’s office to work with local state’s attorneys to review each case.

“We will determine whether reinvestigation is warranted in these matters,” Brown said. He later said if a case would need to be reopened, that’s “if, and only a big capital, bold if, there was evidence that suggested prosecution.”

Baltimore County State’s Attorney Scott Shellenberger (D) said in a brief interview Wednesday afternoon any cases referred to his office will be reviewed that “might change the status of a case.”

“It’s going to take a bit [of time] because we’ve got to put together the files again,” Shellenberger said. “We’ll have to really do some digging.”

Legislation not needed, but…

During the virtual committee hearing, Del. Robin Grammer Jr. (R-Baltimore County) asked the researchers defined homicide.

Kukucka used an example of a hunter who shoots at game, but misses the animal and accidentally shoots and kills another hunter. From a death investigation standpoint, he said “that death is a homicide.”

“So how does the office of the chief medical examiner differentiate between an accident and a homicide?” Grammer asked. “Where’s the actual different difference here? Because it could be accidental when a person dies, and now you’re subject to felony murder, or if it’s negligence, maybe manslaughter.”

Del. N. Scott Phillips (D-Baltimore County) asked Brown if any of the audit’s recommendations should be codified into legislation.

Some of the recommendations included requiring better quality autopsy photos from the medical examiner’s office (some were black-and-whites); sending mental health experts on some emergency responses; and reviewing audit cases the pathologists determined a cause of death to be a homicide.

Brown said the recommendations can be handled administratively such as through the medical examiner’s office or the state Department of Health.

Del. J. Sandy Bartlett (D-Anne Arundel), vice chair of the committee, asked about a recommendation to conduct a follow-up audit in another five years. Bartlett asked why not sooner, especially with the biases noted in the audit.

Kukucka said five years provides more time to collect data to conduct a comprehensive audit.

“After two or three years, there may simply not be enough cases to draw firm conclusions,” he said.