BALTIMORE — A first-of-its-kind audit report released Thursday revealed that 36 deaths in police custody should have been deemed homicides. Instead, they were misclassified as undetermined, accidental or natural by the Maryland Office of the Medical Examiner, or OCME. under Dr. David Fowler.

Nearly all cases examined were men, and three-quarters were people of color, according to Dr. Jeff Kukucka, a psychology professor, decision scientist, and audit manager.

“The findings of this audit are deeply concerning,” Gov. Wes Moore, a Democrat, said at an Annapolis news conference Thursday afternoon.

The 70-page report reexamined death determinations under Fowler, who served as Maryland’s chief medical examiner from 2003 to 2019.

The audit is the result of a four-year investigation of Fowler’s practices and was initiated in 2021 following his testimony in the murder trial of former Minneapolis police officer Derek Chauvin, who knelt on George Floyd’s neck for nine minutes in May 2020. In the case, Fowler testified that he believed Floyd’s cause of death could not be determined because of a number of factors, including heart problems, drug usage, carbon monoxide and “excited delirium.”

“Excited delirium” has been discredited by leading medical institutions.

Following his testimony, 450 medical experts signed a letter calling for an independent investigation into death determination practices under Fowler’s tenure at the OCME. Former Attorney General Brian Frosh, a Democrat, along with then- Gov. Larry Hogan’s office, convened an audit design team of forensic pathologists, psychologists and research scientists to independently examine death determinations in cases involving restraint.

In 44 out of 87 cases in which people died after being restrained — mostly by police — independent forensic reviewers disagreed with the original manner of death determinations from the OCME.

The findings will be presented before the National Academies of Sciences, Engineering, and Medicine study committee Friday.

Deaths of Black people and those involving restraint by law enforcement were significantly less likely to be ruled homicides than other cases, the report found.

Two notable cases — Tyrone West in 2013 and Anton Black in 2018 — were ruled as natural causes by Fowler, but are now included on the list of cases that should have been ruled homicides.

Fowler’s office is also known for the death of Freddie Gray in 2015, in which the autopsy concluded that the officers’ failure to give Gray proper care and seek medical attention made his death a homicide. As a result, former State’s Attorney Marilyn Mosby filed charges against six officers. All were either acquitted or had their charges dropped.

Moore said that the audit results are “not an attack” on law enforcement but a “need to initiate a thorough and systemic review that will help us create a more just and transparent system.”

According to a news release from the Attorney General’s Office, cases where the cause of death had been reclassified as homicides “(do) not automatically indicate police misconduct or suggest criminal culpability.” Cases will be reviewed to determine if additional investigation is appropriate or necessary.

“There’s no suggestion that anyone is criminally culpable,” Maryland Attorney General Anthony Brown, a Democrat, said Thursday.

“These members of the medical community were concerned that our state’s death determination had been tainted by racial- or pro-law-enforcement bias, or were otherwise inconsistent with the standard practices for investigating and certifying in-custody deaths,” Brown said.

Of more than 1,300 in-custody deaths that occurred under Fowler’s tenure, 87 involved restraint. The Attorney General’s Office hired a team of 12 forensic pathologists, who were not made aware of the decedent’s race or the original cause of death ruling. Each case was reviewed by three reviewers, who had to come to a unanimous conclusion regarding the cause of death in order for the deaths to be reclassified.

The Maryland State’s Attorneys’ Association said in a statement Thursday it’s not in the position “to support or oppose the analysis or conclusions” found in the report until the group completes its own investigation, which includes consulting with the American Board of Pathology.

Among the findings of the audit report are recommendations that the OCME stop using “excited delirium” as a diagnosis and standardize its procedures for investigations into restraint-related deaths. Law enforcement should be better trained on the dangers of improper restraint techniques and include mental health professionals in crisis response procedures.

In response to the report, Moore announced executive actions Thursday that will allow Brown’s office to investigate the 36 cases where reviewers unanimously determined that the cause of death should be homicide.

The governor is also establishing the Maryland Task Force on In-Custody Restraint-Related Death Investigations to develop a plan to implement recommendations from the audit. According to Moore, the task force will include government officials, legal professionals, law enforcement, forensic pathology experts, members of the community, and victim advocates.

Brown said his office has contacted approximately half of the families of decedents in the audit. His office launched a hotline Thursday for families who believe its findings could affect them. To contact the attorney general’s office regarding the audit, call 833-282-0961 or email OCMEAuditHotline@oag.state.md.us.

“To any Marylander grieving someone who is mentioned in our report, we are there for you,” Brown said.

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