Audit finds Maryland medical examiner misclassified homicide deaths, prompting executive order to improve transparency
An independent review of Maryland's Office of the Chief Medical Examiner (OCME) uncovered major issues with how certain deaths were classified, the attorney general's office said Thursday.
At a Thursday press conference, Gov. Wes Moore and Attorney General Anthony Brown shared the findings of a 70-page audit, which showed that outside reviewers disagreed with the OCME's original determination of the manner of death in over half of the cases they examined.
Audit reveals inconsistencies, racial disparities, in death reports
The report flagged serious inconsistencies in how deaths - especially those involving police restraint, were categorized. Reviewers found that 36 cases initially labeled as undetermined, accidental, or natural should have been ruled as homicides. The audit also pointed to patterns suggesting racial disparities in these classifications and criticized the continued use of outdated and discredited terms like "excited delirium."
Out of 87 cases reviewed, independent experts disagreed with the original conclusions in 44, the AG said. In 36 of those, all three experts agreed the death should have been classified as a homicide. Five additional cases had two out of three reviewers reach the same conclusion.
"These findings highlight the need for real reform," Attorney General Brown said. "Marylanders deserve a system rooted in fairness, transparency, and accountability."
The audit also revealed systemic problems in how autopsies were documented. Many cases lacked full incident details—such as missing body cam footage or photographs—and there were inconsistencies in documenting injuries linked to police restraints.
One particularly troubling finding: deaths involving Black individuals or those involving police restraint were significantly less likely to be classified as homicides.
Governor responds with executive order
In response, Gov. Moore signed an executive order creating the Maryland Task Force on In-Custody Restraint-Related Death Investigations. The group includes a range of stakeholders—government officials, forensic experts, legal professionals, law enforcement, and community advocates.
Their mission: improve how these deaths are investigated, recommend oversight processes for future cases, and suggest changes to training and collaboration with mental health and substance use professionals. The task force will also consider whether further audits are needed.
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