Review of Maryland autopsies to focus on deaths of people restrained by law enforcement

An independent audit of Maryland autopsies completed under longtime former Chief Medical Examiner Dr. David Fowler — whose credibility was called into question after he refused to label George Floyd’s death a homicide — will focus on about 100 cases involving people who died after being restrained by law enforcement.

State officials announced new details Wednesday about the upcoming review. Plans for the audit are outlined in a report produced by a team of forensic pathologists and behavioral scientists that convened last fall.


Officials are now seeking a separate team of reviewers to complete the audit, which seeks to determine whether Fowler and his subordinates “exhibited racial or pro-law enforcement bias or failed to follow appropriate practices and protocols.”

Fowler was well-respected in the relatively small field of forensic pathology for many years. But his professional reputation tanked after he testified in defense of the former Minneapolis police officer who kneeled on Floyd’s neck for roughly nine minutes, ignoring his pleas for help. Floyd’s death, which was captured on cellphone video, became a catalyst for widespread racial justice protests that lasted for months during the summer of 2020.


Ex-officer Derek Chauvin was arrested and charged with murder. The case went to trial in March 2021, when Fowler testified for the defense.

On the witness stand, Fowler blamed a combination of Floyd’s bad heart, drug use and restraint by police. Fowler testified that the tailpipe of the police car may have leaked carbon monoxide into Floyd’s face and contributed to his death. When asked about the manner of death, Fowler chose “undetermined.” Nonetheless, Chauvin was convicted of murder and manslaughter and sentenced to over two decades in prison.

In 2005, Dr. David Fowler discussed a need for a new facility for forensic medicine.  ELIZABETH MALBY/BALTIMORE SUN STAFF

Days after Fowler appeared in court, the Maryland Attorney General’s Office received a letter from the former medical examiner of Washington, D.C., Roger A. Mitchell, signed by 431 doctors from around the country. They said Fowler’s testimony and conclusions were so far outside the bounds of accepted forensic practice that all of his previous work could come into question.

Maryland Attorney General Brian Frosh announced an independent investigation soon thereafter and began working with Gov. Larry Hogan’s office to coordinate the review. The move brought relief to a small group of Maryland families whose prior campaigns to challenge the state’s in-custody death findings had largely fallen flat.

At the time, Fowler defended his office’s work, saying he wasn’t solely responsible for autopsy conclusions. And even amid the outcry over his testimony and swirling questions about racial bias in death investigations, some forensic pathologists agreed with the points he made in court.

Several years earlier, Fowler’s office classified Freddie Gray’s death a homicide, saying Baltimore police officers failed to follow proper safety procedures when they placed Gray in a van, where he suffered a severe spinal injury.

The announcement Wednesday marks the latest step in the ongoing effort to examine some of his work.

Frosh said a group of experts, which he called the Audit Design Team, assessed more than 1,300 in-custody deaths examined by state pathologists under Fowler, who served as chief medical examiner from 2002 to 2019. The team decided the audit should focus on about 100 of those cases — incidents involving physical restraint.


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According to the team’s plan, independent experts will review the roughly 100 cases to see if they agree with the prior determinations of cause and manner of death.

Reaching accurate conclusions in restraint cases is especially important because such deaths could be preventable, the team said in its report.

“If it is recognized that such deaths result from intentional actions of the police, then questions can be raised about whether those actions were truly necessary or whether other less dangerous police procedures might be adopted,” they wrote.

In addition to determining whether the investigations were thorough enough, the team said, auditors should interrogate whether there’s reason to believe any findings were “influenced by inappropriate factors.”

Reviewers will complete their own assessment of each case and then engage in group discussion, according to the plan. In choosing the reviewers, the team recommended forensic pathologists and medical examiners who had not signed the letter criticizing Fowler’s testimony — “to reduce any perception of partisanship.”

“We embarked on this process with the goal of overseeing a professional and independent audit that adheres to the highest standards of impartiality and integrity,” Frosh said in a statement Wednesday.


He said his office is now recruiting reviewers to perform the audit. Officials didn’t provide a timeline for completion.