Audit finds Maryland OCME undercounted homicides in many restraint-related deaths; task force, case reviews ordered

Attorney General Anthony Brown told the House Judiciary Committee that an independent audit found systemic problems in the Office of the Chief Medical Examiner’s (OCME) classification of deaths that occurred during or soon after restraint, and that state officials would move to review the cases and change policies.

The audit, conducted by an independent team and described in a 70-page report presented to the committee, reviewed more than 13,000 deaths during Dr. David Fowler’s tenure and selected 87 cases judged to resemble restraint-related deaths (sudden deaths during or soon after application of restraint). The review used 12 independently contracted forensic pathologists who examined each case blind and in panels of three; reviewers initially made determinations without autopsy photographs or OCME’s original findings and could later revise after photos were revealed.

The audit found substantial disagreement between OCME’s original manner-of-death classifications and the independent reviewers’ unanimous opinions. Dr. Jeff Kukuka, the audit’s case manager, told the committee that reviewers unanimously judged 48 of the 87 audited cases to be homicides while OCME had certified only 12 of the same 87 as homicides. "We hired 12 independent forensic pathologists to conduct blind reviews," Kukuka said. The auditors identified 36 cases in which all three reviewers agreed the death should have been classified as a homicide even though OCME had categorized them as undetermined, accidental or natural; five additional cases showed two-thirds reviewer agreement that OCME’s classification was incorrect, producing 41 cases the report describes as evidence of systemic misclassification.

The audit also identified…