Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody (2025)
Chapter: Front Matter
Consensus Study Report
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: National Academies Press. https://doi.org/10.17226/29232.
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COMMITTEE ON ADVANCING THE FIELD OF FORENSIC PATHOLOGY: LESSONS LEARNED FROM DEATH-IN-CUSTODY INVESTIGATIONS
RAYMOND J. LOHIER JR. (Co-Chair), Judge, U.S. Court of Appeals for the Second Circuit
JOHN A. RICH (NAM) (Co-Chair), Director, Rush BMO Institute for Health Equity
PAUL S. APPELBAUM (NAM), Elizabeth K. Dollard Professor of Psychiatry, Medicine & Law, Columbia University
EDWARD K. CHENG, Hess Chair in Law, Vanderbilt University School of Law
DABNEY FRIEDRICH, Judge, U.S. District Court for the District of Columbia
MIRIAM S. GOHARA, Clinical Professor of Law, Yale Law School
MARK L. GRABER, Founder and President Emeritus, Society to Improve Diagnosis in Medicine
JONATHAN LUCAS, Chief Medical Examiner, San Diego County Department of the Medical Examiner
ROGER MITCHELL JR., President, National Medical Association
JOSIAH “JODY” RICH (NAM), Professor of Medicine and Epidemiology, Brown University
L. SONG RICHARDSON, Chancellor’s Professor of Law, University of California, Irvine
JULIE ROBINSON, Senior Judge, U.S. District Court for the District of Kansas
NANCY RODRIGUEZ, Director, Latino Research Institute, The University of Texas at Austin
MICHAEL ROSENBLUM, Professor of Biostatistics, Johns Hopkins Bloomberg School of Public Health
MARC F. STERN, Affiliate Assistant Professor, University of Washington School of Public Health
PETER STOUT, Chief Executive Officer and President, Houston Forensic Science Center
National Academies Staff
ANNE-MARIE MAZZA, Project Director and Senior Director, Committee on Science, Technology, and Law, National Academies of Sciences, Engineering, and Medicine
STEVEN KENDALL, Senior Program Officer, Committee on Science, Technology, and Law, National Academies of Sciences, Engineering, and Medicine
RENEE A. DALY, Senior Program Assistant, Committee on Science, Technology, and Law, National Academies of Sciences, Engineering, and Medicine (until April 2025)
STELLA FORS, Christine Mirzayan Science and Technology Policy Graduate Fellow (until May 2024)
Consultant Writer
YUDHIJIT BHATTACHARJEE (until February 2025)
COMMITTEE ON SCIENCE, TECHNOLOGY, AND LAW
MARTHA MINOW (Co-Chair), Professor of Law, Harvard Law School
HAROLD VARMUS (NAS/NAM) (Co-Chair), Lewis Thomas University Professor, Meyer Cancer Center, Weill Cornell Medicine
DAVID APATOFF, Senior Partner, Arnold & Porter
ERWIN CHEMERINSKY, Dean and Jesse H. Choper Distinguished Professor of Law, University of California, Berkeley School of Law
ELLEN WRIGHT CLAYTON (NAM), Professor of Law, Professor of Health Policy, Vanderbilt University Medical Center
JOHN S. COOKE, Director (retired), Federal Judicial Center
JENNIFER EBERHARDT (NAS), Professor of Psychology, Stanford University
KENNETH C. FRAZIER, Chairman, Health Assurance Initiatives, General Catalyst
CAROL GREIDER (NAS/NAM), Distinguished Professor of Molecular, Cell, and Developmental Biology, University of California, Santa Cruz
STEVE HYMAN (NAM), Harald McPike Professor of Stem Cell and Regenerative Biology, Core Institute Member and Director, The Broad Institute of MIT and Harvard
JON M. KLEINBERG (NAS/NAE), Tisch University Professor, Cornell University
BARBARA MCGAREY, Deputy General Counsel (retired), U.S. Department of Health and Human Services
ERNEST J. MONIZ, Cecil and Ida Green Professor of Physics and Engineering Systems, Post-Tenure, Massachusetts Institute of Technology
KIMANI PAUL-EMILE, Professor of Law, Fordham University Law School
K. SABEEL RAHMAN, Professor of Law, Cornell Law School
NATALIE RAM, Professor of Law, University of Maryland Francis King Carey School of Law
JULIE ROBINSON, Senior Judge, U.S. District Court for the District of Kansas
PATTI SARIS, Chief Judge, U.S. District Court for the District of Massachusetts
VICKI SATO, Chair, VIRbio
BARBARA SCHAAL (NAS), Mary-Dell Chilton Distinguished Professor, Washington University in St. Louis
JOSHUA SHARFSTEIN (NAM), Distinguished Professor of the Practice, Johns Hopkins Bloomberg School of Public Health
CLIFFORD TABIN (NAS), Leder Professor and Chair, Harvard Medical School
Staff
ANNE-MARIE MAZZA, Senior Director
STEVEN KENDALL, Senior Program Officer
RENEE A. DALY, Senior Program Assistant (until April 2025)
Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or
recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by THOMAS D. ALBRIGHT (NAS), Salk Institute for Biological Studies, and PHILIP J. COOK (NAM), Duke University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Acknowledgment of Presenters
The committee gratefully acknowledges the thoughtful contributions of the following individuals who made presentations before the committee:
Thomas D. Albright (NAS), Salk Institute for Biological Studies; Andrea Armstrong, Loyola University College of Law; Theodore “Ted” Brown, Arkansas State Crime Laboratory; Simon Cole, University of California, Irvine; Abby Collier, National Center for Fatality Review and Prevention; Maria Cuellar, University of Pennsylvania; Itiel E. Dror, University College London; Lucy Easthope, University of Bath; Harry Edwards, U.S. Court of Appeals for the District of Columbia Circuit; Cilina Evans, Shelby County Coroner’s Office; Keith A. Findley, University of Wisconsin–Madison Law School; Jeffrey Fiore, U.S. Government Accountability Office; Linda Franks, Fair Fight Initiative; Michelle Garcia, Bureau of Justice Assistance; Constantine Gatsonis, Brown University; James J. Gerace, Colonie Police Department; James R. Gill, Office of the Chief Medical Examiner of Connecticut; David J. Gorman, U.S. Attorney’s Office, District of Columbia; Jan Gorniak, World Peace Forensic Consulting, LLC; Michael E. Horowitz, U.S. Department of Justice, Office of the Inspector General; Josh Jackson, Arnold Ventures; Michelle Jorden, Medical Examiner’s Office, Santa Clara County, California, and National Association of Medical Examiners; Katherine H. Judson, Center for Integrity in Forensic Sciences; Terence Keel, University of California, Los Angeles; Corene Kendrick, American Civil Liberties Union; Kelly Keyes, International Association of Coroners & Medical Examiners; David Kintz Jr., Park County Coroner’s Office; Jeff Kukucka, Towson
University; Josh Leung-Gagné, Stanford University; Erin Linde, Physicians Laboratory Services, Inc.; Chris Magnus, Policing Project at NYU School of Law; Nicole Martin, Know Your Rights Camp Autopsy Initiative; Kedar Mate, Institute for Healthcare Improvement; Evan Matshes, NAAG Forensic PC; Peter Neufeld, Innocence Project; Cheryl Pilate, Morgan Pilate, LLC; J. Keith Pinckard, Medical Examiner’s Office, Travis County, Texas; Alexis Piquero, University of Miami; Adele Quigley-McBride, Simon Fraser University; Reade A. Quinton, Mayo Clinic and National Association of Medical Examiners; Jed Rakoff, U.S. District Court for the Southern District of New York; Altaf Saadi, Massachusetts General Hospital; Kevin Scott, Bureau of Justice Statistics; Bethany Smith, American Board of Medicolegal Death Investigators; Jennifer Sommers, Police Executive Research Forum; Seth Stoughton, University of South Carolina School of Law; Hayley L. Thompson, Skagit County Coroner’s Office; Alfredo E. Walker, University of Ottawa; Margaret Warner, Centers for Disease Control and Prevention; Victor Weedn, The George Washington University; Lachelle D. Weeks, Harvard Medical School; John Wetzel, Keystone Restituere Justice Center; Deland Weyrauch, Montana Medical Examiner’s Office; Zenita Wickham Hurley, Maryland Office of the Attorney General; Johnny Wu, Centurion Health; and Lucas Zarwell, National Institute of Justice.
Contents
2 The Medicolegal Death Investigation System in the United States
3 Data on Deaths and Deaths in Custody
4 Carceral Health and Deaths in Custody: Types, Causes, Manner, and Response
5 Forensic Pathology and Cause and Manner of Death: Challenges and Opportunities
6 Findings and Recommendations
Boxes, Figures, and Table
BOXES
1-1 The Role of Forensic Pathology in Public Health and Safety
1-3 What Is an “In-Custody” Death?
1-4 Who Are Medical Examiners, Coroners, and Medicolegal Death Investigators?
2-2 Death Investigation in Nebraska and Alabama: Case Studies
2-3 Medical Examiners in New York City
2-4 Identifying Trends in Causes of Death
2-5 The Importance of Scientifically Based Assessments of Cause and Manner of Death: George Floyd
3-1 Types of Carceral Facilities and Numbers Incarcerated
4-1 Private Health Care and Mortality in Carceral Facilities
4-2 Medical Neglect in Carceral Facilities
4-3 Responding to Medical Emergencies in Carceral Facilities
4-4 The Restraint of Individuals During Encounters with Law Enforcement and Corrections Officers
4-5 Colonie, New York: A Case Study of a Restraint Technique
D-1 Examples of DCRA Reportable and Nonreportable Death Scenarios
FIGURES
2-1 Type of medicolegal death investigation system, by county
3-1 U.S. Standard Certificate of Death (page 1)
3-3 Number of federal arrest-related deaths and deaths in custody, fiscal years (FY) 2016–2022
3-4 Cause of jail deaths in South Carolina, 2015–2021
5-1 Information that may inform determinations of cause and manner of death
5-2 How might bias affect medicolegal death investigations?
TABLE
Preface
In 2024, the National Academies of Sciences, Engineering, and Medicine convened a committee to assess the state of the medicolegal death investigation (MLDI) system in the United States through the important prism of deaths in custody in carceral facilities, as well as in police custody, and to recommend improvements to that system. It has been our privilege to co-chair that committee.
Our committee’s review consisted of analyzing relevant literature and data, external submissions, and presentations made by several experts and interested parties. In considering the testimony and evidence that was presented to the committee, what struck us most was the consistency of the message that we heard: The MLDI system lacks adequate resources, uniformity, enforceable standards, data, and incentives to produce consistent results regarding cause and manner of death. Although the MLDI system comprises many highly trained medical professionals, the shortage of board-certified forensic pathologists and the fragmented network of those who investigate deaths hinder the reliability of public health data and imperil the delivery of justice in civil and criminal proceedings. Further, manner of death conclusions in in-custody deaths, even in well-intentioned hands, can be misleading and misinterpreted by the users of that information, such as carceral facility administrators, oversight bodies, and legislatures.
To be blunt, the MLDI system in our nation is in dire need of a comprehensive upgrade. The significant variation in death investigation systems and inadequacies in data collection involving deaths have served only to impede the development of standardized best practices in death
investigations and in the performance of medicolegal autopsies. In our report, the committee identifies significant opportunities to improve these systems. It also offers recommendations on how to improve and maintain consistency and reduce bias in making cause- and manner-of-death determinations generally and for deaths in custody in particular. In addition, the committee examines the need for national uniform standards and improved data collection relating to deaths in custody for the public health and justice systems. For example, the lack of accurate and complete data relating to cause and manner of death severely degrades the ability of public health officials to monitor and improve public health and our legal system to hold accountable those responsible for unnatural deaths. Meanwhile, the absence of agreed-upon national standards of practice has complicated efforts to make jurisdictions accountable for reporting accurate data and thoroughly and independently investigating and auditing deaths in custody. In the end, we feel confident that the committee’s recommendations, if adopted, will enhance understanding of the conditions that cause deaths in custody and improve the MLDI system for everyone’s benefit.
Improving the quality and reach of the MLDI system can provide data that are critical to preventing deaths in custody. Tragic recent examples of deaths in custody have undermined public confidence in the MLDI system in general. And it appears that a significant percentage of deaths related to police violence have either been unreported or misclassified, severely hindering efforts to prevent such tragic deaths (GBD 2019 Police Violence US Subnational Collaborators, 2021). In addition, the attribution of deaths in custody in some jurisdictions to causes that have been medically discredited persists. Although the committee’s charge did not require an exhaustive examination of health conditions and health care in carceral settings, the committee’s work suggests that future studies and actions in this area are crucial. Nevertheless, the carceral system is, by default, the largest provider of behavioral health care in the nation; we were struck by the fact that resources for suicide prevention and treatment for substance use disorders are sorely lacking.
Our committee’s assignment required serious thought and listening. The MLDI system is complex and extremely decentralized, with various actors, jurisdictions, demands, and limitations based on geography, budget, and expertise. Throughout our discussions, the committee heard testimony from the stakeholder community, including coroners, medical examiners, and others who investigate deaths; we carefully considered their concerns. We also learned from professionals who manage forensic laboratories and medical examiner or coroner offices here and abroad, teachers who are devoted to training the next generation of forensic pathologists, scholars who have conducted important research in a number of fields that bear on
MLDI issues, and members of the legal profession and law enforcement agencies who are involved in the MLDI system.
Most importantly, we heard testimony from families whose loved ones died within days of an arrest or in lockups, jails, and prisons, where the circumstances of their loved one’s death remained a mystery. The cause and manner of death of those in custody should not be shrouded in secrecy, nor should they remain undetermined due to inadequate investigation. Despite a societal view that too often devalues the lives of those in custody, the committee was reminded time and time again that these are sons, daughters, fathers, mothers, grandfathers, and grandmothers of families in our communities.1 The Eighth and Fourteenth amendments to the Constitution ban cruel and unusual punishment, including deliberate indifference to the serious physical and mental health needs of people in carceral facilities. Injustice festers when an individual’s basic rights can be disregarded with little accountability and when the cause or manner of death is shrouded in secrecy or ambiguity or otherwise remains undetermined. Too many deaths in custody can be prevented. The MLDI system should function to provide timely, accurate, and unbiased information that can be used to help us prevent such deaths, whenever possible, and to serve as an objective voice for those who die in custody. Strengthening the system is even more urgent today, as detention centers proliferate in this country with a tremendous potential for disease, abuse, and enduring psychological trauma.
We are deeply grateful to all of the presenters and experts who spoke to the committee and submitted papers. We are also grateful to Arnold Ventures, The Just Trust for Education, and Universal Music Group for their support of this study.
We are particularly indebted to the members of the committee, which was composed of many talented professionals—some experts in areas of forensic science and medicine, others in law, and still others in a range of scientific fields including social science. They listened, read, questioned, and brilliantly discussed the findings and recommendations offered in this report, and then worked hard to help complete the research, writing, and editing required to produce it. These individuals devoted untold hours to the review of materials, meetings, conference calls, analyses, and report writing. This report is very much the result of the enormous contributions of an engaged community of scholars and practitioners who reached their findings and recommendations after thoughtful discussions and deliberations.
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1 Research suggests that many Americans feel the prison system is ineffective and needs reform, but it is challenging to find comprehensive data on attitudes about incarcerated individuals. Some literature suggests that a set of mental models predicts public stigma about people with prison records (see, e.g., Shi, Silver, and Hickert, 2022).
We are also grateful to the staff, especially Anne-Marie Mazza and Steven Kendall, for their superb work and dedication to this project; staff member Renee Daly, for her assistance; consultant writer Yudhijit Bhattacharjee, for early report drafts; and Allison Boman, Danielle Nasenbeny, and Rebecca Morgan, for their contributions in checking source materials and assisting with the final production of the report.
Raymond J. Lohier Jr., Co-Chair
John A. Rich, Co-Chair
Committee on Advancing the Field of Forensic Pathology:
Lessons Learned from Death-in-Custody Investigations
October 2025
