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¹ A medical examiner is a forensic pathologist (a medical doctor with subspecialty training) who has particular expertise in investigating violent, sudden, unexpected, suspicious, or unattended deaths. A coroner is a public official elected or appointed to determine cause of death in cases of violent, sudden, unexpected, suspicious, or unattended deaths. The roles of these individuals are discussed in detail in Chapters 1 and 2.

are investigated and establishes professional and continuing education requirements for individuals who conduct death investigations (CDC, 2024).

The MLDI system conducts death investigations and certifies the cause and manner of unnatural, untimely, or unexplained deaths.² It is a producer of data that play a critical role in justice and public health and a consumer of data that are generated by those systems. For example, the public health system relies upon the MLDI system to assist in the tracking of drug overdoses and to chronicle the emergence of infectious disease outbreaks. The MLDI system may also provide data that allow public health systems to monitor changes in prevalence and incidence of deaths from chronic diseases (National Center for Health Statistics, 2023). In the criminal justice system, the findings of the MLDI system may justify and support charging decisions and convictions, prevent convictions of innocent individuals, exonerate the wrongfully accused or convicted, or help reach conclusions about the causes of deaths in custody.

The MLDI system in this nation must be substantially improved. Recent high-profile deaths in custody have drawn widespread attention to the determinations of cause and manner of death made by forensic pathologists, medical examiners, and coroners. These high-profile cases have raised questions about the scientific validity of such determinations. In some cases, deaths certified as accidental or natural by one pathologist have been certified as homicides³ by others who, upon reexamination, have identified what they believe to be mistakes, omissions, or questionable conclusions (Christopher, 2024; Shapiro and Keel, 2024). In other cases, cause of death has been attributed to conditions such as sickle cell trait (which may play a role in a death but has not been shown to be causal) or excited delirium, which the medical community now concludes is not a valid medical diagnosis. In some situations, forensic pathologists, medical examiners, and coroners have certified a cause of death without acknowledging or determining the underlying etiology, which may range from natural disease to drug toxicity to restraint methods used by law enforcement or corrections officers.

Incomplete or inaccurate data on the cause and circumstances of a death hinder both the ability of public health officials to generate findings that improve population health and the ability of the legal system to hold accountable those responsible for unnatural deaths. Unfortunately,

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² The MLDI system is discussed in detail in Chapter 2.

³ Homicide is defined as a death resulting from the volitional actions of another person. For the purposes of death certification, homicide is viewed by the medical examiner community as a neutral term that does not indicate or imply criminal intent. Determinations of intent are understood as a legal rather than a public health function (see Chapter 5). Note, however, that the Centers for Disease Control and Prevention defines homicide as “a death resulting from the intentional use of force or power, threatened or actual, against another person, group, or community” (emphasis added; CDC, 2022, p. 9).

information about death-in-custody cases is incomplete or inaccurate, and this lack of accurate data precludes a comprehensive picture of the landscape of deaths in custody. This, in turn, compromises the nation’s ability to address systemic issues that may increase the risk of death in custody. In contrast, a clear picture would help the nation reduce the incidence of such deaths, improve public health and the practice of forensic medicine, and serve the interests of justice.

When called upon as expert witnesses in court proceedings, those who have made determinations of cause and manner of death are tasked with explaining their findings and conclusions, which often rely on complex medical and scientific information, to a lay audience of judges and juries. Because their testimony can significantly influence determinations of guilt or innocence, it can come under intense scrutiny.

Given ongoing concerns about the MLDI system and its role in identifying, investigating, and reporting in-custody deaths and the importance of complete and accurate determinations of cause and manner of death to justice and public health broadly, a committee was convened under the auspices of the Committee on Science, Technology, and Law of the National Academies of Sciences, Engineering, and Medicine to conduct the study “Advancing the Field of Forensic Pathology: Lessons Learned from Death-in-Custody Cases.” Committee members had expertise in anatomic and forensic pathology, forensic psychiatry, infectious disease and addiction, primary care, correctional medicine, diagnostic error, crime laboratories, biostatistics, cognitive bias, incarceration, racial inequities, forensic and statistical evidence, law, and civil and criminal litigation. Biographies of committee members are provided in Appendix A.

The study was funded by Arnold Ventures, The Just Trust for Education, and Universal Music Group.

CHARGE TO THE COMMITTEE

The committee was charged with conducting a study on the handling of deaths in custody by the MLDI system in the United States and medical death investigations more generally. The committee was asked to consider

1. the number of deaths while in custody throughout the criminal justice process and how those deaths are investigated, diagnosed, recorded, reported, and made transparent;
2. the distribution of diagnoses for deaths that occur in custody (cause and manner of death) and the scientific bases for attributing such diagnoses to those deaths;
3. measures (and limitations thereof) that forensic pathologists should follow to conduct independent assessments of cause of death generally and in particular for deaths in custody;

4. the proper range of attributions for cause and manner of death that should be made in a medicolegal death investigation and the scientific bases and associated evidence needed to justify a diagnosis related to any death in general and, in particular, to deaths in custody;
5. mitigation strategies to be used to protect forensic pathologists from factors that may bias their diagnosis;
6. an assessment of the dual role played by the MLDI system as fact finders of manner of death for public health as opposed to for the criminal justice system; and
7. quality standards and regulations needed for improvement.

To communicate its findings and recommendations, the committee was asked to produce a consensus report that would advance the field of forensic pathology.

While issues associated with the high rate of incarceration in the United States, health care for vulnerable populations, practices and procedures of law enforcement and emergency responders, and racial justice are relevant to deaths in custody and merit careful consideration, the committee maintained its focus on the role of the medical examiner and coroner system in determinations of cause and manner of death particularly in in-custody situations.⁴

FINDINGS AND RECOMMENDATIONS

The importance of a strong MLDI system cannot be overstated, as it serves both justice and public health. A strong MLDI system can reveal, for example, that certain policing practices might lead to a death in custody, that certain carceral facilities have inadequate monitoring to prevent resident-on-resident violence or suicides, or that certain carceral facilities have inadequate health care practices. In addition, a strong system can identify instances where law enforcement or correctional officers have been unjustly accused. From a broader public health perspective, if those in custody die from highly infectious diseases, this information can be critical for local authorities trying to track the spread of disease. Further, accurate and comprehensive data about deaths in custody may also provide useful information for the development and implementation of carceral standards.

However, as this report demonstrates, the MLDI system in the United States faces significant challenges. A lack of uniformity creates inadequacies and inconsistencies. Further, demand for forensic pathologists significantly exceeds supply nationwide, and this shortage has significantly impeded

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⁴ For the committee’s definition of death in custody, see Box 1-3 in Chapter 1.

medicolegal death investigations. Medical examiners and coroners often face major obstacles, such as outdated facilities and lack of trained personnel. Many facilities are not accredited, and many practitioners are not board certified. The current state of the system undermines the credibility of death investigations and limits opportunities for its practitioners to connect with the broader medical and public health communities. Without adequate resources and standards, MLDI professionals struggle to provide the accurate information needed to protect communities and ensure justice.

Medical examiners and coroners face pressure from the public, law enforcement, the media, and others when making determinations of cause and manner of death. Incorrect or biased conclusions undermine confidence in medical systems, can misdirect public health outcomes, and may result in a lack of accountability or culpability. A coordinated effort to enhance the MLDI system is necessary to ensure that all deaths are appropriately identified and properly investigated so that the data collected can improve the nation’s understanding of deaths in custody and ultimately improve outcomes, thereby serving both justice and public health.

The committee’s findings and recommendations build on those offered in Chapter 9 of the 2009 National Research Council report Strengthening Forensic Science in the United States: A Path Forward (NRC, 2009). That chapter focused on the role of the medical examiner and coroner in the context of the broader forensic science system. It found, as has this committee, that across the country, medical examiners and coroners are often functioning under great duress. These individuals may lack facilities and equipment (routinely relying, e.g., on personal phones and fax machines to fulfill reporting requirements), may need to delegate postmortem examinations to others (due, in many cases, to the lack of an adequate supply of forensic pathologists), or operate with insufficient staff support or in unaccredited facilities with physicians who may lack board certification in forensic pathology or medicolegal death investigators who do not have appropriate certification (as resources for staffing and to support accreditation and certification are often unavailable). As was documented in the 2009 report, “most systems are under budgeted and understaffed” (NRC, 2009, p. 264). That report called upon Congress to appropriate and authorize funds “for allocation to states and jurisdictions to establish medical examiner systems, with the goal of replacing and eventually eliminating existing coroner systems” (NRC, 2009, p. 267).

While progress has been made since the release of the 2009 report, the committee found that the U.S. MLDI system remains fragmented; continues to lack sufficient resources and forensic pathologists; suffers from a lack of accredited facilities and certified professionals; has inadequate support for research that would strengthen the system, especially with regard to emerging knowledge of factors contributing to death; and is weakly linked to the

broader medical and public health communities. Nonetheless, progress has been made as a result of efforts by the National Association of Medical Examiners, the International Association of Coroners & Medical Examiners, the Bureau of Justice Assistance (BJA) and Bureau of Justice Statistics (BJS) of the U.S. Department of Justice, the Centers for Disease Control and Prevention, and the National Institute of Standards and Technology. These efforts need to be recognized, and the federal and state governments need to renew their commitment to the creation of a modern system that meets the needs of justice and public health.

As this report demonstrates, robust medicolegal death investigations require full and accurate information, resources to process that information, determinations that are based on sound scientific and medical knowledge, a culture that mitigates cognitive bias and external influence, and testimony that provides an accurate accounting of cause and—where deemed admissible—manner of death.

The committee offers steps to continue to strengthen the current MLDI system and ensure that both coroner and medical examiner systems are more squarely embedded in the broader medical system. Strengthening coroner and medical examiner systems will ultimately create a stronger, more modern, highly trained system of professionals able to address both the justice and public health needs of the nation.

While the committee’s recommendations are primarily addressed to Congress and the federal government, state and local governments have an essential role to play in advancing and ensuring the quality of forensic pathology practices in their jurisdictions. States and localities can provide useful information to one another in the form of pilot programs, innovative approaches, and cooperative training. Nevertheless, given the degree of unevenness in the current MLDI system, the committee believes that significant federal attention will be required to develop a robust MLDI system in the United States. Although this report does not call for a centralized national system, it does call for a well-resourced system wherein determinations of the cause and manner of a specific death in custody in one jurisdiction would be governed by the same standards as in another jurisdiction. By allocating funds for infrastructure improvements; mandating accreditation and certification; and increasing coordination among federal, state, and local systems, the nation can build a more robust MLDI system that benefits society as a whole.

After careful consideration of relevant literature and expert input and analysis and discussion, the committee offers the following findings and recommendations.

exoneration cases or case reports from audits); education about how forensic pathologists may become involved in legal proceedings and how their work may be used in legal proceedings; and education on the health risks of incarceration.

RECOMMENDATION 3: As a supplement to traditional forensic pathology training programs, Congress should allocate funds to the National Institutes of Health to establish a 1-year forensic pathology fellowship, in partnership with the Office of Justice Programs and the National Institute of Standards and Technology, where fellows conduct original forensic pathology research.

RECOMMENDATION 4: To maintain the quality of forensic pathology services, all medical examiner and coroner offices should arrange for rigorous, meaningful peer review of no less than 10 percent of cases at least annually. This review should include special case types, such as infant fatality cases, maternal fatality cases, death-in-custody cases, homicide cases, and cases where manner of death was listed as undetermined. Criteria for quality review should be based on standards established by relevant professional organizations, including the National Institutes of Health, the Centers for Disease Control and Prevention, the National Institute of Standards and Technology, and the U.S. Department of Justice.

RECOMMENDATION 5: States should require licensure of all medicolegal death investigators. Licensure should be granted by an appropriate regulatory body, such as a state department of health or licensing board. As a condition of licensure, licensees should meet prescribed training and educational requirements and pass a nationally recognized certification examination (e.g., the exam administered by the American Board of Medicolegal Death Investigators). To maintain their license, licensees should meet continuing education requirements. Reciprocity provisions should be developed to recognize licenses from other states.

RECOMMENDATION 6: State or local public health departments should conduct mortality reviews of deaths in custody. These reviews should be conducted by multidisciplinary review committees operating under state or local jurisdiction. A report summarizing the findings of the reviews should be submitted to state attorneys general offices and state health departments at least annually to indicate the prevalence of particular types of deaths. As merited by the findings of the summary reports, state attorneys general offices should conduct routine

multidisciplinary audits to ensure accuracy and reproducibility in manner-of-death determinations for deaths in custody.⁵

RECOMMENDATION 7: Congress should allocate funds to the U.S. Department of Justice and the National Institutes of Health to establish opportunities for cross-disciplinary research and collaborations that will foster the development of enforceable standards for the practice of forensic pathology and the investigation of deaths in custody. Relevant professional organizations such as the National Association of Medical Examiners, the International Association of Coroners & Medical Examiners, and the College of American Pathologists should be encouraged to collaborate with this federal effort so that the standards are well understood, practical, and endorsed by their memberships.

RECOMMENDATION 8: Congress should allocate funding to the National Institute of Justice (NIJ) to support research on methods to reduce deaths in custody. NIJ should consult with the U.S. Department of Health and Human Services (HHS) (National Institutes of Health [NIH] and Centers for Disease Control and Prevention [CDC]) and the National Institute of Standards and Technology to identify priority research in this space. As new approaches are developed, the U.S. Department of Justice should provide enhanced training programs for law enforcement and corrections officers to make them aware of these approaches. Further, standards should be incorporated into training materials that require law enforcement and corrections officers to follow proven evidence-based practices to reduce deaths in custody. Congress should also allocate funding to HHS (NIH, CDC) to support research to quantify the accuracy of cause- and manner-of-death determinations.

RECOMMENDATION 9: Congress should direct the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention, in consultation with the National Association of Medical Examiners (NAME), the International Association of Coroners & Medical Examiners (IACME), the American Medical Association, and the National Medical Association, to develop consensus definitions for the five common manner-of-death categories (homicide, suicide, accident, natural, and undetermined) that are specific and objective. The consensus definitions should be adopted and used consistently throughout

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⁵ After the report was released, one recommendation directed toward improving the MLDI system (originally Recommendation 19, now Recommendation 6) was moved to align with the sections that address this topic in the Summary and Chapter 6. The subsequent recommendations have been renumbered as a result of this change.

the medicolegal death investigation and public health systems. In addition, to improve the accuracy of (and reduce bias in) manner-of-death determinations, Congress should direct NCHS, in consultation with NAME and IACME, to develop unified, national methodological and documentation standards.

RECOMMENDATION 10: Congress should direct the U.S. Department of Health and Human Services (National Institutes of Health, Centers for Disease Control and Prevention), in consultation with the National Institute of Justice and the National Institute of Standards and Technology, to convene a panel to define the characteristics of a death in custody that should require an autopsy. When considering reasons for autopsy, barriers to care and interruption of treatment should be taken into account.

Data Collection on Deaths in Custody

The Death in Custody Reporting Act of 2013 (DCRA) transferred responsibility for collecting data on deaths in custody from BJS to BJA. This has resulted in decreased reporting of in-custody deaths and adversely affected our nation’s ability to understand the scope and causes of deaths in custody. As a statistical agency, BJS was better positioned to collect and collate data and had in place the relationships and infrastructure necessary to collect death-in-custody data across jurisdictions.

In addition, current incentives or sanctions to motivate accurate, complete, and timely reporting of deaths occurring in local, state, or federal custody are inadequate. Autopsies are not performed for all in-custody deaths.

In-custody deaths are generally understood as occurring at any point from the time of a first encounter with law enforcement through pretrial processing and incarceration, to the point of release from prison, jail, or other detention. However, a death may also occur in a hospital in a community after release from custody, where the condition leading to hospitalization began or was exacerbated during incarceration—such deaths are not classified as “deaths in custody” by DCRA. In-custody deaths result from a range of natural and unnatural causes including disease, suicide, drug overdose, conditions at detention facilities, medical neglect and incompetence, accident, excessive force, and homicide. Many of these deaths are preventable.

Emerging research indicates that there are new approaches that can be followed by law enforcement and corrections officers to prevent deaths from the use of restraints or suicide.

complete information, which may include medical records, test results, law enforcement and carceral staff interviews, and postmortem examinations. In the absence of information from an autopsy, the accuracy of cause- and manner-of-death determinations for some in-custody deaths may be suspect.

What is more, there are no consistent and agreed-upon criteria for making manner-of-death determinations. For example, in some jurisdictions all vehicle-related collision deaths are considered homicides, whereas in other jurisdictions some vehicle-related collision deaths may be considered accidents.

Key Finding: A range of factors (e.g., the condition of the body, whether there is an individual who can attest to the circumstances of a death) affects the reliability and degree of certainty of determinations about cause and manner of death. While in some cases there is little doubt about cause and manner of death (e.g., a stab wound to the chest inflicted by another person that was witnessed by multiple people and captured on a surveillance camera), in other cases determinations about cause and manner of death may be much less reliable and certain (e.g., with a body found years after death).

RECOMMENDATION 16: In legal proceedings, a forensic pathologist should testify only to medical and scientific findings and information collected as part of a medicolegal death investigation. Testimony should be constrained by the principles enumerated in Federal Rules of Evidence 702 and 703.

RECOMMENDATION 17: In legal proceedings, it is likely that the five common manner-of-death categories (homicide, suicide, accident, natural, and undetermined) will be more confusing than helpful to the fact finder because the terms have different meanings in legal and public health contexts. In the medicolegal death investigation system, the designation of homicide as a manner of death is a medical, not legal, determination and should not be interpreted to mean that a person did or did not commit a crime. Further, as the accuracy of these determinations is currently unknown, their probative value is questionable. Consequently, the courts should seriously consider whether to exclude statements on manner of death.

RECOMMENDATION 18: Any testimony related to cause and manner of death should be subject to rigorous judicial gatekeeping standards. Judges should, for example, assess