for forensic pathology and the medicolegal death investigation (MLDI) system.¹

As a first step in all death investigations where an autopsy is performed, a body must be transported to an autopsy facility. In the Weyrauch case, the local coroner transported the body from the location of the death in northeast Montana to the Montana Medical Examiner’s Office in Billings in south central Montana, a 4.5-hour drive.

Weyrauch collected preautopsy information from law enforcement and preincarceration medical records. This material revealed that after an emergency room visit, the decedent had been in a tribal prison for 2.5 days for aggravated disorderly conduct, had a history of schizophrenia and methamphetamine use, and was reportedly in his normal state of health 20 minutes before he was found unresponsive.

The decedent had visited the emergency department because of a suspected overdose of psychiatric medications. There, he was treated per poison control recommendations and showed no clinical, diagnostic testing, or laboratory findings concerning serious intoxication or physiological derangement. He was subsequently discharged to law enforcement and died in prison.

Weyrauch proceeded with an autopsy. In his initial physical examination of the body, Weyrauch found no obvious signs of traumatic injury, struggle, or self-harm. Photographs were taken to document all visible injuries, which included scrapes and healing bruises.

Procedures were used to dissect every neck muscle individually to look for subtle bleeds and signs of neck compression. The examination yielded no indications (such as petechial hemorrhages) that would support a finding of traumatic asphyxia (such as neck or chest compression or airway obstruction resulting in a deficient supply of oxygen to the body). Having found no indications of obvious disease or injury, Weyrauch proceeded to conduct a microscopic tissue examination, which revealed myoglobin casts in the kidneys. Recognizing that rhabdomyolysis (a condition where muscle tissue breaks down and releases myoglobin, potassium, and other intracellular contents into the bloodstream) is the only way to get such

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¹ In correspondence to the committee dated May 16, 2025, Weyrauch suggested that this type of case is quite rare (delayed toxicity death related to rhabdomyolysis that also happens to occur in custody). He noted that, in general, “1) in-custody deaths generally involve more time-intensive investigation because they are higher profile/higher scrutiny, carry a burden to rule out many diseases/injuries, may have complex circumstances, and generally have more documentation to review such as prison video, body cam footage, custodial facility records, etc. and 2) we frequently investigate deaths that are equally as complex as the one I presented, but are very different in the details,” estimating that “somewhere around 1/20 to 1/30 medical examiner cases require a similar degree of time/effort/resources.”

casts, Weyrauch sent a tissue sample for laboratory testing to confirm the diagnosis. The test was positive, and Weyrauch proceeded to consult clinical resources to clarify whether rhabdomyolysis could stop a person’s heart in the absence of outward symptoms. His research found that symptoms of rhabdomyolysis “may be vague or absent in up to 50 percent of patients”; with this condition, the muscles spill potassium into the blood and, with extensive muscle damage, can trigger cardiac arrest by arrythmia.²

Weyrauch now had what he believed to be a plausible diagnosis for mechanism of death. However, as the underlying causes (etiologies) of rhabdomyolysis are numerous (see Table 5-1), cause and manner of death remained to be determined. Haloperidol and atypical antipsychotics as a drug class have specifically been implicated and associated with the condition, and in medical records from the emergency department, “per family report,” the decedent’s refill of psychiatric medications “included over 80 tablets of haloperidol and over 60 of a drug called olanzapine, which is an atypical antipsychotic.” Postmortem toxicology results indicated that these two drugs were the only active drugs in the decedent’s system; methamphetamine was detected in a urine sample, but was not present in the blood, suggesting methamphetamine had been used while he was in the community but had been completely metabolized out of the blood during his time in prison. The decedent had not been administered any medication while in prison in the days leading up to death, indicating the postmortem haloperidol and olanzapine levels were attributable to ingestion prior to incarceration.

Physical restraint may lead to rhabdomyolysis; given the decedent’s history of psychiatric illness and Weyrauch’s knowledge of deaths in custody, he thought it advisable to investigate whether the decedent had been physically restrained. He “reviewed reports, made phone calls, [and] crucially obtained all the video the prison had showing the decedent, from intake to [prison staff] ushering him into his cell.” Staff “did put him in [a] wheelable restraint chair,” but, Weyrauch wondered, “did being in this restraint chair contribute to the death?” Was “there struggle, fighting against the restraints, muscle exertion, [or] an actual mechanism for how this would have led to the rhabdomyolysis?”

According to Weyrauch, video showed the decedent throughout his arraignment in prison sitting calmly in a restraint chair,

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² Rhabdomyolysis typically results from severe muscle damage, and evidence of extensive muscle damage was absent in this case. The medications prescribed to the decedent can cause sedation, and in suicidal ingestions, asphyxia from drug-induced torpor or coma could also cause death.

are considered, beginning with components most evident in the case Weyrauch presented.

Access to Forensic Pathologists and Autopsy Services

As noted in Chapter 2, the shortage of board-certified forensic pathologists in the United States places limits on the ability of the MLDI system to perform investigations into cause and manner of death in every instance. The dearth of forensic pathologists means that, particularly in cases where a death occurs in a remote area (as was the case in the Weyrauch example), time, cost, and resources for transporting a body to a medical examiner or forensic pathologist’s office may determine which cases receive an autopsy.⁴ In Montana, a state of 1.13 million people,⁵ the Montana Medical Examiner’s Office, which provides autopsy services and death investigation resources for county coroners, law enforcement agencies, and county

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⁴ Presentation to the committee, Deland Weyrauch, Deputy Medical Examiner, Montana Medical Examiner’s Office, February 4, 2025.

⁵ 1,137,233 as of July 1, 2024 (U.S. Census Bureau, 2024b).

attorneys, has only two locations: the Montana State Crime Lab in Missoula and the Eastern Forensic Science Division in Billings. Similarly, Nebraska, which has just over 2 million residents, is served by the Douglas County morgue in Omaha, the state’s only public autopsy facility.⁶ For Washington state, geography complicates autopsy services for eastern counties, as all contracted forensic pathologists reside west of the Cascade Mountains.⁷ According to Hayley L. Thompson, coroner for Skagit County, Washington, “Currently, only one pathologist is willing to drive to the eastern side” of the state, and “this has resulted in coroner offices having to forgo an autopsy (because there’s no pathologist available) or wait several days for an autopsy to be done.”⁸

Collecting Information That Informs Determinations of Cause and Manner of Death

From preinvestigations conducted in advance of an autopsy through certification of cause and manner of death, a range of information from multiple sources is needed to ensure that determinations of cause and manner of death are correct. As the Weyrauch case illustrates, such information can be circumstantial (e.g., information from scene investigation, interviews, police reports, video, medical records) or obtained directly from the decedent’s body postmortem (e.g., external or internal examination of the body, analysis of laboratory test results) (see Figure 5-1). Inaccurate determinations can result from incomplete or incorrect information (e.g., due to a lack of access to information), poor communication (e.g., between medical examiners and coroners and investigative agencies, law enforcement officials, corrections officials, medicolegal death investigators, health care providers, and social service personnel), or implicit or explicit bias. Information collection may also be constrained by financial⁹ and other limitations.¹⁰ As in any practice of medicine, even if all of the information concerning a case is complete and correct, biased reasoning can lead to an inaccurate determination. These limitations mirror and are emblematic of errors and inaccuracies in other medical specialties (e.g., internal medicine),

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⁶ An office performing autopsies in the central part of the state closed in 2022 and an office performing autopsies in the western part of the state closed in 2024 (presentation to the committee, Erin Linde, Forensic Pathologist, Omaha, Nebraska, February 4, 2025).

⁷ Contract forensic pathologists serve the coroner offices in eastern Washington, other than those serviced by the Spokane County medical examiner.

⁸ Presentation to the committee, Hayley L. Thompson, Skagit County Coroner, Mount Vernon, Washington, September 19, 2024.

⁹ Certain investigative techniques (e.g., genetic testing, genetic genealogy) are too expensive for many offices.

¹⁰ These might include time constraints, inadequate facilities, and lack of access to (or unfamiliarity with) relevant medical literature.

reflecting the reality that forensic pathology is the practice of medicine and not a strict forensic science (Graber, Franklin, and Gordon, 2005).

Medicolegal death investigators are a critical source of information for forensic pathologists, as they often rely on the information gathered by medicolegal death investigators to interpret the physical findings from the examination of the decedent’s body. Medicolegal death investigators are also important because they are usually the first to examine death scenes.¹¹ Their information-gathering assists medical examiners and coroners by providing not only documentation of the scene of a death but also the decedent’s medical history, statements from witnesses and family members, and photographs of the body. Beyond initial scene investigation, medicolegal death investigators establish the decedent’s identity, identify and notify next of kin, manage the proper handling of the body before autopsy, assist in maintaining the chain of custody for evidence, and work to ensure that all documentation is thorough and accurate. The absence of an investigation by a medicolegal death investigator may make it more difficult to determine cause and manner of death, disadvantage those conducting autopsies and conducting prosecutions, and hinder prevention efforts.¹²

The National Institute of Justice publication Death Investigation: A Guide for the Scene Investigator describes medicolegal death investigators as the foundation of a medicolegal death investigation (NIJ, 2024a). The guide emphasizes the importance of their role in documenting relevant information about deaths, including at minimum the reporting agency’s information; the reporting individual’s name and call-back number; the associated law enforcement case number and/or hospital record number; the decedent’s demographics, including name, date of birth, age, race, ethnicity, and biological sex; details about suspected cause and manner of death; summary of terminal events and reported medical history; and apparent scene safety or security concerns (NIJ, 2024a, p. 2). The guide also emphasizes the importance of medicolegal death investigators in facilitating collaboration and ensuring timely notification of other parties (e.g., next of kin, law enforcement, district attorneys/prosecutors, public health officials, crime lab personnel, forensic pathologists, anthropologists, body transport services, funeral homes, emergency management, organ and tissue procurement agencies) to facilitate a coordinated response to a death (NIJ, 2024a, p. 8).

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¹¹ Examination of incident scenes may also yield critical information (e.g., in cases where an individual experienced a health emergency and was transported to a medical facility, it may be important to examine the scene where the health emergency occurred).

¹² Presentation to the committee, Jan Gorniak, Forensic Pathologist, World Peace Forensic Consulting, LLC, February 4, 2025. As an example, Gorniak cited the role of a failed jack in a death to illustrate how investigations contribute to prevention efforts by reporting faulty products to the Consumer Product Safety Commission. For a discussion of how medicolegal death investigations benefit public health and safety, see Chapter 2.

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¹³ Presentation to the committee, Jan Gorniak, Forensic Pathologist, World Peace Forensic Consulting, LLC, February 4, 2025.

¹⁴ Gorniak, 2025.

¹⁵ For-profit private facilities or health care providers often have policies and procedure in place that limit the exchange of information with other parties (presentation to the committee, Johnny Wu, Executive Vice President and Chief Clinical Officer, Centurion Health, February 4, 2025).

¹⁶ In her presentation to the committee, Gorniak described some of the information that should be collected in cases of suicide deaths in custody, including housing status (e.g., whether the decedent was in a single cell or “pod” [a smaller, self-contained housing unit, typically holding 8–16 individuals]) and whether the decedent was on suicide watch, was restrained (and, if restrained, the type of restraint used, how many people were involved in the restraint, and how long they were restrained), and received medical treatment (Gorniak, 2025).

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¹⁷ Va. Code Ann. § 32.1-285.

important that the forensic pathologist document injuries to assist in determining “the nature of the object used to inflict the wounds, how the injuries were incurred, and whether the injuries were a result of an accident, homicide, or suicide” (NAME, 2020, p. 15).

In internal examinations, thoracic and abdominal cavities are “examined before and after the removal of organs so as to identify signs of disease, injury, and therapy” (NAME, 2020, p. 18). NAME standards state that forensic pathologists should examine internal organs in situ, describe adhesions and abnormal fluids, document abnormal position of medical devices, and describe evidence of surgery. Forensic pathologists (or their representatives) remove, weigh, dissect, and describe internal organs from the cranial, thoracic, abdominal, and pelvic cavities. Scalp and cranial contents are examined before and after the removal of the brain. A layer-by-layer dissection is performed to properly evaluate trauma to the anterior neck. Removal and dissection of the upper airway, pharynx, and esophagus are also conducted and, in instances where occult neck injury is suspected, the posterior neck is dissected.

According to NAME (2020) standards, documentation of penetrating injuries and blunt impact injuries “should include detail sufficient to provide meaningful information to users of the forensic autopsy report, and to permit another forensic pathologist to draw independent conclusions based on the documentation” (p. 20). Foreign bodies should be recovered and documented for evidentiary purposes, and internal wound pathways should be described.

Scientific and Diagnostic Tests

As part of examinations, forensic pathologists conduct tests, which may be outsourced, to assist in making determinations of cause and manner of death. The Weyrauch example vividly demonstrates the value of such tests, as it provides a striking example of the importance of histological microscopic examination. It is important to note, however, that the costs of tests may challenge the budgets of smaller offices, especially in complex cases. Tests for a single complex case can deplete a limited budget and limit the amount of money available for routine tests. This may be an instance where small jurisdictions would benefit from access to pooled resources or centralized access to resources.

NAME (2020) standards state that X-rays should be taken to detect fractures (which may be the only physical evidence of abuse or trauma) and to detect and locate foreign bodies and projectiles. Specimens such as blood and urine must be routinely collected, labeled, and preserved to be available for needed toxicological, chemistry, or other laboratory tests. Further, “blood or other appropriate samples should be collected, whenever

possible, for potential genetic testing in sudden, unexplained deaths that remain unexplained at the completion of the autopsy” (NAME, 2020, p. 22). The standards state that forensic pathologists should “perform histological examination [microscopic analysis of tissue samples to identify structural changes and diagnose diseases] in cases having no reasonable explanation of the cause of death following gross autopsy performance, scene/circumstance evaluation, and toxicology and vitreous fluid analyses” (NAME, 2020, p. 22). Toxicology tests are performed to detect and identify substances in the body, such as licit and illicit alcohol, drugs, poisons, and heavy metals.

CHALLENGES IN MAKING DETERMINATIONS OF CAUSE AND MANNER OF DEATH

This section discusses additional challenges encountered by forensic pathologists as they seek to establish cause and manner of death. Some challenges result from overt failures (e.g., incorrect applications of scientific principles, inadequate information), while others result from faulty heuristics, a lack of familiarity with current medical knowledge, or cognitive errors that stem from biases or undue influence.

Establishing the Scientific Bases for Cause and Manner of Death

A proximate cause of death is “that which in a natural and continuous sequence, unbroken by any efficient intervening cause, produces the fatality and without which the end result would not have occurred.”¹⁸ Proximate causes of death include gunshot wounds, atherosclerotic cardiovascular disease, lung adenocarcinoma, acute cocaine intoxication, drowning, compression of the neck, and chronic alcohol use disorder.¹⁹ A mechanism of death describes nonspecific physiologic events that connect the proximate cause of death with the moment of death. Examples of mechanisms of death include cardiac arrhythmia (an abnormal pattern or irregularity in the heartbeat), asphyxia (a deficient supply of oxygen to the body), metabolic acidosis (a condition in which the body accumulates too much acid in the blood), hypo- or hyperkalemia (abnormally low or high levels, respectively, of potassium in the blood), and exsanguination (bleeding to death). The proximate cause of death explains why a body stopped working, whereas the mechanism of death explains how the body stopped working.

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¹⁸ Presentation to the committee, James R. Gill, Chief Medical Examiner, Connecticut Office of the Chief Medical Examiner, April 2, 2024.

¹⁹ Gill, 2024.

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²⁰ Shaken baby syndrome (SBS)* provides an example of how uncertain or evolving science has affected forensic death investigations. The triad of subdural hematoma, cerebral edema, and retinal hemorrhage was believed to be diagnostic of this condition, and the hypothesis formed the basis for murder prosecutions of parents and caregivers whose infants died and whose bodies bore these findings. However, considerable controversy has arisen as to whether shaking alone is the cause of death in instances when the determination is based solely on the presence of the triad of symptoms (see, e.g., Elinder et al., 2018; Narang, Fingarson, and Lukefahr, 2020; Narang et al., 2025; Sirotnak, 2006). The American Academy of Pediatrics, the Society for Pediatric Radiology, the American Association of Certified Orthoptists, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology emphasize that the triad should never be used in isolation for diagnosing SBS and that medical history, an exam, and context must be considered—and other potential causes ruled out—before reaching a conclusion (Choudhary et al., 2018).
* The term SBS has been supplanted by abusive head trauma as the most comprehensive term for the intracranial and spinal lesions in abused infants and children (Choudhary et al., 2018).

It is important to note that sickled red blood cells found in tissues through histological microscopic examination do not mean that a decedent was experiencing a sickle cell crisis; the cells should not, therefore, be taken as evidence of sickling in vivo. Such cells are most likely to be postmortem artifacts.

Excited Delirium

Excited delirium is a term used by some medical examiners and others to describe extreme agitation accompanied by delirium. It has no agreed-upon definition but has frequently been cited as a cause of death in instances where individuals have died during or after police restraint. Critics argue that, like SCT, “excited delirium” has been employed to absolve law enforcement officers from responsibility in cases where excessive force or restraint may have contributed to a detainee’s death (Obasogie, 2021).

The term is believed to have been introduced in the 1980s by David Fishbain, director of psychiatric emergency services at the University of Miami, and Charles Wetli, a forensic pathologist. The condition was associated with extreme agitation, unexpected strength, and hyperthermia, particularly in individuals intoxicated with cocaine. Though never recognized as a formal medical diagnosis, it gained traction among some medical examiners and law enforcement. A small group of authors, many with ties to TASER International (now Axon Enterprise), a company that manufactures conducted energy devices used by law enforcement officers to momentarily incapacitate individuals by delivering an intense electric shock, helped popularize the term excited delirium by publishing articles on it in medical literature. In 2007, TASER/Axon distributed free copies of Excited Delirium Syndrome, a book by Vincent and Theresa Di Maio, which expanded on Charles Wetli’s concept and further promoted the term at medical and law enforcement conferences. By 2014, Di Maio admitted that he and his wife had “come up with” the term, which has since been widely used to explain deaths in police custody involving restraint, substance use, or mental illness (da Silva Bhatia, 2022).

In its 2017 position paper on recommendations for the investigation and reporting of deaths in police custody, NAME referenced “excited delirium,” noting “the more difficult cases are those where the individual is observed to be acting erratically due to a severe mental illness and/or acute

drug intoxication. These cases have been defined in the literature as excited delirium and often result in a law enforcement response and restraint of the decedent” (da Silva Bhatia, 2022, p. 1595).

The symptoms attributed to excited delirium are vague and open to interpretation. An Austin-American Statesman investigation examining nonshooting deaths in Texas police custody from 2005 to 2017 found that over one in six of the 289 cases were attributed to “excited delirium” (Dexheimer and Schwartz, 2018). A Florida Today report from January 2020 revealed that of the 85 deaths labeled as excited delirium by Florida medical examiners since 2010, at least 62 percent involved law enforcement use of force; 94 percent of those cases involved men, and in 36, the decedents were Black (Sassoon, 2019). A 2018 systematic review found that in addition to agitation, signs and symptoms of excited delirium include bizarre behavior, hypervigilance, fear, unusual strength, lack of tiring, insensitivity to pain, elevated temperature, and noncompliance with police commands. Importantly, these symptoms do not align with the clinical definition of delirium as established in the Diagnostic and Statistical Manual of Mental Disorders, a widely used manual for diagnosing and classifying mental disorders, which requires disturbances in attention and cognition (Gonin et al., 2018). Using information from news articles and publicly accessible databases on police killings, one study found that of 166 excited delirium–labeled deaths in police custody from 2010 to 2020, 43.3 percent involved Black individuals (Obasogie, 2021, pp. 1595–1596).²¹

The term continues to be used even though major health organizations, including the American Medical Association (AMA, 2021) and the World Health Organization, do not recognize excited delirium as a legitimate medical diagnosis. In recent years, multiple organizations, including NAME and the American College of Emergency Physicians, have formally withdrawn

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²¹ White individuals, at 53 cases, made up 31.9 percent of the deaths, and

[o]f the 166 cases in which the race of the victim is available, [at 72 cases,] Black people make up almost half (43.3%) of the instances in which excited delirium is used to describe why a person died in police custody. When combined, Black and Latinx people constitute at least 56% of the deaths in custody in this sample attributed to excited delirium. This disparity reflects the disproportionate contact that police have with racial minorities as well as the persistent ways that race has framed excited delirium conversations since Charles Wetli and David Fishbain brought the concept into legal and forensic discourses. It is clear that racial minorities are in general more likely to be killed by police, and this initial data suggest that they may also be more likely to have their deaths attributed to what is perceived to be a psychiatric condition. (Obasogie, 2021, pp. 1595–1596)

support for excited delirium as a legitimate diagnosis.²² The AMA (2021) stated that current evidence does not support excited delirium as an official diagnosis and opposes its use until clear diagnostic criteria are established. Three states—California, Colorado, and Minnesota—have banned the use of the term in contexts such as death certificates, MLDI reports, and police training. However, excited delirium instruction remains part of the curriculum of police training in many areas (Lartey, 2024).

Restraint Asphyxia

Asphyxia may be caused by environmental factors (e.g., an irrespirable atmosphere), external or internal airway obstructions, neck or chest compression, or position (e.g., an inverted posture). External causes of asphyxia are diagnosed based on signs supportive of an asphyxial mechanism (e.g., petechiae, neck bruising, fractures) and physical evidence such as the presence of ligature around the neck.²³ Diagnoses of asphyxia require that forensic pathologists correctly exclude other causes of death.

Several high-profile arrest-related deaths have occurred during interactions with law enforcement that involved forceful restraint, ultimately resulting in detainees becoming unresponsive or dying.²⁴ These deaths have been attributed to restraint asphyxia, which occurs when physical restraint techniques impede normal breathing (Graham, 2025). Positioning an individual’s body in a way that obstructs airway or respiratory movements, such as being placed face down (prone) with weight applied to the back, hampers chest expansion and diaphragmatic movement (OJP, 1995). Excessive physical exertion, especially when combined with restraint, can lead to a buildup of lactic acid in the blood that results in metabolic acidosis. This condition requires increased ventilation to expel carbon dioxide, but

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²² Presentation to the committee, Altaf Saadi, Assistant Professor of Neurology, Harvard University, December 3, 2024.
NAME’s (2023) position statement on excited delirium states, “These terms are not endorsed by NAME or recognized in renewed classifications of the WHO, ICD-10, and DSM-V. Instead, NAME endorses that the underlying cause, natural or unnatural (to include trauma), for the delirious state be determined (if possible) and used for death certification” (p. 1). Similarly, a report by a task force of the ACEP (2021) states, “Excited delirium syndrome is not a currently recognized medical or psychiatric diagnosis in either the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) of the American Psychiatric Association, or the International Classification of Diseases (ICD10) of the World Health Organization” (p. 11). An ACEP (2023) position statement states that the organization “does not recognize the use of the term ‘excited delirium’ and its use in clinical settings.”

²³ Gill, 2024.

²⁴ See, e.g., Eric Garner, George Floyd, and Elijah McClain.
George Floyd had no neck injury, internal injury, or petechiae. Based on the autopsy alone, without considering nonmedical information, his death can be explained by a combination of heart disease and/or a drug intoxication (Gill, 2024).

certain restraint positions impede breathing, exacerbating acidosis, which increases the risk of cardiac arrest (Weedn, Steinberg, and Speth, 2022).^25,26

A 2017 NAME position paper found that manner of death in instances of restraint

Cognitive Bias

Those making cause- and manner-of-death determinations examine data and make interpretations, which means that investigatory evidence is mediated by human and cognitive factors (Dror, 2018). In some cases, contextual information aids examiners in making accurate determinations, but some contextual information can lead to cognitive bias—“unconscious and systematic errors in thinking that occur when people process and interpret information in their surroundings and influence their decisions and judgments” (Da Silva, Gupta, and Monzani, 2023, p. 1).

Bias is not inherently negative or intentional. Rather, bias affects all individuals, with observer effects “rooted in the universal human tendency to interpret data in a manner consistent with one’s expectations” (Krane et al., 2008, p. 1006). Humans are particularly susceptible to cognitive bias when there are insufficient data or when there are constraints that prevent comprehensive analysis. Even with high-quality data, time limitations or uncertainty about the relevance of information can lead to biased conclusions (Croskerry, Singhal, and Mamede, 2013). In addition, “actions that allow relatively high discretion are most likely to be subject to bias-driven errors” (Glaser, 2024, p. 151).²⁷

In forensic science, as in medicine, bias reduces consistency, leading different experts—or even the same expert at different times—to reach

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²⁵ Presentation to the committee, Victor Weedn, Deputy Medical Examiner, Office of the Chief Medical Examiner, Washington, DC, December 3, 2024.

²⁶ “Considerations for both the cause and the manner of death might have been different,” Weyrauch said of his case study, “if the video had indicated a fight with the restraint chair or use of force by staff, or if there was no video made available by the facility to review.”

²⁷ An examination of cases across different policing domains, for instance, revealed that “when discretion is constrained in stop-and-search decisions, the impact of racial bias on searches markedly declines” (Glaser, 2024, p. 151).

different conclusions. This inconsistency is problematic, as it undermines the public’s confidence in the conclusions (Lidén, Thiblin, and Dror, 2023).²⁸

In the absence of training on—or an understanding of—how cognitive bias affects decision-making, forensic pathologists and others conducting death investigations may not appreciate different sources of bias, how bias can impact forensic pathology, or how to mitigate bias.²⁹

Determinations of manner of death may be affected by knowledge that a death has occurred in custody—knowledge, for example, that law enforcement or corrections officers were present at the place of death may affect the decision on whether to label a death a homicide or undetermined. Knowledge that one may be called to testify as to manner of death in a legal proceeding may lead to bias. Further, knowledge of a decedent’s history may also lead to different conclusions³⁰ (see Figure 5-2).

Linear sequential unmasking (LSU) is an approach to mitigating cognitive bias that controls how and when forensic examiners receive case information.³¹ The central tenet is that analysts should first evaluate the most objective and relevant evidence—such as physical or biological evidence—before being exposed to potentially biasing contextual information, such as a suspect’s criminal history or eyewitness accounts. By delaying access to potentially biasing information, LSU offers a method by which forensic analysts might reach more independent and evidence-driven conclusions.

An expansion of LSU called LSU–expanded, offers “an approach that is applicable to all forensic decisions rather than being limited to a particular type of decision” (Dror and Kukucka, 2021, p. 1). The method encourages examiners to document their decision-making process in a worksheet to optimize information sequencing and promote transparency in decision-making (Dror and Kukucka, 2021). Taking detailed, time-stamped notes during investigations is crucial, as it preserves decision-making context and mitigates memory-based inaccuracies. Such documentation protects examiners and laboratories by providing clear records of their procedures, which can be useful for testimony or audits and in encouraging the incorporation of effective, standardized protocols into workflows (Dror and Kukucka,

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²⁸ Presentation to the committee, Adele Quigley-McBride, Assistant Professor, Simon Fraser University, September 19, 2024.

²⁹ Presentation to the committee, Itiel E. Dror, Senior Cognitive Neuroscience Researcher, University College London, September 19, 2024. See also Dror and Kukucka (2021) and Dror and Hampikian (2011).

³⁰ Together with physical examinations and medical tests, knowledge of the decedent’s history provides critical information to medicolegal death investigators much as medical history may provide critical information in clinical medicine. Of course, if contextual information is biasing or fragmentary (or if it is used or assessed incorrectly), an erroneous conclusion may be reached.

³¹ It remains an open question as to who is in the best position to determine what information is released and when.

2021). In addition, detailed, standardized documentation encourages careful decision-making and makes it less likely that steps will be missed. It also preserves the context in which decisions were made and documents the sequence in which an examiner learned information and why an examiner came to a decision.³²

To mitigate bias, researchers have suggested avoiding, as much as possible, context that is not needed. Instead, they recommend mandatory reporting of provided contextual information and using bias mitigating techniques, such as constructing plausible alternative hypotheses, before settling on the most likely (Lidén, Thiblin, and Dror, 2023). Many other approaches to avoiding cognitive bias have been suggested, including more frequent use of second opinions and effective peer review processes, as well as exploiting decision-support resources, including artificial intelligence tools used in medical diagnosis (Croskerry, Singhal, and Mamede, 2013). It is worth noting that it is often easier to detect bias than to prevent it, and that second reviews are particularly useful for bias detection.

Undue Influence

It is critical that medical examiner and coroner offices operate without undue influence from those with a stake in an investigation. In the context of deaths in custody, these offices may face pressure from, among others, law enforcement and corrections officers, attorneys, families of decedents,

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³² Quigley-McBride, 2024.

reform advocates, government officials, professional colleagues, academicians, and members of the press and the public.³³ Proximity to law enforcement can exert particular influence on medicolegal death investigations; it is important to understand relationships between medicolegal death investigators and forensic laboratories, law enforcement, prosecutors, and others when considering possible sources of influence.

A 2013 NAME position paper on medical examiner, coroner, and forensic pathologist independence states that medicolegal death investigators “must investigate cooperatively with, but independent from, law enforcement and prosecutors.³⁴ The parallel investigation promotes neutral and objective medical assessment of the cause and manner of death” (Melinek et al., 2013).

In testimony to the committee, medical examiners and coroners emphasized the importance of independence. Reade A. Quinton, president of NAME, suggested that the best structure for a medical examiner office is an office that is independent of any other agency: “As soon as you get to a point where you have the medical examiner with oversight by, for instance law enforcement or something like it, that’s when obviously you could run into potential problems.” Medical examiners stress that idea—“and I have to do it in court all the time—that ‘I do not work for the sheriff’s office [and] I do not work for the DA’s office.’”³⁵ Coroner Hayley L. Thompson, in testimony to the committee, emphasized that “investigations can be influenced by pressures that police and other government officials exert on coroners.” “To properly understand deaths in custody,” she said, “there needs to be continuity across the nation in how these deaths are reported, investigated, and ultimately certified.”³⁶

There are, however, jurisdictions where law enforcement officers perform the duties of the coroner (see Chapter 2). Further, in jurisdictions where the position of coroner is an elected position, coroners may face political pressure from constituents to make certain determinations. Similarly, in jurisdictions where funeral directors perform the role of coroner,

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³³ Gill, 2024.

³⁴ The 2009 National Research Council report on forensic science endorsed this separation, stating, “Scientific and medical assessment conducted in forensic investigations should be independent of law enforcement efforts either to prosecute criminal suspects or even to determine whether a criminal act has indeed been committed” (NRC, 2009, p. 23).
Surveys of NAME members found that over 70 percent of respondents “had been subjected to pressures to influence their findings, and many had suffered negative consequences for resisting those influences”; in a separate study, over 30 percent of respondents “indicated that fear of litigation affected their diagnostic decision-making” (Melinek et al., 2013, p. 93).

³⁵ Presentation to the committee, Reade A. Quinton, Associate Professor of Pathology and Laboratory Medicine, Mayo Clinic, and President, NAME, February 4, 2025.

³⁶ Presentation to the committee, Hayley L. Thompson, Skagit County Coroner, Mount Vernon, Washington, September 19, 2024.

a desire to align with the interests of the familial clients of decedents may influence the outcome of an investigation (e.g., hesitancy to list suicide or drug overdose as manner of death on a death certificate either to prevent embarrassment or because the cause or manner of death could influence awarding of death benefits to the family).³⁷

QUALITY ASSURANCE AND ACCOUNTABILITY

How often do forensic pathologists get cause and manner wrong? That is a difficult question to answer, as there are instances where it may not be possible to establish ground truth. Determinations of cause and manner of death represent informed expert opinion. As such, depending upon the information considered, different forensic pathologists can reach different conclusions about the same case. While not required as standard practice, mechanisms are nonetheless available to evaluate investigatory rigor and increase the likelihood that determinations of cause and manner of death are correct.

Peer Review

In recent years, forensic pathologists around the world have worked to incorporate peer review into professional practices. Peer review is a process wherein experts from a specific field or discipline evaluate the quality of their peers’ work to assess validity and quality. The goal of peer review is to improve individual or system performance. It is widely used in the medical and scientific communities to identify and correct errors, and it serves as an important vehicle for education. It is important to note, however, that the quality and meaningfulness of peer review is highly dependent on transparency and the protocol employed.

In the United States, some medical examiner offices hold regular meetings to review case conclusions before they are finalized (prospective review) or after the fact (retrospective review).³⁸ Prospective peer review serves as a preventive measure, as it can identify errors prior to the issuance of a final report. In contrast, retrospective peer review serves as an auditing tool that evaluates whether forensic pathologists have adhered to standards of practice. Peer review can be performed by an individual or a group and may be unblinded or blinded. In unblinded reviews, reviewers have access to all contextual information. Blinded reviews, on the other hand, remove contextual information in an effort to minimize cognitive bias.

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³⁷ Presentation to the committee, Cilina Evans, Coroner, Shelby County, Alabama, September 19, 2024.

³⁸ Such reviews are common for infant or child deaths and deaths in custody.

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³⁹ Presentation to the committee, Alfredo E. Walker, Forensic Pathologist and Coroner, Ontario Forensic Pathology Service, February 4, 2025.

⁴⁰ Walker, 2025.
From April 1, 2021, to March 31, 2022, the latest period for which data are publicly available, the CCEC reviewed 21 cases (Ontario Forensic Pathology Service, 2022).

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⁴¹ In correspondence dated May 1, 2025, Andrew Camilleri, Assistant Director, Science & Support, Forensic Science SA, indicated that the procedure reported in Sims, Langlois, and Byard (2013) “remains broadly aligned with FSSA’s current peer review process, although there have been some changes […that] have not been described in the literature.”

⁴² Presentation to the committee, Michelle Jorden, Chief Medical Examiner, Santa Clara County, California, and Vice President, NAME, February 4, 2025.

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⁴³ Manual strangulation can be difficult to diagnose and is subject to misdiagnosis.

case, a bullet was found in the body of an autopsied individual.⁴⁴ In three other cases, decedents’ families were told that an autopsy had been performed when it had not.⁴⁵

In instances where a case is highly sensitive for a jurisdiction, autopsies may be conducted in other jurisdictions to avoid any appearance of bias.

Audits

Several states have mechanisms for audits of the results of death-in-custody investigations.

In testimony to the committee, James R. Gill, Connecticut Office of the Chief Medical Examiner, referred to audits of in-custody deaths by the State of Connecticut.⁴⁶ Connecticut’s Office of the Inspector General issues investigative reports on the use of force by police officers, including incidents that did not result in death (Division of Criminal Justice, 2025). State law provides that “[w]henever a peace officer, in the performance of such officer’s duties, uses physical force upon another person and such person dies as a result thereof or uses deadly force . . . upon another person, the Division of Criminal Justice shall cause an investigation to be made and shall have the responsibility of determining whether the use of physical force by the peace officer was appropriate.”⁴⁷ The law also requires that the investigation into any death resulting from the use of force by a police officer be conducted by a state’s attorney from a judicial district other than where the incident occurred.

In New York State, the Attorney General’s Office of Special Investigation (OSI) “investigates deaths caused by police officers or peace officers, including corrections officers. If an investigation shows that a crime was committed, evidence is presented to a grand jury, and if the grand jury returns an indictment, OSI prosecutes the case.” If the “investigation shows that an officer caused a death, but that a crime cannot be proved beyond a reasonable doubt, OSI publishes a report on” its “website detailing the facts disclosed by the investigation and explaining why the evidence would not demonstrate proof beyond a reasonable doubt” (Office of the New York State Attorney General, 2025).

The Washington State Legislature created the Office of Independent Investigations (OII, n.d.) in 2021 “to conduct thorough, transparent, and

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⁴⁴ Presentation to the committee, Nicole Martin, Legal Program Director, The Autopsy Initiative, February 4, 2025.
In subsequent correspondence, Martin clarified that the bullet was related to the terminal event (and was not, for example, a residual bullet from an earlier incident).

⁴⁵ Martin, 2025.

⁴⁶ Gill, 2024.

⁴⁷ CT Gen Stat § 51-277a. (2024).

unbiased investigations of cases that involve police use of deadly force.” The formation of the agency was recommended by the Governor’s Task Force on Independent Investigations of Police Use of Force (Washington Office of the Governor, 2020). An 11-member advisory board, which includes family affected by incidents of police use of deadly force, law enforcement, community members, a representative of a federally recognized Washington tribe, a mental health professional, a prosecutor, a defense attorney, and a member of the Criminal Justice Training Commission, was established to work with OII and advise on policies and procedures. The OII (n.d.) began actively investigating deaths in December 2024.

As described in Chapter 2 in Box 2-5, at the murder trial of Minneapolis Police Officer Derek Chauvin, David Fowler, former chief medical examiner for the state of Maryland, testified that, in his opinion, George Floyd’s death was caused by a combination of factors, including preexisting heart conditions and drug use, rather than asphyxiation due to Chauvin’s restraint. Following Chauvin’s conviction, more than 450 medical experts signed a letter to the Maryland Attorney General condemning Fowler’s “cause of death opinion, particularly the portion that suggested open-air carbon monoxide exposure as contributory [and said that it] was baseless, revealed obvious bias, and raised malpractice concerns” (Frosh et al., 2021, p.1). They demanded an independent review of all deaths in custody during Fowler’s tenure as chief of the Maryland Office of the Chief Medical Examiner (OCME) (Frosh et al., 2021, p. 2).

In September 2021, Maryland’s Office of the Attorney General appointed an audit design team to design an audit “to assess whether OCME had inappropriately classified deaths that occurred during or soon after restraint, as well as whether OCME’s determinations showed patterns consistent with racial and/or pro-police bias” (Kukucka et al., 2025, p. 9).

Kukucka and colleagues (2025) identified more than 1,300 OCME death-in-custody cases from 2003 through 2019; 87 cases were included in the audit, each involving an unexpected death during or soon after restraint. Extraneous or potentially biasing information was removed from the case files. From September through December 2024, an international group of 12 forensic pathologists reviewed the 87 cases⁴⁸ and independently opined on the cause and manner of death.⁴⁹ This audit found the following:

• Case reviewers’ consensus manner-of-death opinion differed from OCME’s manner determination for more than half (44) of the 87 audit cases, including 36 cases that case reviewers unanimously

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⁴⁸ Each case was reviewed by three pathologists.

⁴⁹ Five of the reviewers practice outside of the United States, where opinions on manner of death are not proffered.

• deemed homicides but which OCME had ruled as either undetermined (29 cases), accidental (5 cases), or natural (2 cases).
• Whereas case reviewers judged 48 of the 87 deaths as homicides, OCME ruled only 12 of those same deaths as homicides.
• OCME ruled deaths as homicides even less often if the decedent was Black (rather than White) or was restrained by police (rather than by others).
• In nearly half (42) of the 87 audit cases, OCME’s cause-of-death statement referenced “excited” or “agitated” delirium, which has been widely rejected as a valid cause of death. In those cases, OCME almost always certified the manner of death as “undetermined” (93 percent), with only one case (2 percent) ruled a homicide. In contrast, case reviewers deemed 25 of those same 42 deaths (56 percent) to be homicides.
• For 47 percent of cases, at least one case reviewer judged OCME’s cause-of-death determination to be “not reasonable.” For 66 percent of cases, at least one case reviewer judged OCME’s manner-of-death determination to be “not reasonable” (Kukucka et al., 2025, p. 9).

In addition, Kukucka and colleagues (2025) stated that

With regard to the quality of OCME’s investigations, “case reviewers frequently commented that key details about the nature and/or duration of restraint were lacking, such that video (e.g., body-worn camera) footage and/or more reliable first-hand accounts of the restraint would have been helpful” (Kukucka et al., 2025, p. 10).

While case reviewers praised “OCME’s regular use of consultation services (e.g., cardiac pathology, neuropathology),” they noted “routine deficiencies in OCME’s post-mortem examinations, including the number, content, and quality of autopsy photographs” (Kukucka et al., 2025, p. 10). Case reviewers “suggested that law enforcement should be better educated on the dangers of improper restraint and trained in non-lethal restraint techniques, and that crisis response teams should include not only law enforcement but also professionals who specialize in mental health and/or de-escalation” (Kukucka et al., 2025, p. 10).

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⁵⁰ In the United Kingdom, coroners are not medical professionals. Rather, they are independent judicial officers appointed and funded by local governments who act as advocates for the dead to safeguard the living. Under the Coroners and Justice Act 2009, a coroner has a duty to investigate a death if made aware that the body is within that coroner’s area of jurisdiction and has reason to suspect that the deceased died a violent or unnatural death, and the cause of the death is unknown or the deceased died while in custody. The coroner may (1) certify death as being due to natural causes without obtaining a postmortem report; (2) certify death as being due to natural causes after obtaining a postmortem report that confirms it; (3) open an investigation; or (4) open an inquest (which may or may not be held before a jury) to ascertain who the deceased was and how, when, and where the deceased came by their death (presentation to the committee, Lucy Easthope, Visting Research Fellow, Centre for Death and Society, University of Bath, January 9, 2025).

⁵¹ The Coroners and Justice Act 2009, c. 25 (UK) states that a coroner must issue a PFD if (1) there is “a concern (arising from the investigation) that circumstances creating a risk of other deaths will occur or continue in the future,” and (2) the coroner formed the opinion that “‘action should be taken’” to prevent the occurrence or continuation of the circumstances creating a risk of death, or to reduce the risk of future deaths created by those circumstances.’ See https://www.judiciary.uk/guidance-and-resources/reports-to-prevent-future-deaths-pfds/#related_content.

⁵² Easthope, 2025.

Chief Coroner thinks fit” and “send a copy of the report to any person who the Chief Coroner believes may find it useful or of interest.”⁵³ A thematic review of recent PFDs conducted by a British law firm identified “concerns in relation to inadequate staffing levels within prisons and the impact that has on the safety of prisoners” (Munden and Wright, 2023).

Transparency

Transparency measures can be important tools for improving the quality of medicolegal death investigations. In addition to making public the findings of the audits of determinations of cause and manner of death, introducing limited autopsies for a circumscribed set of cases and entering statistics on numbers and types of deaths into the public record can help identify trends in public health and deaths in custody and support a better understanding of their causes.

To increase transparency on numbers and causes of deaths, many have proposed that a checkbox be added to death certificates where a medical examiner or coroner can indicate that a death has occurred in custody. Currently, the U.S. Standard Certificate of Death has fields where the certifier of a death may add information on the “chain of events—diseases, injuries, or complications—that directly caused the death” and “other significant conditions contributing to death.” However, if a certifier of a death does not specify that the decedent died in custody or does not indicate, for instance, that a gunshot wound was caused by a law enforcement weapon, the fact that a death occurred in custody will not be captured.

Data dashboards are another method for increasing transparency about deaths in custody. One example is the public-facing data dashboard launched in 2022 by the Office of the Medical Examiner-Coroner by the County of Santa Clara (2025). It was created in response to numerous public records requests related to cases investigated by the Office of the Medical Examiner-Coroner. The dashboard, which is updated nightly and contains deidentified data from 2018 onward, provides information on jurisdictional and/or nonjurisdictional cases including deaths in custody.⁵⁴

Standards, Certification, Accreditation, and Continuing Education

In testimony to the committee, Cilina Evans, coroner of Shelby County, Alabama, addressed the broader issues affecting the MLDI system:

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⁵³ The Coroners (Investigations) Regulations 2013 (UK), p. 8.

⁵⁴ Presentation to the committee, Michelle Jorden, Chief Medical Examiner, Santa Clara County, California, and Vice President, NAME, February 4, 2025.

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⁵⁵ Presentation to the committee, Cilina Evans, Coroner, Shelby County, Alabama, September 19, 2024.

⁵⁶ In the case of NAME, professional practice standards focus on medical practices formulated by experienced practitioners, mainly forensic pathologists. External input is not solicited, and draft standards are not subject to public comment. Instead, they are reviewed and approved by members within the organization.

statistical purposes. It is not a legal conclusion. Nevertheless, coroners and medical examiners are routinely called to testify⁵⁷ as to both cause and manner of death in legal proceedings.

While there is little debate about the admissibility of cause-of-death testimony,⁵⁸ many forensics and legal professionals question the appropriateness of allowing manner-of-death testimony in legal proceedings, citing concerns about the credibility and reliability of manner-of-death determinations, the methodologies used to reach these determinations, and the existence of examples where different forensic pathologists reached different conclusions about manner of death for the same case. In addition, there are concerns that manner-of-death determinations may be overly influenced by nonscientific information.

Some forensic pathologists have suggested that manner-of-death testimony be excluded from legal proceedings categorically. As J. Keith Pinckard, immediate past president of NAME, explained in remarks to the committee, medical examiners hold this view, in part, because their use of the term homicide differs from the definition of the term in federal and state law. In the medical examiner community, Pinckard said, a “homicide occurs when death results from a volitional act committed by another person to cause fear, harm, or death. Intent to cause death is a common element but is not required for classification as homicide.” Importantly, for medical examiners and coroners, “the classification of homicide for the purposes of death certification is a ‘neutral’ term and neither indicates nor implies criminal intent, which remains a determination within the province of legal processes” (Hanzlick, Hunsaker, and Davis, 2002, p. 6).

The Police Executive Research Forum (PERF) guidelines for managing officer-involved critical incidents note that, “broadly speaking,” NAME’s position paper on deaths in custody⁵⁹ recommends that officer-involved crit-

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⁵⁷ Other members of the MLDI system are being called to testify in legal proceedings with increasing frequency. In her remarks to the committee, Gorniak (2025) stated,

I believe that death investigators are going to start going to court. It used to be, “We protect you as a forensic pathologist. It’s okay, we won’t have to go.” Even I know [of] forensic techs, the person who’s drawing the blood [being called to testify], because I can’t say, “I drew the blood, and I put it in this tube.” Other people are starting to go to court, so they can’t hide behind the forensic pathologist anymore. That’s why I think it’s important that they’re certified. . . . Get the forensic autopsy tech certified also, so when they go into court, they have that.

Increased demand for testimony places additional pressure on MLDI system resources.

⁵⁸ Testimony on cause of death is generally accepted as appropriate expert testimony, as cause of death determinations typically involve specialized medical knowledge.

⁵⁹ See Mitchell Jr. et al., 2017.

ical incidents (i.e., fatal shootings and restraints) “be designated ‘homicides’ since the deaths occurred ‘at the hands of another;’ in other words, the decedent would not have died at that moment if not for the actions of the officer” (Police Executive Research Forum, 2025, p. 63). The PERF guidelines note, however, that “the designation of ‘homicide’ by a medical examiner or coroner does not mean an officer committed a crime—the determination of whether a crime took place involves the application of criminal statutes and legal principles” (Police Executive Research Forum, 2025, p. 63):

The difference in definitions can be confusing to jurors and unfairly prejudicial in court proceedings. NAME’s 2002 Guide for Manner of Death Classification provides support for this view. “Medical examiners and coroners have debated for decades about how the manner of death should be classified in certain situations, and more recently, whether certifiers should be required to classify manner of death at all” (Hanzlick, Hunsaker, and Davis, 2002, p. 3). While “one cannot escape the need to consider intent when classifying manner of death . . . the definition of, or need to consider ‘intent’ may vary depending on the case” (Hanzlick, Hunsaker, and Davis, 2002, p. 5).

NAME’s guide emphasizes the importance of the “but-for” principle: “But-for the injury (or hostile environment), would the person have died when he/she did?” It notes that

The guide further suggests that an assessment of intent relates to manner-of-death classifications. Intent

In remarks to the committee, NAME president Reade A. Quinton asserted that “even though manner of death is an opinion, [medical examiners] do believe it has value from the public health perspective for many different issues in our community. However, it just does not—or should not—drive, necessarily, prosecution,” particularly since conclusions on manner of death can be amended over time as more information comes to light.⁶⁰ In remarks to the committee, Zenita Wickham Hurley, deputy attorney general, Maryland Office of the Attorney General, noted that in legal systems outside the United States, “medical examiners do not try to opine on manner of death.”⁶¹

As is the case elsewhere, judges in the United States play an essential gatekeeping role in assessing whether manner-of-death expert testimony is admissible in legal proceedings. Although evidentiary standards vary slightly across jurisdictions, in general, expert testimony is admissible only if the qualified expert’s opinion is based on sufficiently reliable data and

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⁶⁰ Presentation to the committee, Reade A. Quinton, Associate Professor of Pathology and Laboratory Medicine, Mayo Clinic, and President, NAME, February 4, 2025.

⁶¹ Presentation to the committee, Zenita Wickham Hurley, Deputy Attorney General, Maryland Office of the Attorney General, May 16, 2025.

methods and is helpful to a trier of fact.⁶² Experts are also barred from testifying about whether a defendant had the requisite mental state to commit a crime.⁶³

As courts have explained, “whether a medical examiner’s opinion on cause or manner of death is admissible depends on the particular circumstances of each case.”⁶⁴ In cases in which the medical examiner’s opinion is based primarily on an autopsy and other objective evidence whose authenticity is not in question (e.g., on video and photographic evidence), manner-of-death testimony is more likely to be admitted in court.⁶⁵ But in cases where an expert’s opinion is based largely on witness statements and other evidence on which credibility determinations of the jury depend, such testimony is often excluded.⁶⁶

Although it does not appear that any court in the United States has adopted a per se rule excluding manner-of-death testimony, some argue that manner-of-death testimony should be excluded from the courtroom categorically (see, e.g., Findley and Strang, 2022).⁶⁷ Others emphasize the need for rigorous vetting of such testimony in pretrial hearings or carefully circumscribing its use in the courtroom (e.g., by ensuring that opinions on

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⁶² See, e.g., Fed. R. Evid. 702, which states,

A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if the proponent demonstrates to the court that it is more likely than not that:

1. the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue;
2. the testimony is based on sufficient facts or data;
3. the testimony is the product of reliable principles and methods; and
4. the expert’s opinion reflects a reliable application of the principles and methods to the facts of the case.

⁶³ See Fed. R. Evid. 705.

⁶⁴ Iowa v. Tyler, 867 N.W.2d 136 (IA Sup. Ct. 2015).

⁶⁵ Iowa v. Tyler, 867 N.W.2d 136 (IA Sup. Ct. 2015).

⁶⁶ Iowa v. Tyler, 867 N.W.2d 136 (IA Sup. Ct. 2015).

⁶⁷ In correspondence to the committee dated September 19, 2024, Keith A. Findley, Professor of Law, University of Wisconsin–Madison School of Law, argued,

In all death cases . . . the ultimate manner determination is fundamentally an etiological determination that goes far beyond medical diagnosis, that always requires consideration of ordinary case information that a jury is fully capable of considering itself, and that, while required for public health statistics purposes, is therefore not appropriate for expert opinion evidence in court.

Findley also spoke to the committee at its September 2024 meeting.

manner of death are qualified with terminology such as “consistent with” homicide or “consistent with”suicide).⁶⁸

These views are informed by the concerns highlighted above, including the reliability of opinion, the risk that such testimony will unduly influence a trier of fact, and the lack of consistent standards regarding how manner of death is established.

THE IMPACT OF MANNER-OF-DEATH DETERMINATIONS ON INVESTIGATIONS

Methodological rigor is necessary to make accurate manner-of-death determinations. In some cases, deficiencies in the MLDI system such as insufficient training; lack of diligence, resources, or standards; or undue influence can lead to incomplete or inaccurate determinations that can, if taken at face value, lead to unjust outcomes. In cases of death in custody, the consequences can range from the lack of further investigation of a death by law enforcement to inadequate policy responses from corrections officials.

Consider the example of 35-year-old LaShawn Thompson, who died on September 13, 2022, in Atlanta’s Fulton County Jail. Thompson had been found unresponsive and slumped over the toilet of his jail cell covered with feces and body lice. He was moved outside the cell and corrections officers engaged in cardiopulmonary resuscitation (CPR) for approximately 24 minutes until fire and rescue staff arrived. Emergency services staff performed CPR for approximately 17 more minutes until Thompson was pronounced dead.

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⁶⁸ NAME’s Guide for Manner of Death Classification states, for example, that

[b]ecause the cause and manner of death are opinions, judgment is required to formulate both for reporting on the death certificate. The degree of certainty required to classify the manner of death depends sometimes on the circumstances of the death:

• Undetermined (less than 50% certainty)
• Reasonable medical or investigative probability (Greater than a 50:50 chance; more likely than not)
• Preponderance of medical/investigative evidence (For practical purposes, let’s say about 70% or greater certainty)
• Clear and convincing medical/investigative evidence (For practical purposes, let’s say 90% or greater certainty)
• Beyond any reasonable doubt (essentially 100% certainty)
• Beyond any doubt (100% certainty)

Seldom, for the purpose of manner-of-death classification, is “beyond a reasonable doubt” required as the burden of proof. In many cases, “reasonable probability” will suffice, but in other instances such as suicide, case law or prudence may require a “preponderance” of evidence—or in homicide—“clear and convincing evidence” may be required or recommended. (Hanzlick, Hunsaker, and Davis, 2002, pp. 4-5)

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⁶⁹ Roger Mitchell Jr., a member of the study committee.

⁷⁰ Study committee member Roger Mitchell Jr.

⁷¹ In January 2025, the U.S. Department of Justice and Fulton County officials “announced that they had entered into the court-enforceable consent decree. That agreement provided for an independent monitor to be appointed for an initial period of two years to assess the jail’s implementation of its requirements and to provide a public report every six months” (The Associated Press, 2025).