Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody (2025)
Chapter: 6 Findings and Recommendations
6
Findings and Recommendations
The medicolegal death investigation (MLDI) system in the United States faces significant challenges, as a lack of uniformity creates inadequacies and inconsistencies. Medical examiners and coroners often face major obstacles, such as outdated facilities and lack of trained personnel. Many facilities aren’t accredited, and many practitioners are not board certified. Further, demand for forensic pathologists significantly exceeds supply nationwide, and this shortage has significantly impeded medicolegal death investigations.
The current state of the MLDI system undermines the credibility of death investigations and limits opportunities for 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. Further, 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.
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), which 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.
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.
Progress has been made as a result of efforts by the National Association of Medical Examiners, the International Association of Coroners & Medical Examiners, the National Institute of Justice Bureau of Justice Assistance (BJA), 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 information, 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.
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 recommendations are primarily addressed to Congress and the federal government, but 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.
MLDI SYSTEM IMPROVEMENTS
The MLDI system plays a critical role in justice and public health, providing important information to the public about deaths.
Those who investigate deaths are relied upon to make accurate determinations of cause and manner of death by providing data on individual deaths and evaluating aggregate data collected in local communities and states and from across the nation.
Rigorously designed and analyzed studies led by independent researchers are needed to evaluate the accuracy of forensic pathology reports and final cause- and manner-of-death determinations. High rates of accuracy are a prerequisite for establishing trustworthiness, but accuracy rates of cause- and manner-of-death determinations are currently unknown. Accuracy rates must be established to improve public health and criminal justice.
Key Finding: While there have been efforts to improve standards of practice and scientific rigor across the MLDI system, medicolegal death investigations continue to suffer from a lack of sufficient resources, well-trained personnel, rigorous and enforceable standards, research on controversial areas of death determinations, peer review, and connections to the broader medical and research communities.
RECOMMENDATION 1: For medical examiner and coroner offices to meet basic equipment, training, and staffing needs and to strengthen the nation’s medicolegal death investigation (MLDI) system, Congress should allocate funds to states to
- improve physical infrastructure for those entities that are accredited or are seeking accreditation of their facilities and certification of their practitioners;
- increase coordination among federal, state, and local MLDI systems; and
- develop experimental programs and pilot studies to identify novel ways to increase coroner access to medical examiner and forensic pathologist expertise and services (e.g., by enabling small medical
- examiner and coroner offices to pool resources to improve regional operations and efficiency).
RECOMMENDATION 2: The Accreditation Council for Graduate Medical Education and the American Board of Pathology should integrate additional requirements into forensic pathology fellowship programs. The requirements should include the review of disputed cases or cases that have previously undergone formal review (e.g., adjudicated 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.1
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.
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1 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.
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 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 for 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.
Key Finding: Comprehensive data on deaths in custody are not available. Incomplete or inaccurate data on any death deprive the nation of information that is essential to justice and public health. Incomplete or inaccurate data on the cause and circumstances of a death in custody hinder society’s ability to protect the health and safety of incarcerated persons and correctional staff, the ability of public health officials to generate findings that affect population health positively, and the ability of the criminal justice system to hold accountable those who cause the unnatural deaths of persons in custody.
RECOMMENDATION 11: To compile comprehensive death-in-custody data, Congress should amend the Death in Custody Reporting Act to
- return responsibility for collecting state and local death-in-custody data from the Bureau of Justice Assistance to the Bureau of Justice Statistics (BJS);
- require states to collect and report data on all deaths in custody to BJS;
- expand the definition of a reportable in-custody death to include deaths that occur in a hospital in a community after release from custody, where the condition leading to hospitalization began or was exacerbated during incarceration; and
- mandate that all deaths that occur while in custody be certified by a medical examiner or coroner.
The legislation should require BJS to develop mandatory uniform data collection and reporting protocols for state deaths in custody.
RECOMMENDATION 12: Recognizing that the Bureau of Justice Statistics does not have authority to penalize entities for noncompliance, Congress should require the U.S. Department of Justice to develop effective incentive mechanisms and enforceable requirements to ensure that in-custody deaths are reported.
RECOMMENDATION 13: Congress should direct the National Center for Health Statistics to add a checkbox on the U.S. Standard Certificate of Death to indicate whether a death occurred in custody. Regardless of whether a checkbox is available, all deaths in custody should be noted as such on death certificates and appropriate contextual information should be provided.
RECOMMENDATION 14: To increase transparency and understanding of the nature of in-custody deaths, Congress and state legislatures should mandate that all death-in-custody cases be referred to an independent (i.e., unaffiliated with law enforcement or the institution where the death occurred) certified forensic pathologist to undertake a postmortem examination of appropriate scope. In some circumstances, autopsies may be required and may need to be conducted by certified forensic pathologists outside the jurisdiction of the death. In such cases, the postmortem examination report should be filed with the U.S. Department of Justice (DOJ). While respecting privacy concerns, data from these postmortem examination reports should be aggregated and made publicly available by DOJ for analysis and publication.
RECOMMENDATION 15: Congress should authorize and appropriate funding to the Centers for Medicare & Medicaid Services to reimburse state and local governments for the cost of autopsies performed on those who have died in custody.
TESTIMONY REGARDING CAUSE AND MANNER OF DEATH IN LEGAL PROCEEDINGS
Medical examiners, forensic pathologists, coroners, and others who investigate deaths are often called upon in legal proceedings to provide expert testimony on cause and manner of death. Their testimony can exert significant influence on findings of culpability and thus merits close scrutiny. It may be appropriate to exclude or impose limitations on manner-of-death testimony in legal proceedings.
The use of field-specific terminology in court by a forensic pathologist can be confusing and unfairly prejudicial, because some terms carry different or more specific meanings than they do in other contexts. Cause of death is the medical condition or injury that led to an individual’s death. Causes may include diseases (e.g., cancer, heart disease), injuries (e.g., trauma from a fall), intoxication (e.g., drug overdoses), or other situations (e.g., asphyxiation). This information is vital to public health surveillance, government funding priorities, health policy decisions, research and prevention, and
emergency preparedness. Manner of death is a classification that describes how an individual died. It is not a legal conclusion. Rather, it was designed to provide a way to glean information from death certificates for statistical and public health purposes about the circumstances of a death. Additionally, triers of fact need to understand the distinction between the term homicide as a public health concept and homicide as used in criminal codes.
Cause- and manner-of-death determinations are made by medical examiners, forensic pathologists, and coroners following investigations. Accurate determinations of both cause and manner of death depend upon 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
- whether the expert’s opinion is based primarily on medical/postmortem findings;
- in instances where an expert’s opinion relies on nonmedical information (e.g., police body camera video), whether that information is accurate and reliable;
- whether the expert’s method is based on sound scientific methodology and whether the expert reliably applied that methodology in the case at hand as articulated in Federal Rule of Evidence 702; and
- whether the expert’s opinion assumes facts not in evidence or lacks transparency in its reasoning.
RECOMMENDATION 19: Terminology used in forensic reports and testimony should avoid the use of terms with legal significance in favor of more precise, descriptive, and neutral language. Terminology should reflect medical findings rather than investigative or legal judgments.
RECOMMENDATION 20: To prevent improper testimony on cause and manner of death from being admitted in legal proceedings, federal and state courts should enhance judicial training on cause and manner of death. In addition, stakeholders in the criminal justice system—such as the Federal Judicial Center and the National Center for State Courts and federal and state prosecutor and defense attorney associations—should develop model jury instructions for manner-of-death testimony, consistent with the federal and state rules of evidence and effective standards of professional medicolegal death investigation organizations, including the National Association of Medical Examiners, the American Board of Medicolegal Death Investigators, and the International Association of Coroners & Medical Examiners. These instructions should identify the limitations inherent in cause- and manner-of-death determinations.
CONCLUSION
A robust MLDI system is crucial for both justice and public health. The committee’s findings emphasize the need for reform, highlighting the gaps and challenges faced by medical examiners and coroners. By implementing the committee’s recommendations, the nation can create a modern system that meets the needs of its citizens. A commitment to making improvements will lead to more accurate determinations of cause and manner of death, better public health outcomes, and a fairer criminal justice system.
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