Previous Chapter: 6 Findings and Recommendations
Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

References

AAPC. 2025. “What is ICD-10?” https://www.aapc.com/resources/what-is-icd-10 (accessed June 2025).

ACEP (American College of Emergency Physicians). 2023. “ACEP reaffirms positions on hyperactive delirium.” https://www.acep.org/news/acep-newsroom-articles/aceps-position-on-hyperactive-delirium (accessed June 2025).

ACEP Hyperactive Delirium Task Force. 2021. “ACEP task force report on hyperactive delirium with severe agitation in emergency setting.” https://www.acep.org/siteassets/new-pdfs/education/acep-task-force-report-on-hyperactive-delirium-final.pdf (accessed June 2025).

ACLU (American Civil Liberties Union) Delaware. 2023. “Class action lawsuit filed against Delaware prisons, healthcare providers.” https://www.aclu-de.org/en/lawsuit-prisons-healthcare-providers (accessed June 2025).

Adams, X. 2021. “Bad medicine in Louisiana prisons.” Scalawag, May 5. https://scalawag-magazine.org/2021/05/la-restricted-prison-health/.

Aiken, S. S., and M. Nashelsky. 2023. “Position paper: Second autopsies.” The National Association of Medical Examiners. https://www.thename.org/assets/docs/2ndautopsyfinal2023.pdf.

Alsan, M., C. S. Yang, J. R. Jolin, L. Tu, and D. J. Rich. 2023. “Health care in U.S. correctional facilities—A limited and threatened constitutional right.” New England Journal of Medicine 388(9): 847–852. https://doi.org/10.1056/NEJMms2211252.

Alsan, M., and C. S. Yang. 2025. “The Hidden Health Care Crisis Behind Bars: A Randomized Trial to Accredit U.S. Jails.” Working Paper 33357. National Bureau of Economic Research. http://www.nber.org/papers/w33357.

AMA (American Medical Association). 2021. “New AMA policy opposes ‘excited delirium’ diagnosis.” https://www.ama-assn.org/press-center/ama-press-releases/new-ama-policy-opposes-excited-delirium-diagnosis (accessed June 2025).

American Law Institute. 2025. The principles of law, policing. (Reporter: Barry Friedman; Associate Reporters: Brandon L. Garrett, Rachel A. Harmon, Tracey L. Meares, Maria Ponomarenko, Christopher Slobogin). Washington, DC: American Law Institute.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

ASH (American Society of Hematology). 2025. “ASH position on sickle cell trait.” https://www.hematology.org/advocacy/policy-statements/2021/ash-position-on-sickle-cell-trait (accessed June 2025).

The Associated Press. 2017. “Woman’s suicide leads to $7 million settlement with private prison company.” CBS News, November 11. https://www.cbsnews.com/news/janene-wallace-suicide-philadelphia-community-education-centers-settlement/.

—. 2025. “Judge appoints monitor to oversee agreement to reform Georgia’s Fulton County Jail.” U.S. News, February 21. https://www.usnews.com/news/us/articles/2025-02-21/judge-appoints-monitor-to-oversee-agreement-to-reform-georgias-fulton-county-jail.

Avila, C. J. 2022. “Prison health care is only available if you can afford it.” PRISM, October 31. https://prismreports.org/2022/10/31/prison-health-care-hidden-costs/.

Becker, H., and N. Einbinder. 2024. “The untimely death of Christopher Cox.” Business Insider, December 24. https://www.businessinsider.com/prison-medical-health-care-neglect-2024-12.

Becton, D. 2022. “Addendum to the law enforcement involved fatal incident investigation of Angelo Voithugo Quinto on December 24th, 2020.” Contra Costa County District Attorney. https://www.contracosta.ca.gov/DocumentCenter/View/80995/Angelo-Quinto-LEIFI-Addendum-Final (accessed June 2025).

Binswanger, I. A., P. M. Krueger, and J. F. Steiner. 2009. “Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population.” Journal of Epidemiology and Community Health 63(11): 912–919. https://doi.org/10.1136/jech.2009.090662.

BJA (Bureau of Justice Assistance). 2019a. “About the Bureau of Justice Assistance.” U.S. Department of Justice. https://bja.ojp.gov/about (accessed June 2025).

—. 2019b. “Edward Byrne Memorial Justice Assistance Grant (JAG) Program.” U.S. Department of Justice. https://bja.ojp.gov/program/jag/overview (accessed June 2025).

—. 2022. “Death in Custody Reporting Act (DCRA) data collection overview.” U.S. Department of Justice. https://bja.ojp.gov/program/dcra/overview (accessed June 2025).

—. 2023. “Death in Custody Reporting Act: Compliance guidelines.” U.S. Department of Justice. https://bja.ojp.gov/doc/dcra-compliance-guidelines.pdf (accessed June 2025).

—. 2024a. “Death in Custody Reporting Act (DCRA) data collection: State implementation plans.” U.S. Department of Justice. https://bja.ojp.gov/program/dcra/state-implementation-plans (accessed June 2025).

—. 2024b. “Death in Custody Reporting Act (DCRA) data collection: State reported deaths in custody interactive tables.” U.S. Department of Justice. https://bja.ojp.gov/program/dcra/reported-data (accessed June 2025).

—. 2025. “Death in Custody Reporting Act: Reporting guidance and frequently asked questions.” Version 5.2. https://bja.ojp.gov/funding/performance-measures/DCRA-Reporting-Guidance-FAQs.pdf.

BJS (Bureau of Justice Statistics). 2017. “Indicators of mental health problems reported by prisoners and jail inmates, 2011-12.” U.S. Department of Justice. https://bjs.ojp.gov/content/pub/pdf/imhprpji1112_sum.pdf (accessed October 2025).

—. 2020. “Federal Law Enforcement Agency Deaths in Custody Reporting Program (FD-CRP).” U.S. Department of Justice. https://bjs.ojp.gov/data-collection/federal-law-enforcement-agency-deaths-custody-reporting-program-fdcrp (accessed June 2025).

—. 2021a. “Medical examiner and coroner offices, 2018.” NCJ 302051. U.S. Department of Justice. https://bjs.ojp.gov/content/pub/pdf/meco18.pdf (accessed June 2025).

—. 2021b. “Medical problems reported by prisoners: Survey of prison inmates, 2016.” NCJ 252644. U.S. Department of Justice. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/mprpspi16st.pdf (accessed June 2025).

—. 2021c. “Mortality in local jails, 2000–2019—Statistical tables.” NCJ 301368. U.S. Department of Justice. https://bjs.ojp.gov/content/pub/pdf/mlj0019st.pdf (accessed June 2025).

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

—. 2021d. “Mortality in state and federal prisons, 2001–2018—Statistical tables.” NCJ 255970. U.S. Department of Justice. https://bjs.ojp.gov/content/pub/pdf/msfp0118st.pdf (accessed June 2025).

—. 2021e. “Mortality in state and federal prisons, 2001–2019—Statistical tables.” NCJ 300953. U.S. Department of Justice. https://bjs.ojp.gov/content/pub/pdf/msfp0119st.pdf (accessed June 2025).

—. 2023. “Prisoners in 2022—Statistical tables.” NCJ 307149. U.S. Department of Justice. https://bjs.ojp.gov/document/p22st_sum.pdf (accessed June 2025).

—. 2024a. “Federal deaths in custody and during arrest, 2022—Statistical tables.” NCJ 309427. U.S. Department of Justice. https://bjs.ojp.gov/document/fdcda22st.pdf (accessed June 2025).

—. 2024b. “Preliminary data release—Jails (2023).” NCJ 309039. U.S. Department of Justice. https://bjs.ojp.gov/preliminary-data-release-jails-2023 (accessed June 2025).

—. 2025. “Jail inmates 2023—Statistical tables.” NCJ 309965. U.S. Department of Justice. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/ji23_example.pdf (accessed June 2025).

—. n.d. “Correctional institutions.” U.S. Department of Justice. https://bjs.ojp.gov/topics/corrections/correctional-institutions (accessed June 2025).

Bollard, G. A., D. McArdle, J. Meade, P. Pappas, B. Springer, M. D. Sztajnkrycer, and F. Czarnecki (Eds). 2018. “IACP police physicians section: Emergency trauma care.” International Association of Chiefs of Police. https://www.theiacp.org/sites/default/files/2018-08/Emergency%20Trauma%20Care.pdf (accessed June 2025).

Brinkley-Rubinstein, L., J. Sivaraman, D. L. Rosen, D. H. Cloud, G. Junker, S. Proescholdbell, M. E. Shanahan, and S. I. Ranapurwala. 2019. “Association of restrictive housing during incarceration with mortality after release.” JAMA Network Open 2(10): e1912516. https://doi.org/10.1001/jamanetworkopen.2019.12516.

Brooks, C. 2021. “Medical examiner and coroner offices, 2018.” NCJ 302051. The Bureau of Justice Statistics, U.S. Department of Justice. https://bjs.ojp.gov/content/pub/pdf/meco18.pdf (accessed June 2025).

Brooks, E. G., and K. D. Reed. 2015. “Principles and pitfalls: A guide to death certification.” Clinical Medicine & Research 13(2): 74–82. https://doi.org/10.3121/cmr.2015.1276.

Burghart, D. B. 2025. “Fatal encounters.” https://fatalencounters.org (accessed June 2025).

Campaign Zero. 2025. “Mapping police violence.” https://mappingpoliceviolence.org/ (accessed June 2025).

CAP (College of American Pathologists). n.d. “What you need to know about forensic pathology.” https://www.cap.org/member-resources/articles/what-you-need-to-know-about-forensic-pathology (accessed June 2025).

Carda-Auten, J., E. A. Dirosa, C. Grodensky, K. M. Nowotny, L. Brinkley-Rubinstein, D. Travers, M. Brown, S. Bradley-Bull, C. Blue, and D. L. Rosen. 2022. “Jail health care in the Southeastern United States from entry to release.” Milbank Quarterly 100(3): 722–760. https://doi.org/10.1111/1468-0009.12569.

CBS Bay City News Service. 2024. “Antioch agrees to $7.5M settlement with family of Angelo Quinto over in-custody death.” CBS, May 15. https://www.cbsnews.com/sanfrancisco/news/antioch-angelo-quinto-in-custody-death-7-5m-settlement-with-family/.

CDC (Centers for Disease Control and Prevention). 2003. “U.S. standard certificate of death.” https://www.cdc.gov/nchs/data/dvs/death11-03final-acc.pdf (accessed June 2025).

—. 2022. “National Violent Death Reporting System (NVDRS) Web Coding Manual, Version 6.1.” https://www.cdc.gov/nvdrs/media/pdfs/2025/03/nvdrs-coding-manual-version-6.1_508.pdf (accessed October 2025).

—. 2023. “Medicolegal death investigation systems, by country.” https://www.cdc.gov/nchs/comec/Medical-Death-Investigation-System-by-County.pdf (accessed June 2025).

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

—. 2024. “Coroner and medical examiner laws.” https://www.cdc.gov/phlp/php/coroner/index.html (accessed June 2025).

The Center for Health and Justice Transformation. 2025. “Jail & prison opioid project.” https://prisonopioidproject.org/ (accessed June 2025).

Chen, S. 2021. “Forensic pathologist: George Floyd died from neck restraint.” Axios, April 9. https://www.axios.com/2021/04/09/chauvin-trial-george-floyd-forensic-pathologist.

Choudhary, A. K., S. Servaes, T. L. Slovis, V. J. Palusci, G. L Hedlund, S. K. Narang, J. A. Moreno, M. S. Dias, C. W. Christian. M. D. Nelson Jr., V. M. Silvera, S. Palasis, M. Raissaki, A. Rossi, and A. C. Offiah. 2018. “Consensus statement on abusive head trauma in infants and young children.” Pediatric Radiology 48(8):1048–1065. https://doi.org/10.1007/s00247-018-4149-1.

Christopher, T. 2024. “There is little scrutiny of ‘natural’ deaths behind bars.” NPR, January 2. https://www.npr.org/2024/01/02/1219667393/there-is-little-scrutiny-of-natural-deaths-behind-bars.

CMS (Centers for Medicare & Medicaid Services). n.d. “Reentry section 1115 demonstration opportunity.” https://www.medicaid.gov/medicaid/section-1115-demonstrations/reentry-section-1115-demonstration-opportunity (accessed June 2025).

County of Santa Clara. 2025. “Me-C data dashboard.” https://mec.santaclaracounty.gov/education-and-awareness/me-c-data-dashboard (accessed June 2025).

Croskerry, P., G. Singhal, and S. Mamede. 2013. “Cognitive debiasing 2: Impediments to and strategies for change.” BMJ Quality & Safety 22 (Suppl 2): ii65–ii72. https://doi.org/10.1136/bmjqs-2012-001713.

da Silva Bhatia, B. 2022. “‘Excited delirium’ and deaths in police custody: The deadly impact of a baseless diagnosis.” Physicians for Human Rights, March 2. https://phr.org/our-work/resources/excited-delirium/#_edn7.

Da Silva, S., R. Gupta, and D. Monzani. 2023. “Editorial: Highlights in psychology: Cognitive bias.” Frontiers in Psychology 14: 1242809. https://doi.org/10.3389/fpsyg.2023.1242809.

Darke, S., S. Larney, and M. Farrell. 2017. “Yes, people can die from opiate withdrawal.” Addiction 112(2): 199–200. https://doi.org/10.1111/add.13512.

Data Foundation. 2024. “Reimagining vital records: A digital, interoperable, & timely public health data infrastructure.” https://datafoundation.org/news/data-sharing/37/37-Reimagining-Vital-Records-A-Digital-Interoperable-Timely-Public-Health-Data-Infrastructure (accessed June 2025).

Deitch, M. 2020. “But who oversees the overseers?: The status of prison and jail oversight in the United States.” American Journal of Criminal Law 47(2): 207–274.

Democracy Now! 2023. “Family of Lashawn Thompson demands justice after he was ‘eaten alive’ by insects in Atlanta jail.” https://www.democracynow.org/2023/4/18/lashawn_thompson_atlanta_jail_eaten_alive (accessed July 2025).

Dexheimer, E., and J. Schwartz. 2018. “In fatal struggles with police, a controversial killer is often blamed.” Austin American-Statesman, May 27. https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007/.

Division of Criminal Justice. 2025. “Reports on the use of force by police officers.” State of Connecticut. https://portal.ct.gov/dcj/whats-news/reports-on-the-use-of-force-by-peace-officers/reports-on-the-use-of-force-by-police-officers?language=en_US (accessed June 2025).

DOJ (U.S. Department of Justice). 2016. “Report of the Attorney General to Congress pursuant to the Death in Custody Reporting Act.” https://www.justice.gov/archives/page/file/918846/dl?inline=.

—. 2024. “Investigation of the Fulton County Jail.” https://www.justice.gov/crt/media/1377011/dl (accessed October 2025).

Dror, I. E. 2018. “Biases in forensic experts.” Science 360(6386): 243. https://doi.org/10.1126/science.aat8443.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

Dror, I. E., and G. Hampikian. 2011. “Subjectivity and bias in forensic DNA mixture interpretation.” Science & Justice 51(4): 204–208. https://doi.org/10.1016/j.scijus.2011.08.004.

Dror, I. E., and J. Kukucka. 2021. “Linear sequential unmasking-expanded (LSU-E): A general approach for improving decision making as well as minimizing noise and bias.” Forensic Science International: Synergy 3: 100161. https://doi.org/10.1016/j.fsisyn.2021.100161.

Dumont, D. M., B. Brockmann, S. Dickman, N. Alexander, and J. D. Rich. 2012. “Public health and the epidemic of incarceration.” Annual Review of Public Health 33: 325–339. https://doi.org/10.1146/annurev-publhealth-031811-124614.

Duret, D. 2024. “5 takeaways from our investigation into police use of spit hoods.” The Marshall Project, February 15. https://www.themarshallproject.org/2024/02/15/florida-texas-police-deaths-spit-hood-takeaways.

Duwe, G. 2022. “National Institute of Justice literature review and data analysis on Deaths in Custody Report to Congress.” U.S. Office of Justice Programs. https://www.ojp.gov/pdffiles1/nij/305802.pdf (accessed July 2025).

Dyer, K. R., D. J. Foster, J. M. White, A. A. Somogyi, A. Menelaou, and F. Bochner. 1999. “Steady-state pharmacokinetics and pharmacodynamics in methadone maintenance patients: Comparison of those who do and do not experience withdrawal and concentration-effect relationships.” Clinical Pharmacology and Therapeutics 65(6): 685–694. https://doi.org/10.1016/s0009-9236(99)90090-5.

Dyer, K. R., J. M. White, D. J. Foster, F. Bochner, A. Menelaou, and A. A. Somogyi. 2001. “The relationship between mood state and plasma methadone concentration in maintenance patients.” Journal of Clinical Psychopharmacology 21(1): 78–84. https://doi.org/10.1097/00004714-200102000-00014.

The Editors. 2021. “Those who investigate premature deaths should have medical training.” Scientific American, May 1. https://www.scientificamerican.com/article/those-who-investigate-premature-deaths-should-have-medical-training/.

Elassar, A., and R. Romo. 2025. “Florida lawmakers allowed into ‘Alligator Alcatraz’ say detainees packed into cages.” CNN, July 13. https://www.cnn.com/2025/07/12/us/alligator-alcatraz-lawmaker-tour-conditions.

Elinder, G., A. Eriksson, B. Hallberg, N. Lynøe, P. M. Sundgren, M. Rosén, I. Engström, and B. E. Erlandsson. 2018. “Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking.” Acta Paediatrica 107(Suppl 472): 3–23. https://doi.org/10.1111/apa.14473.

FAMM (Families Against Mandatory Minimums). n.d. “The desperate need for prison oversight: A prison tragedy.” https://famm.org/the-desperate-need-for-prison-oversight-a-prison-tragedy/ (accessed June 2025).

Fazel, S., A. J. Hayes, K. Bartellas, M. Clerici, and R. Trestman. 2016. “Mental health of prisoners: Prevalence, adverse outcomes, and interventions.” Lancet Psychiatry 3(9):871–881. https://doi.org/10.1016/S2215-0366(16)30142-0.

Findley, K. A., and D. A. Strang. 2022. “Ending manner-of-death testimony and other opinion determinations of crime.” Duquesne University Law Review 60(302).

Fiscella, K., M. Noonan, S. H. Leonard, S. Farah, M. Sanders, S. E. Wakeman, and J. Savolainen. 2020. “Drug- and alcohol-associated deaths in U.S. jails.” Journal of Correctional Health Care 26(2): 183–193. https://doi.org/10.1177/1078345820917356.

Florido, A. 2021. “Forensic expert for Chauvin’s defense said heart disease, drugs killed George Floyd.” NPR, April 14. https://www.npr.org/2021/04/14/987371938/forensic-expert-for-chauvins-defense-said-heart-disease-drugs-killed-george-floy.

Fortin, J. 2021. “California man died after police knelt on him for 5 minutes, family says.” The New York Times, February 25. https://www.nytimes.com/2021/02/25/us/angelo-quinto-death-police-kneel.html.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

Frosh, B., A. W. Taylor, M. Garland, and R. Walensky. 2021. “Open letter to political leadership.” https://www.mncourts.gov/mncourtsgov/media/High-Profile-Cases/27-CR-20-12949-TT/Exhibit505122021.pdf (accessed June 2025).

GAO (U.S. Government Accountability Office). 2017. “Bureau of prisons: Better planning and evaluation needed to understand and control rising inmate health care costs.” GAO-17-379. https://www.gao.gov/assets/d17379.pdf (accessed June 2025).

—. 2022. “Deaths in custody: Additional action needed to help ensure data collected by DOJ are utilized.” Statement of Gretta L. Goodwin, Director, Homeland Security and Justice. Testimony Before the Permanent Subcommittee on Investigations, Committee on Homeland Security and Governmental Affairs, U.S. Senate. GAO-22-106033. https://www.gao.gov/assets/d22106033.pdf (accessed June 2025).

GBD 2019 Police Violence US Subnational Collaborators. 2021. “Fatal police violence by race and state in the USA, 1980–2019: A network meta-regression.” The Lancet 398 (10307): 1239–1255. https://doi.org/10.1016/S0140-6736(21)01609-3.

Gerace, J. J., and M. W. Dailey. 2023. “Police practice: Safe restraint of agitated patients.” FBI Law Enforcement Bulletin, January 10. https://leb.fbi.gov/articles/additional-articles/police-practice-safe-restraint-of-agitated-patients.

Glaser, J. 2024. “Disrupting the effects of implicit bias the case of discretion & policing.” Daedalus 153(1): 151–173.

Gonin, P., N. Beysard, B. Yersin, and P. N. Carron. 2018. “Excited delirium: A systematic review.” Academic Emergency Medicine 25(5): 552–565. https://doi.org/10.1111/acem.13330.

Graber, M. L., N. Franklin, and R. Gordon. 2005. “Diagnostic error in internal medicine.” Archives of Internal Medicine 165(13): 1493–1499. https://doi.org/10.1001/archinte.165.13.1493.

Graham, M. A. 2025. “Asphyxial death pathology.” Medscape. https://emedicine.medscape.com/article/1988699-overview (accessed June 2025).

Hammett, T. M. 2006. “Chapter 12—Epidemiology of HIV/AIDS and other infectious diseases in correctional facilities.” In Clinical practice in correctional medicine (second edition), edited by Michael Puisis, 167–174. Philadelphia: Mosby.

Haney, C. 2018. “Restricting the use of solitary confinement.” Annual Review of Criminology 1 (1): 285–310. https://doi.org/10.1146/annurev-criminol-032317-092326.

Hanzlick, R., J. C. Hunsaker, III, and G. J. Davis. 2002. “A guide for manner of death classification.” National Association of Medical Examiners. https://name.memberclicks.net/assets/docs/MANNEROFDEATH.pdf (accessed June 2025).

Hennepin County Medical Examiner’s Office. 2020. “Autopsy report: George Floyd.” ME NO: 20-3700. https://www.hennepin.us/-/media/hennepinus/residents/public-safety/medical-examiner/floyd-autopsy-6-3-20.pdf (accessed June 2025).

Herbers, D., and J. Turley. 2025. “No autopsy, no answer.” Flatwater Free Press, January 31. https://flatwaterfreepress.org/no-autopsy-no-answer/.

Herring, T. 2022. “COVID looks like it may stay. That means prison medical copays must go.” Prison Policy Initiative, February 1. https://www.prisonpolicy.org/blog/2022/02/01/pandemic_copays/.

IACME (International Association of Coroners & Medical Examiners). n.d. “Accreditation.” https://theiacme.com/page/Accreditation (accessed June 2025).

Incarceration Transparency. 2023a. “Louisiana deaths behind bars 2015–2021.” Loyola University New Orleans College of Law. https://www.incarcerationtrans-parency.org/wp-content/uploads/2023/06/Death-Behind-Bars-Report-2023-Final-06.05.23.pdf (accessed June 2025).

—. 2023b. “South Carolina deaths behind bars 2015–2021.” https://www.incarcerationtransparency.org/wp-content/uploads/2023/02/SC-Deaths-Behind-Bars-Final-Report-2.13.23.pdf (accessed June 2025).

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

IOM (Institute of Medicine). 2003. Medicolegal death investigation system: Workshop summary. Washington, DC: The National Academies Press.

James, N. 2023. “Death in Custody Reporting Act: Background and legislative considerations.” R47559. Congressional Research Service. https://www.congress.gov/crs-product/R47559 (accessed June 2025).

Janovsky, D. 2024. “How states are (and aren’t) collecting death-in-custody data.” Project on Government Oversight (POGO). https://www.pogo.org/analysis/how-states-are-and-arent-collecting-death-in-custody-data (accessed June 2025).

Jenkins, J. 2020. “Incarcerated people near death await Arizona Gov. Ducey’s signature for release.” KJZZ, March 26. https://www.kjzz.org/2020-03-26/content-1504341-incarcerated-people-near-death-await-arizona-gov-duceys-signature-release.

Khatri, U. G., J. K. Hakes, D. Buckler, A. Zebrowski, and T. Winkelman. 2025. “Individual- and area-level incarceration and mortality.” JAMA Network Open 8(6): e2513537. https://doi.org/10.1001/jamanetworkopen.2025.13537.

Krane, D. E., S. Ford, J. R. Gilder, K. Inman, A. Jamieson, R. Koppl, I. L. Kornfield, D. M. Risinger, N. Rudin, M. S. Taylor, and W. C. Thompson. 2008. “Sequential unmasking: A means of minimizing observer effects in forensic DNA interpretation.” Journal of Forensic Sciences 53(4): 1006–1007. https://doi.org/10.1111/j.1556-4029.2008.00787.x.

Kukucka, J., W. C. Tompson, M. D. Freeman, D. Davis, A. E. Walker, and J. Crane. 2025. “An independent audit of restraint-related death investigations at Maryland OCME from 2003–2019.” https://wjla.com/resources/pdf/84c036d1-69f0-49b8-b4c8-13a135c0f336-051525_OCME_audit_report_FINAL.pdf (accessed June 2025).

LaForgia, M., and J. Valentino-DeVries. 2021. “How a genetic trait in Black people can give the police cover.” The New York Times, May 15. https://www.nytimes.com/2021/05/15/us/african-americans-sickle-cell-police.html.

Lartey, J. 2024. “More states restricting ‘excited delirium’ as cause of death in police custody.” The Marshall Project, June 15. https://www.themarshallproject.org/2024/06/15/police-custody-excited-delirium-meaning.

Lathrop, S. L. 2011. “Forensic pathology and epidemiology, public health and population-based research.” Academic Forensic Pathology 1(3): 282–287. https://doi.org/10.23907/2011.039.

Law Enforcement Policy Center. 2019. “Arrests and investigatory stops.” International Association of Chiefs of Police. https://www.theiacp.org/sites/default/files/2020-06/Arrests%20etc.%20June%202020.pdf (accessed June 2025).

LeMasters, K., M. F. Behne, J. Lao, M. Peterson, and L. Brinkley-Rubinstein. 2023. “Suicides in state prisons in the United States: Highlighting gaps in data.” PLoS One 18(5): e0285729. https://doi.org/10.1371/journal.pone.0285729.

Levy, B. 2015. “The need for informatics to support forensic pathology and death investigation.” Journal of Pathology Informatics 6: 32. https://doi.org/10.4103/2153-3539.158907.

Levy, M. K., D. K. Tan, D. Q. McArdle, M. McEvoy, D. F. Kupas, G. Beltran, and D. L. Miller. 2024. “Consensus statement of the National Association of EMS Physicians, International Association of Fire Chiefs, and the International Association of Chiefs of Police: Best practices for collaboration between law enforcement and emergency medical services during acute behavioral emergencies.” Prehospital Emergency Care 28(8): 1058–1062. https://doi.org/10.1080/10903127.2024.2402530.

Lewis, C. 2024. “NYC stops doing autopsies in Queens as more medical examiners leave.” Gothamist, November 8. https://gothamist.com/news/nyc-stops-doing-autopsies-in-queens-as-more-medical-examiners-leave.

Lidén, M., I. Thiblin, and I. E. Dror. 2023. “The role of alternative hypotheses in reducing bias in forensic medical experts’ decision making.” Science and Justice 63(5): 581–587. https://doi.org/10.1016/j.scijus.2023.07.005.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

Lobel, J., and H. Akil. 2018. “Law & neuroscience: The case of solitary confinement.” Daedalus 147(4): 61–75. https://doi.org/10.1162/daed_a_00520.

Maccio, U., C. A. Meier, M. Reinehr, F. Ruschitzka, R. Schüpbach, H. Moch, and Z. Varga. 2025. “Clinically undiagnosed diseases in autopsies: Frequency and risk factors.” Archives of Pathology and Laboratory Medicine 149(1): 60–66. https://doi.org/10.5858/arpa.2023-0429-OA.

Mack, A. K., R. S. Bercovitz, and H. Lust. 2021. “Some medical examiners say sickle cell trait causes sudden death—They’re wrong.” Scientific American, June 20. https://www.scientificamerican.com/article/some-medical-examiners-say-sickle-cell-trait-causes-sudden-death-theyre-wrong/.

McCann, S., and E. Bryant. 2025. “Fifth confirmed jail death of 2025 brings New York City’s total to 38 under Mayor Adams.” Vera Institute of Justice, April 1. https://www.vera.org/news/nyc-jail-deaths.

McCloskey, C., and C. Riyad. 2025. “SES048 specialty update: Pathology.” 2025 ACGME Annual Educational Conference: Meaning in Medicine, Nashville, TN, February 21, 2025. https://www.acgme.org/globalassets/pfassets/presentations/2025-specialty-updates/pathology-update-2025.pdf.

McKillop, M. 2017. “Prison health care spending varies dramatically by state.” The Pew Charitable Trusts, December 15. https://www.pew.org/en/research-and-analysis/articles/2017/12/15/prison-health-care-spending-varies-dramatically-by-state.

Melinek, J., L. C. Thomas, W. R. Oliver, G. A. Schmunk, and V. W. Weedn. 2013. “National Association of Medical Examiners position paper: Medical examiner, coroner, and forensic pathologist independence.” Academic Forensic Pathology 3(1): 93–98. https://doi.org/10.23907/2013.013.

Mental Health America. 2015. “Mental health treatment in correctional facilities.” https://mhanational.org/position-statements/mental-health-treatment-in-correctional-facilities/ (accessed June 2025).

Mitchell, R. A., Jr., F. Diaz, G. A. Goldfogel, M. Fajardo, S. E. Fiore, T. V. Henson, M. A. Jorden, S. Kelly, S. Luzi, M. Quinn, and D. A. Wolf. 2017. “National Association of Medical Examiners position paper: Recommendations for the definition, investigation, postmortem examination, and reporting of deaths in custody.” Academic Forensic Pathology 7(4): 604–618. https://doi.org/10.23907/2017.051.

Montana Department of Justice. 2024. “Coroner liaison position.” Montana Public Safety Officer Standards and Training Council: Coroner committee meeting agenda, February 19. https://dojmt.gov/wp-content/uploads/2024/11/2-19-25-Coroner-Committee-Agenda-Materials.pdf.

Munden, P., and E. Wright. 2023. “A thematic review of recent Prevention of Future Deaths (‘PFD’) reports.” Hill Dickinson, September 12. https://www.hilldickinson.com/insights/articles/thematic-review-recent-prevention-future-deaths-pfd-reports#:%7E:text=Deaths%20in%20prison%20custody,a%20range%20of%20dangerous%20effects.

NAME (National Association of Medical Examiners). 2020. “Forensic autopsy performance standards.” https://www.thename.org/assets/docs/2016%20NAME%20Forensic%20Autopsy%20Standards%209-25-2020.pdf (accessed July 2025).

—. 2023. “Excited delirium statement.” https://name.memberclicks.net/assets/docs/Excited%20Delirium%20Statement%203%20-%202023.pdf (accessed June 2025).

—. 2024. “Name inspection and accreditation checklist.” https://name.memberclicks.net/assets/docs/NAME%20Accreditation%20Checklist%202024%20-%202029.pdf (accessed June 2025).

—. n.d.-a. “The history of the National Association of Medical Examiners.” https://www.thename.org/history-of-name (accessed June 2025).

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

—. n.d.-b. “Inspection and accreditation.” https://www.thename.org/inspection-accreditation (accessed October 2025).

NAMI (National Alliance on Mental Illness). 2025. “Mental health by the numbers.” https://www.nami.org/about-mental-illness/mental-health-by-the-numbers/ (accessed July 2025).

Narang, S. K., A. Fingarson, and J. Lukefahr. 2020. “Abusive head trauma in infants and children.” Pediatrics 145(4). https://doi.org/10.1542/peds.2020-0203.

Narang, S. K., S. Haney, A. C. Duhaime, J. Martin, G. Binenbaum, A. G. de Alba Campomanes, R. Barth, G. Bertocci, M. Care, D. McGuone, the Council on Child Abuse and Neglect, Section on Ophthalmology, Section on Radiology, Section on Neurological Surgery, Society for Pediatric Radiology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology. 2025. “Abusive head trauma in infants and children: Technical report.” Pediatrics 155(3). https://doi.org/10.1542/peds.2024-070457.

NASEM (National Academies of Sciences, Engineering, and Medicine). 2019. Medications for opioid use disorder save lives. Edited by A. I. Leshner and M. Mancher. Washington, DC: The National Academies Press.

—. 2020. The effects of incarceration and reentry on community health and well-being: Proceedings of a workshop. Edited by S. Olson and K. M. Anderson. Washington, DC: The National Academies Press.

National Center for Health Statistics. 2023. “Impact of medical examiners and coroners in public health.” U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nvss/medical-examiners-coroners.htm# (accessed June 2025).

—. 2024. “Drug overdose deaths.” U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nvss/drug-overdose-deaths.htm (accessed June 2025).

NCCHC (National Commission on Correctional Health Care) and National Sheriffs’ Association. 2018. “Jail-based medication-assisted treatment: Promising practices, guidelines, and resources for the field.” https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf (accessed July 2025).

NCJA (National Criminal Justice Association). n.d. “State administering agencies.” https://www.ncja.org/state-administering-agencies (accessed June 2025).

NIDA (National Institute on Drug Abuse). 2020. “Criminal justice drug facts.” The National Institutes of Health. https://nida.nih.gov/publications/drugfacts/criminal-justice (accessed June 2025).

NIJ (National Institute of Justice). 2009. “The use-of-force continuum.” U.S. Department of Justice. https://nij.ojp.gov/topics/articles/use-force-continuum (accessed June 2025).

—. 2019. “Report to Congress: Needs assessment of forensic laboratories and medical examiner/coroner offices.” U.S. Department of Justice. https://www.justice.gov/olp/page/file/1228306/dl (accessed June 2025).

—. 2024a. “Death investigation: A guide for the scene investigator.” NCJ 308955. U.S. Department of Justice. https://nij.ojp.gov/library/publications/death-investigation-guide-scene-investigator-2024 (accessed June 2025).

—. 2024b. “National Center on Forensics.” U.S. Department of Justice. https://nij.ojp.gov/program/national-center-forensics/creating-coroner-liaison-position (accessed June 2025).

—. 2024c. “Understanding and reducing deaths in custody: Interim summary report to Congress.” https://www.ojp.gov/pdffiles1/nij/309952.pdf (accessed October 2025).

NIST (National Institute of Standards and Technology). n.d. “Forensic science standards library.” The Organization of Scientific Area Committees for Forensic Science. https://www.nist.gov/osac/standards-library (accessed July 2025).

NRC (National Research Council). 1928. The coroner and the medical examiner. Washington, DC: Bulletin of the National Research Council No. 64.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

—. 2009. Strengthening forensic science in the United States: A path forward. Washington, DC: The National Academies Press.

NSTC (National Science and Technology Council). 2016. “Strengthening the medicolegal-death-investigation system: Improving data systems.” https://www.ojp.gov/pdffiles1/NIJ/251423.pdf (accessed June 2025).

Obasogie, O. K. 2021. “Excited delirium and police use of force.” Virginia Law Review 107(8): 1545–1619.

Office of the New York State Attorney General. 2025. “Office of special investigation.” https://ag.ny.gov/office-special-investigation (accessed June 2025).

OIG (Office of Inspector General). 2024. “Evaluation of issues surrounding inmate deaths in Federal Bureau of Prisons institutions.” 24-041. U.S. Department of Justice. https://oig.justice.gov/sites/default/files/reports/24-041.pdf (accessed June 2025).

OII (Office of Independent Investigations). n.d. “About OII.” State of Washington. https://oii.wa.gov/about-oii (accessed June 2025).

OJP (Office of Justice Programs). 1995. “Positional asphyxia—Sudden death.” NCJ 206121. U.S. Department of Justice. https://www.ojp.gov/library/publications/positional-asphyxia-sudden-death (accessed June 2025).

Ontario Forensic Pathology Service. 2022. 2021–2022 annual report of the Ontario Forensic Pathology Service. Toronto: Ontario Ministry of the Solicitor General. https://www.ontario.ca/document/2021-2022-annual-report-ontario-forensic-pathology-service (accessed September 2025).

PBS (Public Broadcasting Service). 2011. “Post mortem: Death investigation in America.” FRONTLINE. https://www.pbs.org/wgbh/pages/frontline/post-mortem/things-to-know/autopsy-101.html#:~:text=A%20private%20autopsy%20by%20an,and%20from%20the%20autopsy%20facility (accessed June 2025).

Penal Reform International. 2023. “Investigating deaths in prison: A guide to a human rights-based approach.” University of Nottingham. https://cdn.penalreform.org/wp-content/uploads/2023/09/Deaths-investigations-guide.pdf (accessed June 2025).

Police Executive Research Forum. 2024. “15 principles for reducing the risk of restraint related death.” https://www.policeforum.org/assets/Restraint.pdf (accessed August 2025).

—. 2025. “Managing officer-involved critical incidents: Guidelines to achieve consistency, transparency, and fairness.” Critical Issues in Policing Series. https://www.policeforum.org/assets/ManagingOICIs.pdf (accessed August 2025).

Pont, J., H. Stöver, and H. Wolff. 2012. “Dual loyalty in prison health care.” American Journal of Public Health 102(3): 475–480. https://doi.org/10.2105/ajph.2011.300374.

Prados, M. J., T. Baker, A. N. Beck, D. B. Burghart, R. R. Johnson, D. Klinger, K. Thomas, and B. Karl Finch. 2022. “Do sheriff-coroners underreport officer-involved homicides?” Academic Forensic Pathology 12(4) 140–148. https://doi.org/: 10.1177/19253621221142473.

Reuters. 2020. “Dying inside: The hidden crisis in America’s jails.” https://www.reuters.com/investigates/section/usa-jails/.

—. n.d. “The taser cases.” https://www.reuters.com/investigates/special-report/usa-taser-database/.

Rho, E. H., M. Harrington, Y. Zhong, R. Pryzant, N. P. Camp, D. Jurafsky, and J. L. Eberhardt. 2023. “Escalated police stops of Black men are linguistically and psychologically distinct in their earliest moments.” Proceedings of the National Academy of Sciences 120(23): e2216162120. https://doi.org/10.1073/pnas.2216162120.

Rising, J., S. Whaley, and B. Saloner. 2022. “How the Drug Enforcement Administration can improve access to methadone in correctional facilities and save lives.” Johns Hopkins Bloomberg School of Public Health. https://americanhealth.jhu.edu/sites/default/files/JHU-026%20Methadone%20White%20Paper-r1.pdf (accessed June 2025).

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

Romo, V. 2022. “Maryland officials order the reinvestigation of about 100 deaths in police custody.” NPR, October 22. https://www.npr.org/2022/10/20/1130076058/david-fowler-maryland-autopsies-george-floyd.

Rosen, D. 2023. “Survey indicates jail healthcare falls short of community standards.” UNC Institute for Global Health and Infectious Diseases. https://globalhealth.unc.edu/2023/11/survey-indicates-jail-healthcare-falls-short-of-community-standards/ (accessed June 2025).

RTI. 2024a. “Understanding and reducing deaths in custody case study report.” RTI Project Number 0218273.000. Office of Justice Programs. https://www.ojp.gov/pdffiles1/nij/310044.pdf.

—. 2024b. “Understanding and reducing deaths in custody analysis of the Bureau of Justice Assistance Death in Custody Reporting Act (DCRA) data.” RTI Project Number 0218273.000. Office of Justice Programs. https://www.ojp.gov/pdffiles1/nij/310043.pdf (accessed July 2025).

—. 2024c. “Understanding and reducing deaths in custody interim report.” RTI Project Number 0218273.000. Office of Justice Programs. https://www.ojp.gov/pdffiles1/nij/309441.pdf (accessed July 2025).

Sassoon, A. M. 2019. “Excited delirium: Rare and deadly syndrome or a condition to excuse deaths by police?” Florida Today, October 24. https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001/.

Sawyer, W., and P. Wagner. 2025. “Mass incarceration: The whole pie 2025.” Prison Policy Initiative. https://www.prisonpolicy.org/reports/pie2025.html (accessed June 2025).

Schwartzapfel, B., and J. Jenkins. 2021. “Overdose deaths in state prisons have jumped dramatically since 2001.” NPR, July 15. https://www.npr.org/2021/07/15/1015447281/overdose-deaths-state-prisons-increase.

Shalit, M., and M. R. Lewin. 2004. “Medical care of prisoners in the USA.” The Lancet 364: 34–35. https://doi.org/10.1016/S0140-6736(04)17633-2.

Shapiro, N., and T. Keel. 2024. “Naturalizing unnatural death in Los Angeles County jails.” Medical Anthropology Quarterly 38(1): 6–23. https://doi.org/10.1111/maq.12819.

Shi, L., J. R. Silver, and A. Hickert. 2022. “Conceptualizing and measuring public stigma toward people with prison records.” Criminal Justice and Behavior 49(11): 1676–1698. https://doi.org/10.1177/00938548221108932.

Sims, D. N., N. E. Langlois, and R. W. Byard. 2013. “An approach to peer review in forensic pathology.” Journal of Forensic and Legal Medicine 20(5): 402–403. https://doi.org/10.1016/j.jflm.2013.02.010.

Sirotnak, A. P. 2006. “Medical disorders that mimic abusive head trauma.” In Abusive Head Trauma in Infants and Children: A Medical, Legal, and Forensic Reference, 191–226. St. Louis, MO: GW Medical Publishers.

Stern, M. F. 2019. “Report to the court in the matter of Parsons v. Ryan, et al.” [Federal Rule 706 Expert]. Case 2:12-cv-00601-ROS, Document 3379. U.S. District Court for Arizona. https://www.prisonlegalnews.org/media/publications/Parsons_v._Ryan_report_Stern_2019.pdf (accessed June 2025).

Stevens, T., J. Pritchard, and H. Wieffering. 2024. “This is how reporters documented 1,000 deaths after police force that isn’t supposed to be fatal.” The Associated Press, March 28. https://apnews.com/article/associated-press-investigation-deaths-police-encounters-ba08cef07a4481bfb0e455dc33b9495d.

Szep, J., N. Parker, L. So, P. Eisler, and G. Smith. 2020. “Dying inside: The hidden crisis in America’s jails part two.” Reuters, October 26. https://www.reuters.com/investigates/special-report/usa-jails-privatization/.

Tatsumi, K., and M. Graham. 2022. “Death investigation in the United States: Forensic pathology.” Missouri Medicine 119(5): 411–415.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

Teller, S. E. 2017. “Inmate’s suicide leads to $7 million settlement for her estate.” Legal Reader, November 10. https://www.legalreader.com/inmates-estate-receive-7-million-suicide/.

Tiernan, C. 2022. “Even before $27 million Spokane County Jail lawsuit, Naphcare had a rocky legal history.” The Spokane Review, July 24. https://www.spokesman.com/stories/2022/jul/24/even-before-27-million-spokane-county-jail-lawsuit/.

TRAC Immigration. 2025. “Detention facilities average daily population.” https://tracreports.org/immigration/detentionstats/facilities.html (accessed September 2025).

Tucker, W. 2016. “Profits vs. prisoners: How the largest U.S. prison health care provider puts lives in danger.” Southern Poverty Law Center, October 27. https://www.splcenter.org/resources/reports/profits-vs-prisoners-how-largest-us-prison-health-care-provider-puts-lives-danger/.

U.S. Census Bureau. 2024a. “Quick facts: Lousiana.” https://www.census.gov/quickfacts/fact/table/LA,US/PST045224 (accessed June 2025).

—. 2024b. “Quick facts: Montana.” https://www.census.gov/quickfacts/fact/table/MT/PST045224 (accessed June 2025).

—. 2024c. “Quick facts: Nebraska.” https://www.census.gov/quickfacts/fact/table/NE/PST045224 (accessed June 2025).

—. 2024d. “Quick facts: South Carolina.” https://www.census.gov/quickfacts/fact/table/SC/PST045224 (accessed June 2025).

U.S. Senate Committee on Homeland Security & Governmental Affairs, Permanent Subcommittee on Investigations. 2022. Uncounted deaths in America’s prisons and jails: How the Department of Justice failed to implement the Death in Custody Reporting Act. Majority & Minority Staff Report. https://www.hsgac.senate.gov/subcommittees/investigations/library/files/majority-and-minority-staff-report_-uncounted-deaths-in-americas-prisons-and-jails-how-the-department-of-justice-failed-to-implement-the-death-in-custody-reporting-act/.

Valencia, N. 2023. “Man’s death at a Georgia County Jail was a homicide caused by neglect, independent medical review commissioned by attorneys says.” CNN, May 23. https://www.cnn.com/2023/05/22/us/lashawn-thompson-atlanta-inmate-death-independent-medical-review.

Vaughn, J., and B. Hailer. 2023. “How many deaths occurred in your county’s jail? See our database.” Penn Live, November 9. https://www.pennlive.com/news/2023/11/how-many-deaths-occurred-in-your-countys-jail-see-our-database.html.

Vera Institute of Justice. 2025. “ICE detention trends.” https://www.vera.org/ice-detention-trends (accessed September 2025).

Von Quednow, C. 2024. “Family of California man who died days after police restrained him is getting $7.5M in settlement with city.” CNN, May 16. https://www.cnn.com/2024/05/16/us/angelo-quinto-death-police-antioch-settlement.

Warner, M., P. A. Braun, and P. A. Brown. 2017. “Public health impact: How medicolegal death investigation data help the living.” Academic Forensic Pathology 7(4): xiv–xvi. https://doi.org/10.1177/192536211700700405.

Washington Office of the Governor. 2020. “Governor’s task force on independent investigations of police use of force.” https://oii.wa.gov/sites/default/files/2023-08/Governors%20Task%20Force%20on%20Independent%20Investigations%20of%20Police%20Use%20of%20Force%20Report.pdf (accessed June 2025).

Weedn, V., A. Steinberg, and P. Speth. 2022. “Prone restraint cardiac arrest in in-custody and arrest-related deaths.” Journal of Forensic Sciences 67(5): 1899–1914. https://doi.org/10.1111/1556-4029.15101.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

Wilper, A. P., S. Woolhandler, J. W. Boyd, K. E. Lasser, D. McCormick, D. H. Bor, and D. U. Himmelstein. 2009. “The health and health care of US prisoners: Results of a nationwide survey.” American Journal of Public Health 99(4): 666–672. https://doi.org/10.2105/ajph.2008.144279.

World Population Review. 2025. “Autopsy laws by state 2025.” https://worldpopulationreview.com/state-rankings/autopsy-laws-by-state (accessed June 2025).

Zaychik, D. 2024. “Improving state medicolegal death investigation: Does system level reform improve public health data concerning drug-related mortality?” Journal of Forensic and Legal Medicine 103: 102680. https://doi.org/10.1016/j.jflm.2024.102680.

Suggested Citation: "References." National Academies of Sciences, Engineering, and Medicine. 2025. Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody. Washington, DC: The National Academies Press. doi: 10.17226/29232.

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Next Chapter: Appendix A: Committee and Staff Biographies
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