Office of the Attorney General Announces Process for Notifying Families and Releasing Findings in OCME Audit Case Reviews

​​​​​​​​​​​FOR IMMEDIATE RELEASE

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Comprehensive Review of 41 Cases Expected to Span Many Months; Findings to Be Released Case-by-Case

BALTIMORE, MD – The Office of the Attorney General (OAG) today announced a framework for transparency, family notification, and public accountability in its independent, case-by-case review of 41 restraint-related deaths that a 2025 audit of the Maryland Office of the Chief Medical Examiner (OCME) determined should have been classified as homicides. The purpose of the OAG’s case-by-case review is to determine whether the evidence in each case warrants reopening the matter for further criminal investigation.

OAG Case Review Notification Process 

Case reviews are ongoing. As each case review is completed, the OAG will make every effort to directly notify the decedent’s family.

• A family member – and any attorney representing them, where applicable – will receive a written letter outlining the results of OAG’s preliminary review and will be given 30 days to submit any additional information or materials they believe may be relevant to any determination of potential criminal liability. This input will be carefully considered before any final determination is made.
  
• Upon the expiration of the 30-day period and following a review of any materials submitted by the family or their attorney, the OAG will make its final determination and will notify the family of its findings before any public statement is made.
• The OAG will then issue an individual press release publicly announcing its findings for that case.
• Additionally, upon the completion of each review, the family will be offered the opportunity to personally review the investigative case file in keeping with the OAG’s commitment to keeping families informed and empowered in this process.
• The OAG will seek to contact all 41 families as it conducts its review of the OCME cases. Families who have questions in the meantime can reach out using the OAG’s OCME Audit Hotline below.

“Behind each of these 41 cases is a parent, grandparent, or child that lost a loved one,” said Attorney General Brown. “Our Office recognizes the grief these families have been carrying as they await further information about their loved one’s final moments. As we complete these reviews, we will give each case the careful, thorough, and independent examination that Marylanders expect and these families are owed.”

Maryland is the first state in the nation to undertake a review of this kind. Given the nature and scope of the independent review, the OAG is not able to provide a projected end date. Each of the 41 cases presents its own distinct facts, evidence, and circumstances, and each will follow a timeline dictated by the facts of that case. The OAG is committed to giving each case the time and attention it requires.

Background 

In May 2025, Attorney General Brown and Governor Wes Moore released a 70-page audit report – the first of its kind in the nation – examining in-custody death determinations made by the OCME between 2003 and 2019. 

From a pool of more than 1,300 in-custody deaths investigated by OCME, the Audit Design Team selected 87 cases involving deaths during or after restraint for independent review.

Key findings from that audit included:

• In 44 out of 87 cases reviewed, one or more of three independent forensic reviewers disagreed with the OCME’s original determination of the manner of death.
• In 36 cases, all three independent reviewers unanimously concluded the death should have been classified as a homicide.
• In 5 additional cases, 2 out of 3 reviewers concluded the death should have been classified as a homicide.

According to the National Association of Medical Examiners (NAME), the classification of the manner of death is not a legal conclusion. A death is classified as a homicide when it results from a volitional act committed by another person. The classification does not by itself establish criminal intent or criminal culpability, which are determinations made through the legal process. Since the release of the audit’s findings in 2025, the OCME has not changed the manner or cause of death certification in any of the 41 cases. 

The 41 Cases Under Review

The following individuals are the 41 decedents whose cases the OAG is reviewing pursuant to Governor Moore’s Executive Order. The 36 cases marked “Homicide” reflect a unanimous determination by all three independent reviewers. The five cases marked “No Consensus” reflect a determination by two out of three independent reviewers that the manner of death should have been classified as homicide. 

County, as listed below, is the jurisdiction that OCME listed on the cover page of the decedent’s autopsy report, which may differ from the county in which the decedent died or where the restraint occurred.

OAG’s OCME Audit Hotline

If you believe your loved one is a decedent whose case was impacted by the OCME audit, please contact the Office of the Attorney General:

Email: [email protected]

Phone: 833-282-0961

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