Governor Moore Signs Executive Order to Support Office of the Chief Medical Examiner Audit Findings in In-Custody Restraint-Related Death Investigations

ANNAPOLIS, MD—Governor Wes Moore signed an executive order to improve accountability and transparency in the conduct of in-custody restraint-related death investigations following the release of audit findings related to the investigation of the Office of the Chief Medical Examiner from 2003-2019. The order extends the unprecedented cooperation between the Office of the Governor, Office of the Attorney General, the Office of the Chief Medical Examiner, and a Maryland-led team of world-class medical examiners, forensic pathologists and social scientists whose work to design and execute this first-in-the-nation audit has created the opportunity for Maryland to develop a national model for the investigation of in-custody restraint-related deaths to advance justice, transparency and accountability.

“Maryland will continue to be a national leader in accountability, action, and equal justice under law. This executive order takes us one step closer to a more just and transparent system and was crafted with the same values that have guided our approach to public safety since Day One—true partnership with both law enforcement and the communities they protect; a close, objective examination of the facts; and an abiding commitment to making Maryland safer and uplifting the brave public servants who keep us safe,” said Gov. Moore. “Maryland was the first state in the nation to launch a comprehensive, methodical, and objective audit of our Office of the Chief Medical Examiner. And today, we become the first state in the nation to respond to such an audit with responsible action that brings everyone to the table.”

“Our audit’s findings exposed profound failures that denied families the true picture of what happened to their loved ones and weakened public trust in our institutions,” said Attorney General Brown. “Thanks to Governor Moore’s leadership, our Office is committed to confronting these wrongs, correcting them, and rebuilding faith in a system meant to serve and protect all people equally. We will do whatever it takes to get families the information they need to heal and will reexamine these cases to determine what, if any, action should be taken and how we can work to reduce police-involved deaths going forward.”

The executive order signed today includes the following:

• Directs the Attorney General, in consultation with local State’s Attorneys Offices, to review each case included within the audit to determine if the case should be reopened for investigation.

• Creates the Maryland Task Force on In-Custody Restraint-Related Death Investigations—a multidisciplinary entity consisting of state and government officials, the Office of the Chief Medical Examiner, the Maryland Department of Health, legal professionals, law enforcement, a community advocate, and experts in forensic pathology or medicolegal death investigations, charged with:

1. Identifying ways to improve in-custody restraint-related death investigations in Maryland;
2. Making recommendations to establish a permanent multidisciplinary statewide oversight committee to review future manner-of-death determinations for all in-custody restraint-related deaths within the state;
3. Implementing ways to reduce the risk of in-custody restraint-related deaths;
4. Evaluating current training standards for law enforcement and promoting greater collaboration with mental health and substance abuse professionals; and
5. Exploring the need and feasibility of conducting a subsequent audit.

• Directs the Maryland Department of Health to both review the practice and policy recommendations provided in the audit and conduct a need-based analysis for implementing the recommendations related to the Office of the Chief Medical Examiner.

• The Maryland Department of Health will also work with the Office of the Chief Medical Examiner to improve how in-custody restraint-related deaths are investigated, facilitate any necessary training, and ensure that the Office of the Chief Medical Examiner consistently operates in accordance with National Association of Medical Examiners standards.

• Requires the Maryland Department of Health and the Office of the Chief Medical Examiner to deliver a report detailing their progress in carrying out the duties outlined in the Executive Order.

The governor’s executive order builds upon previous action the Maryland Department of Health has implemented to increase oversight and accountability in the Office of the Chief Medical Examiner under the Moore-Miller Administration, including:

• Conducting a national recruitment search and appointing Dr. Stephanie Dean as the Chief Medical Examiner in November 2023; under Dr. Dean’s leadership, the Office of the Chief Medical Examiner:

• Agreed to follow the recognized best practices of the National Association of Medical Examiners recommendations for handling in-custody deaths;

• Regularly holds case conferences to assist medical examiners in completing difficult or complex cases by presenting the cases to a group of peers for review;

• Reduced the case backlog and is meeting the NAME standard of completing 90% of cases within 90 days;

• Reduced a staffing shortage; and

• Maintained a provisional NAME accreditation.

In 2023, the General Assembly passed and Governor Moore signed HB977. The legislation changed the role of the Post Mortem Examiners Commission and transferred direct responsibility and accountability for the Office of the Chief Medical Examiner’s operations to the Maryland Department of Health, including oversight authority over the Office of the Chief Medical Examiner’s policies, procedures, and personnel.

In 2024, the General Assembly passed and Governor Moore signed HB969. The legislation allows decedent families to petition the Office of the Chief Medical Examiner to correct findings and conclusions related to the cause and manner of death.

Per state guidelines, updates to COMAR for regulations governing the Office of the Chief Medical Examiner occur at a 10 year interval. The last update was completed in 2015. Review is underway to prepare a report to the Administrative, Executive and Legislative Committee, with a scheduled completion date of August 15, 2025.

“It is our responsibility as health care professionals to understand, identify, and address bias,” said Maryland Department of Health Secretary Dr. Meena Seshamani. “The Maryland Department of Health has been working closely with the Office of the Attorney General and will continue to implement thoughtful, transparent improvements that reflect our dedication to serving Marylanders.”