Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody (2025)
Chapter: 1 Introduction
1
Introduction
Accurate determinations of cause and manner of death are essential to the nation’s public health and legal systems. In both systems, the responsibility for determining and certifying cause and manner of death often rests with physicians, such as emergency room physicians, hospitalists, critical care physicians, and forensic pathologists, who typically perform this work in hospital settings. Forensic pathologists specialize in anatomic pathology and perform forensic investigations and autopsies in instances of sudden, unexpected, or violent deaths to determine whether disease or toxic exposure is present, identify injuries and reconstruct how they were sustained, evaluate investigative information relating to cause and manner of death, and collect forensic evidence such as secretions and trace evidence. Forensic pathologists are frequently called upon by the legal system as they provide crucial information about the deceased and why deaths occurred.
CAUSE AND MANNER OF DEATH
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), or other processes (e.g., respiratory failure, asphyxiation). By contrast, manner of death describes how an individual died—that is, the circumstances of death (e.g., how an injury was sustained). Manner of death is not a legal conclusion; rather, it is an opinion listed on death certificates to inform the public about the circumstances that led to a death. In the United States, the commonly used manner-of-death classifications are (1) natural, or death resulting from natural causes (e.g.,
disease, aging); (2) accidental, or death resulting from an unintentional injury or incident (e.g., fall, car accident); (3) suicide, or death resulting from intentional self-harm; (4) homicide, or death resulting from the volitional actions of another person; and (5) undetermined, or cases where the cause and/or manner of death cannot be clearly established (Hanzlick, Hunsaker, and Davis, 2002).1
THE BROADER ROLE OF FORENSIC PATHOLOGY
In the public consciousness, the role of forensic pathologist emerges in the context of criminal investigations, as they typically determine cause and manner of death in instances of violent or suspicious deaths. However, these practitioners also play a critical role in public health and safety by identifying trends that can guide policy, prevention strategies, and community health initiatives (see Box 1-1).
In the context of the criminal justice system, forensic pathologists play a critical role in identifying cause of death and manner of death, as that information is used by the criminal justice system to determine guilt and hold individuals accountable. They may also play a role in civil lawsuits where the manner of death is an issue in determining liability.
DEATHS IN CUSTODY
In the United States, thousands of individuals die each year while in the custody of law enforcement or corrections officers. The circumstances of many of these deaths—and determinations made regarding their cause and manner—often raise troubling questions (see Box 1-2). In-custody deaths and the practice of forensic pathology occur at many jurisdictional levels (e.g., county, state, federal) and have important roles in the complex, decentralized medicolegal death investigation (MLDI) system, which is responsible for conducting death investigations and certifying the cause and manner of unnatural and unexplained deaths.
Concerned about the handling of deaths in custody by the MLDI system and recognizing that death-in-custody cases might provide important information about this complex system, the National Academies of Sciences, Engineering, and Medicine convened an ad hoc study committee to consider this system’s handling of recent in-custody deaths and to identify practices and measures that could advance and ultimately improve the field of forensic pathology.
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1 Processes for making determinations of cause and manner of death are discussed in detail in Chapter 5.
BOX 1-1
The Role of Forensic Pathology in Public Health and Safety
Forensic pathologists collect data about the deceased from physical examination findings, laboratory results, and histories, and they indicate cause of death on death certificates. These data support public health efforts such as disease study and surveillance and describing trends in substance use disorder deaths. Thus, forensic pathologists help public health practitioners determine where to focus public health resources (Lathrop, 2011; Levy, 2015).
The data collected by forensic pathologists can complement public health and safety data collected by other components of the federal statistical system. The National Vital Statistics System of the Centers for Disease Control and Prevention, for example, “collects and shares critical information on deaths from drug overdoses, such as what substances were used and where deaths are happening in America” (National Center for Health Statistics, 2024). In death investigations, toxicology tests performed on the deceased enable the identification of novel illicit drugs (and mixtures of drugs) and permit public health agencies to deploy public health resources in a targeted manner. Text descriptions on death certificates often provide information about drugs involved in a death, which can be useful in alerting public health officials to the introduction of new drugs in a community (National Center for Health Statistics, 2024). And death certificate data have long been used to surveil influenza mortality and have also been used to track epidemics that include HIV and, most recently, COVID-19.
Other agencies also use death certificate information. For example, the U.S. Department of Transportation has used the information to improve the designs of motor vehicles and roadways. The U.S. Department of Labor and the National Institute for Occupational Safety and Health have effectively used death certificate data to improve workplace safety. Notably, in 1976, the U.S. Consumer Product Safety Commission established the Medical Examiners and Coroners Alert Project to identify incidences where consumer products played a significant role in a death. Levy (2015) reported that, “since its creation, more than 9,000 reports have been submitted that resulted in product recalls or product standards development” (p. 3).
The committee’s work builds on the 2009 National Research Council report Strengthening Forensic Science in the United States: A Path Forward (NRC, 2009). Chapter 9 of that report examined the role of medical examiners and coroners in forensic science. The present report recommends actions to further strengthen the nation’s MLDI system.
DEFINING AND ACCOUNTING FOR DEATHS IN CUSTODY
In the United States, the most significant actions taken to collect death-in-custody data were passage of the federal Death in Custody Reporting
BOX 1-2
Examples of Individuals Who Have Died in Custody: Angelo Quinto, Janene Wallace, and John Jackson
Angelo Quinto, a 30-year-old Navy veteran, was restrained by two police officers at his family’s home in Antioch, California, on December 3, 2020. The police had been called because Quinto, who struggled with anxiety and depression, was experiencing a mental health episode, and his sister feared that he would hurt their mother (Fortin, 2021; Von Quednow, 2024).a The officers knelt on Quinto for nearly 5 minutes to restrain him (Fortin, 2021). He “lost consciousness, and was taken to a hospital, where he was pronounced dead three days later” (Von Quednow, 2024). An autopsy was performed, and the cause of Quinto’s death was identified as “Excited Delirium Syndrome due to drug intoxication, psychiatric conditions, physical exertion, and cardiac arrest” (Von Quednow, 2024). Quinto’s family filed a wrongful death claim and, according to a lawyer for the family, “after being confronted with another autopsy commissioned by Quinto’s family and attorneys during a deposition” (CBS Bay City News Service, 2024), the attending pathologist who had conducted the initial autopsy agreed that having weight on his back “may have played a role” in Quinto’s “death due to compression of the ribcage causing asphyxiation” and that “in retrospect, he would have worded Mr. Quinto’s cause of death to include the term, ‘positional asphyxiation’” (Becton, 2022, p. 3).b
Janene Wallace, 35 years old, was found dead in her cell at George W. Hill Correctional Facility in Glen Mills, Pennsylvania, on May 26, 2015, after hanging herself with a bra she tied to an air vent (Teller, 2017). Wallace had first been imprisoned in the facility “in 2013 after she left a series of threatening voicemails for a high school classmate that she thought was out to get her” (The Associated Press, 2017). She was subsequently released but was sent back to the Hill facility for a probation violation. When Wallace “refused to bathe, made irrational statements, rubbed menstrual blood on a shower wall and accused the guards of trying to hurt her . . . she was placed in solitary confinement and a sign was put on her door that warned that she was ‘unstable’ and instructed staffers to ‘use caution’” (The Associated Press, 2017). She did not undergo a mental health evaluation or treatment, and after more than 50 days in solitary confinement, Wallace died by suicide.
John Jackson, who had served 18 years of a 20-year sentence for drug and firearms charges, died on August 25, 2019, at the Federal Correctional Institution in
Acts (DCRAs) of 2000 and 2013. This legislation sought to collect comprehensive statistics on the number of deaths that occur in the custody of law enforcement and in correctional facilities and information regarding the circumstances of those deaths.2
Deaths in custody can occur 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 (see Box
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2 For a detailed discussion of DCRA 2000, DCRA 2013, and other efforts to collect data on deaths in custody, see Chapter 3.
Forrest City, Arkansas, while he waited for a court hearing for early release. Jackson had been suffering from deep vein thrombosis and Methicillin-resistant Staphylococcus aureus (MRSA), an infection caused by drug-resistant bacteria. MRSA is not generally fatal if treated immediately, but Johnson, who contracted the infection after he was moved to Forrest City from the Federal Correctional Institution in Allenwood, Pennsylvania, in 2017, still had the infection when he died. In Pennsylvania, Jackson had had regular hospital checks, but according to his wife, Kesha, when he was moved to Arkansas, “they were not sending him out to the hospital as much” (FAMM, n.d.). After contracting MRSA, Jackson “developed a bump on his leg, which subsequently burst, leaving an open wound”; rather than taking him for hospital treatment, the prison initially wrapped the leg in gauze (FAMM, n.d.). By the summer of 2019, Jackson “had been in and out of the hospital for more than a year, but clotting issues, combined with the persistent infection, meant that his wound remained unhealed. He often struggled to stand, and the compression socks he was issued would not fit over the swelling. Instead of blood thinners, [Jackson] was offered only aspirin” (FAMM, n.d.). Eventually, he was placed in the prison’s special housing unit, where he went in and out of consciousness. According to fellow detainees, Jackson tried banging on the door for help. An officer eventually handcuffed him and attempted cardiopulmonary resuscitation. “He died soon after,” his manner of death listed as natural; prison officials were not required to conduct an autopsy (Christopher, 2024).
Quinto, Wallace, and Jackson are three examples of the many individuals who have died in custody in the United States whose deaths were preventable. Not all deaths in custody are—but taken together, their cases highlight serious systemic pre- and postmortem failures that include inadequate restraint policies; unhealthy conditions at detention facilities; the quality of medical care for those in custody; and the ability of crime scene investigators, forensic pathologists, medical examiners, and coroners to make accurate determinations of cause and manner of death.c
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a For a discussion of mental health and custody-related issues, see Chapter 4.
b Forensic autopsies in California must be performed by licensed physicians, and these individuals may or may not be board-certified forensic pathologists. The forensic pathologist in this case was not board certified. The family asserts that Quinto had not been under the influence of drugs.
c The roles played by excessive force (as embodied by Quinto’s case), suicide (as embodied by Wallace’s case), and medical neglect (as embodied by Jackson’s case) in in-custody deaths are examined in Chapter 4.
1-3 and Appendix D). Despite efforts such as the enactment of the DCRAs, information about death-in-custody cases is incomplete.3 Absent accurate data that provide a comprehensive picture of the landscape of deaths in custody, the nation is limited in its ability to address systemic problems, protect public health, advance the practice of forensic medicine, exonerate the wrongfully accused or convicted, hold the guilty accountable, reduce deaths in custody, and reach conclusions about the causes of deaths in custody.
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BOX 1-3
What Is an “In-Custody” Death?
This report largely uses the term death in custody as it is defined in the Deaths in Custody Reporting Act (DCRA) of 2013:
the death of any person who is detained, under arrest, or is in the process of being arrested, is en route to be incarcerated, or is incarcerated at a municipal or county jail, State prison, State-run boot camp prison, boot camp prison that is contracted out by the State, any State or local contract facility, or other local or State correctional facility (including any juvenile facility. . . . [More specifically,] the death of any person who is (1) detained, under arrest, or is in the process of being arrested by any officer of such Federal law enforcement agency (or by any State or local law enforcement officer while participating in and for purposes of a Federal law enforcement operation, task force, or any other Federal law enforcement capacity carried out by such Federal law enforcement agency); or (2) en route to be incarcerated or detained, or is incarcerated or detained at (A) any facility (including any immigration* or juvenile facility) pursuant to a contract with such Federal law enforcement agency; (B) any State or local government facility used by such Federal law enforcement agency; or (C) any Federal correctional facility or Federal pre-trial detention facility located within the United States. (Public Law 113–242. 128 Stat. 2860-61, 2014)
Under DCRA, deaths in custody include the deaths of individuals who die in external facilities where they have been transferred for medical care. However, if an
DEATH INVESTIGATION IN THE UNITED STATES
An effective MLDI system provides consistent assessments of cause and manner of death.4 The system both generates and benefits from data that can play a critical role in justice and public health. As described above, the public health system relies upon the MLDI system to help track drug overdoses, homicides, deadly infectious disease outbreaks, and other preventable situations and identify changes in prevalence and incidence of deaths from chronic diseases (National Center for Health Statistics, 2023). The criminal justice system relies on the MLDI system to provide evidence for charging decisions and adjudications and to exonerate the wrongfully accused or convicted.
Medicolegal death investigations are performed under three systems in the United States: coroner systems; medical examiner systems; and systems
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individual is transferred to a medical facility, is released from custody, and dies, the death would not be counted as a death in custody under DCRA (see Chapter 4). This report does consider such deaths to be deaths in custody.
Deaths that occur when individuals are enrolled in community corrections programs (e.g., home confinement) or while on probation or parole might also be considered deaths in custody as individuals in these situations are wards of the criminal justice system. This report does not include deaths occurring in these situations as deaths in custody as local, state, and federal oversight is limited in such scenarios. Executions, while not explicitly identified as deaths in custody by DCRA, would appropriately be considered deaths in custody—though consideration of the concerns related to such deaths are beyond the scope of the committee’s statement of task.
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* Immigration detention facilities are under the jurisdiction of either U.S. Customs and Border Protection (CBP) or Immigration and Customs Enforcement (ICE), both components of the U.S. Department of Homeland Security. Typically, immediately upon detention, individuals are held by CBP for up to 72 hours, after which, if detention continues, they are transferred to an ICE facility. Approximately 20 percent of all individuals in ICE detention were housed in local jails at the time of publication of this report (TRAC Immigration, 2025). The population of those in detention has grown from a low of approximately 15,000 in mid-2022 to over 50,000 at the time of publication of this report (Vera Institute of Justice, 2025).
The committee did not receive specific testimony regarding deaths in immigration detention facilities. Nevertheless, issues in carceral facilities, such as prisons and jails, would likely be exacerbated in immigration detention facilities because of language barriers, mixed-age populations, and availability of medical services. These types of conditions increase the risk of infectious disease, trauma, and sexual or other violence. Unhealthy conditions and unknown levels of health care have been highlighted in recent reports (see, e.g., Elassar and Romo, 2025).
under the jurisdiction of other county officials5 such as justices of the peace, county attorneys, sheriff-coroners, and other law enforcement personnel (CDC, 2023). The systems may be operated by states, counties, cities, or tribal authorities.
In the United States, medical examiner or coroner offices investigate approximately 20 percent of deaths (Tatsumi and Graham, 2022). In 2018, this translated into approximately 2,000 medical examiner and coroner offices in the United States providing death scene investigations, autopsies, and determinations of cause and manner of death (CDC, 2023).6 That year, more than 1.3 million deaths were referred to medical examiner and coroner offices, which accepted 605,000 referrals for further investigation (Brooks, 2021).
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5 These systems are not customarily counted separately from coroner and medical examiner systems.
In situations where a crime may have been committed or where there are unusual or suspicious circumstances, forensic pathologists frequently engage with the broader MLDI system, which may include coroners and death scene investigators (see Box 1-4), forensic scientists, law enforcement professionals, prosecutors and defense counsel, and the courts.
CHALLENGES FACING THE MLDI SYSTEM
Recent high-profile deaths in custody cases7 drew widespread attention to the determinations of cause and manner of death made by forensic pathologists, medical examiners, and coroners. Questions have been raised about the scientific validity of these determinations; in some cases, deaths certified as accidental or natural by one pathologist have been certified as homicides by others who, upon reexamination, have identified what they
BOX 1-4
Who Are Medical Examiners, Coroners, and Medicolegal Death Investigators?
Medical examiners are typically appointed officials who oversee the investigation of deaths in their jurisdiction. Medical examiners are responsible for conducting autopsies, interpreting forensic evidence, and ensuring that death investigations are conducted according to established procedures. They must be licensed physicians and often have specialized training in forensic pathology (CAP, n.d.).a
Coroners are elected or appointed officials. They may or may not have a medical background or medical degree. A coroner’s primary duty is to investigate violent, sudden, or suspicious deaths and determine the cause and manner of death. To assist in making their determinations, coroners often consult with forensic pathologists and medical examiners.
Medicolegal death investigators perform death scene investigations, collecting and documenting information that provides insights into the circumstances surrounding a death. They photograph and manage the proper handling of the body before autopsy and request and collect relevant medical and police records and patient information relevant to the death.
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a Forensic pathologists investigate nonnatural or suspicious deaths (also known as reportable deaths); they seek to determine cause of death typically via postmortem examinations or autopsies (see Chapter 2).
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7 The cases of Elijah McClain, Daniel Prude, and George Floyd, for example, have raised questions about accountability for deaths in custody (see Chapter 2).
believe to be mistakes, omissions, or questionable conclusions (Christopher, 2024; Shapiro and Keel, 2024). In other cases, cause of death has been attributed to conditions such as sickle cell trait, which may play a role in a death but has not been shown to be causal, or excited delirium, which the medical community now concludes is not a medical diagnosis.8 In some cases, forensic pathologists, medical examiners, and coroners have certified a cause of death without acknowledging or determining the underlying etiology, which may include natural disease, drug toxicity, or restraint methods applied by law enforcement or corrections officers. Moreover, while individuals in custody are entitled to receive a level of health care that meets constitutional standards, the quality and accessibility of health care vary widely (see Chapter 4).9
Many who investigate medicolegal deaths work diligently to provide crucial information about the deceased and why deaths occur. They provide the public with a better understanding of the circumstances of these deaths. Unfortunately, the MLDI system has faced significant challenges for decades. These range from a lack of adequate resources and staffing in many MLDI offices to a lack of standards. In addition to questions raised about specific cause- and manner-of-death determinations (see Chapter 5), the National Academies, National Science and Technology Council, and National Institute of Standards and Technology have raised doubts about the scientific rigor of death investigations and critiqued the practice of medicolegal death investigation. Their reports have called for adhering to rigorous standards; establishing accreditation and certification processes; increasing the number of forensic pathologists and other forensic science professionals; and establishing new medical examiner systems, with the goal
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8 See, e.g., the case of Angelo Quinto described in Box 1-2. For a detailed discussion of sickle cell trait, excited delirium, and other controversial diagnoses, see Chapter 5.
9 The Eighth Amendment to the U.S. Constitution prohibits cruel and unusual punishment, which has been interpreted by the courts to include the provision of inadequate medical care. The U.S. Supreme Court has ruled that incarcerated individuals have a right to receive medical care that is adequate and timely. In Estelle v. Gamble, 1976, the Court ruled that “deliberate indifference” to an incarcerated individual’s medical needs amounts to “unnecessary and wanton infliction of pain,” violating the Eighth Amendment (429 U.S. 97). The protections offered under Estelle were circumscribed by the Prison Litigation Reform Act of 1996, which was enacted in response to a significant increase in litigation brought by incarcerated individuals. The Act was designed to decrease litigation by introducing provisions that include filing fees (though these can be waived for indigent individuals and often may be paid in small installments), the “Three Strikes” Rule (litigants who have had three or more lawsuits dismissed as frivolous or malicious are barred from bringing future lawsuits without the court’s permission), and the deprivation requirement (in some cases, litigants must demonstrate physical injury to recover compensatory damages). The Act contains an exception to procedural barriers for those who are in imminent danger of physical harm.
of replacing and eventually eliminating coroner systems (NIST, n.d.; NRC, 1928, 2009; NSTC, 2016).10
Given ongoing concerns about the MLDI system and its role in identifying, investigating, and reporting in-custody deaths and the importance of accurate determinations of cause and manner of death for justice and public health, an assessment of that system is necessary to ensure that all such deaths are properly identified, investigated, and accounted for.
THE COMMITTEE AND ITS CHARGE
The National Academies’ Committee on Science, Technology, and Law convened an ad hoc committee of experts to conduct the study “Advancing the Field of Forensic Pathology: Lessons Learned from Death-in-Custody Cases” (see Box 1-5). Committee members were selected based upon the relevance of their experience and knowledge to the study’s specific statement of task. After a thorough discussion on conflict of interest, committee composition, and bias, the study committee was appointed in early 2024. Individuals serving on National Academies’ studies are chosen for their individual expertise, not their affiliation to any institution, and they volunteer their time to serve. The committee comprised individuals with expertise in anatomic and forensic pathology, forensic psychiatry, infectious disease and addiction, primary care, correctional medicine, diagnostic error, crime laboratories, biostatistics, cognitive bias, incarceration, racial inequities, forensic and statistical evidence, law, and civil and criminal litigation (see Appendix A for committee member biographies).
The study was funded by Arnold Ventures, The Just Trust for Education, and the Universal Music Group.
While issues such as the high rate of incarceration in the United States, health care for vulnerable populations, practices and procedures of law enforcement and emergency responders, and race and ethnicity play a role in deaths in custody and merit careful consideration, the committee’s focus was the role played by medical examiner and coroner systems in determinations of cause and manner of death.
INFORMATION-GATHERING ACTIVITIES
Over the course of 18 months, the committee held eight meetings. During these meetings, the committee heard from invited experts, including medical examiners, forensic pathologists, coroners, researchers, agency officials, and law enforcement and corrections professionals, as well as from
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10 See also various forensic science standards from the Organization of Scientific Area Committees for Forensic Science of the National Institute of Standards and Technology.
BOX 1-5
Charge to the Committee
An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine will conduct a study on the handling of deaths in custody (detained, arrested, en route to incarceration, or incarcerated in state or local facilities or a boot camp prison) by the medicolegal death investigation system in the United States and study related concerns with medical death investigations more generally. The study will consider:
- the number of deaths while in custody throughout the criminal justice process and how those deaths are investigated, diagnosed, recorded, reported and made transparent;
- the distribution of diagnoses for deaths that occur in custody (cause and manner of death) and the scientific bases for attributing such diagnoses to those deaths;
- measures (and limitations thereof) that forensic pathologists should follow to conduct independent assessments of cause of death generally and in particular for deaths in custody;
- the proper range of attributions for cause and manner of death that should be made in a medicolegal death investigation and the scientific bases and associated evidence needed to justify a diagnosis related to any death in general and, in particular, to deaths in custody;
- mitigation strategies to be used to protect forensic pathologists from factors that may bias their diagnosis;
- an assessment of the dual role played by the medicolegal death investigation system as fact finders of manner of death for public health as opposed to for the criminal justice system; and
- quality standards and regulations needed for improvement.
The committee will produce a consensus report with findings and recommendations.
members of the legal and affected communities.11 Recordings of these meetings and materials provided by speakers are posted on the project website.12 In addition to receiving input from experts, the committee reviewed past reports and peer reviewed research, information from relevant agencies, investigative reports, and other sources as noted throughout this report. After carefully reviewing these inputs and materials, the committee drafted a report for external review (reviewers are listed in the front matter of this
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11 See acknowledgments on p. xi.
12 For committee meeting videos and other meeting materials, see https://www.nationalacademies.org/our-work/advancing-the-field-of-forensic-pathology-lesson-learned-from-death-in-custody-investigations.
report). In response to reviewer comments, the report was revised and approved for publication by the National Academies.
ORGANIZATION OF THE REPORT
This report is organized as follows: Chapter 2 discusses the MLDI system in the United States; Chapter 3 examines death data and data on deaths in custody; Chapter 4 examines carceral health and restraint mechanisms and their role in deaths in custody; and Chapter 5 considers challenges and opportunities for forensic pathology and the MLDI system. The committee’s findings and recommendations are provided in Chapter 6.
