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| Peter Neufeld |
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| Isabelle Cohn |
This story includes descriptions of police violence and the death of a child.
In 2018, 19-year-old Anton Black died on the stoop in front of his mother's Maryland home after several police officers tasered him, wrestled him to the ground, and, even after handcuffing him, continued to restrain him face down on the pavement until he stopped breathing.[1]
The state medical examiner ruled Black's cause of death as sudden cardiac arrest and the manner of death accidental. Relying on that conclusion, the local prosecutor deemed there was insufficient evidence to present the case to a grand jury.
In 2003, an Ohio man, Alan Butts, was convicted in the Franklin County Court of Common Pleas of killing a two-year-old child in his care through violent shaking, a case of what was then known as shaken baby syndrome, or SBS.[2]
As in many SBS prosecutions, the Butts case rested on the cause- and manner-of-death opinions of four medical experts, including a forensic pathologist, who opined that the child's fatal brain injuries could only have resulted from SBS and classified the death as a homicide. They rejected as impossible the defense theory that the child's death stemmed from a series of minor falls, complicated by undiagnosed pneumonia and sepsis. Butts was sentenced to life in prison.
These tragic stories illustrate the failure of the criminal legal system and those tasked with investigating deaths to separate science from speculation. Now is the time for prosecutors and defense lawyers to do something about it.
In late October, the National Academies of Sciences, Engineering, and Medicine, or NASEM, released a groundbreaking report, "Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody," marking a transformative moment for the field of forensic pathology.
The committee's findings are clear: The medicolegal death investigation system, which is responsible for determining why (the cause) and how (the manner in which) people die, lacks the rigorous scientific grounding, standards, and oversight needed to ensure accuracy and fairness. Amid efforts to hold police accountable when their use of restraints causes the death of a person in custody and to prevent the wrongful conviction of the innocent for manslaughter or murder when in fact no crime occurred, this finding could be a game-changer.
Whereas cause of death identifies the specific medical condition or injury that led to an individual's death, such as heart failure, manner of death is a broader classification that infers the circumstances surrounding the death, used primarily for public health and statistical purposes. It places each death into one of five administrative categories: natural, accident, suicide, homicide or undetermined.
Most autopsies do not point to criminal activity, and when they do, the findings are usually straightforward — a gunshot wound in the back of the skull leaves little room for debate. But when the circumstances are ambiguous, such as in the unexplained death of an infant or toddler, or when an unarmed person suddenly stops breathing after being restrained by police, a forensic pathologist's opinion about the manner of death can shape the entire course of an investigation or the outcome of a trial.
The NASEM report makes clear that manner-of-death determinations lack empirical validation, clear standards and safeguards against bias. These classifications rely heavily on nonmedical, nonscientific, contextual information — such as witness statements or police investigative reports — that falls outside a forensic pathologist's scientific expertise, which can sometimes be entirely unreliable.
For example, in determining the manner of death, a pathologist may consider a police report indicating that a suspect confessed, yet false confessions are the leading cause of wrongful homicide convictions among individuals who are later exonerated by DNA evidence.[3] The pathologist, however, lacks the authority — and has no reason — to question the reliability of that statement.
Because manner-of-death opinions, particularly regarding homicide, carry significant legal weight, the report expresses concerns that they can prejudice jurors, influence prosecutorial decisions and undermine justice. Rooted in a 1,000-year-old English coroner system, manner-of-death testimony survives in U.S. courts largely out of historical habit, even though many former British colonies now reserve such classifications solely for public health purposes rather than criminal prosecutions.
The NASEM report states, "High rates of accuracy are a prerequisite for establishing trustworthiness, but accuracy rates of cause- and manner-of-death determinations are currently unknown." Without empirical validation, manner-of-death opinions fail to meet the threshold of reliability demanded by science and the law. Categorizing a death as a homicide "should not be interpreted to mean that a person did or did not commit a crime." Even the National Association of Medical Examiners has acknowledged that assigning a manner of death involves subjective judgment, with "no right or wrong answer."
The NASEM report concludes that these statements are "more confusing than helpful to the fact finder" and thus, their usefulness to the jury is questionable at best. The report recommends that "courts should seriously consider whether to exclude statements on manner of death."
A renewed emphasis on evidence-based, scientifically grounded testimony would serve both prosecutors and defense counsel far better than reliance on conclusory manner-of-death labels. The findings of this report should prompt prosecutors to reconsider how they engage with medical examiners and coroners, and to be mindful that manner-of-death classifications should not be included in expert opinions offered in court.
Instead, prosecutors should consult with their local medical examiner and coroner offices and encourage them to implement the report's recommended bias-mitigation measures. The report highlights linear sequential unmasking, a methodology in which the pathologist initially limits their exposure to potentially biasing contextual information and begins the analysis with the biological and medical facts alone. This approach can produce more defensible autopsy conclusions, reduce the risk of contextual bias, and ultimately strengthen the scientific foundation of the testimony prosecutors rely on.
Defense counsel similarly benefits when the courtroom presentation focuses on cause-of-death evidence grounded in observable pathology, rather than administrative labels jurors might misinterpret as legal conclusions. By centering the underlying science, defense attorneys can challenge the prosecution's case on a firmer footing.
Although manner-of-death determinations remain significant for public health surveillance, the report determines that "their probative value [in a criminal case] is questionable." It is the responsibility of prosecutors and defense counsel alike to ensure courtroom decisions are guided by science, not speculation.
We know that at least 173 documented wrongful convictions were based, at least in part, on faulty forensic pathology or medicolegal death investigation.[4] States should likewise heed the report's recommendation and take on greater oversight of death investigations by requiring mortality and peer reviews, with special attention to in-custody and infant deaths. By establishing evidence-based standards and scientific guardrails, states can strengthen the integrity of death investigations, enhance public health, improve accountability and reduce the risk of future wrongful convictions.
The recent audit of the Maryland Office of the Chief Medical Examiner, published this May, revisited Black's death and determined that the classification of "accident" was inappropriate, unanimously finding the case was a homicide.[5] The audit uncovered that at least 36 other deaths in police custody, all of which were originally labeled accidental, natural or undetermined, were homicides that had been miscategorized by the OCME, underscoring how flawed classifications and bias can obscure the truth.
Although Maryland's audit was unprecedented, the underlying problems are not unique. Therefore, every state should mandate similar independent audits.
In 2022, the Franklin County court in Butts' case revisited his SBS homicide conviction.[6] Following an extensive evidentiary hearing, the court found that the science on infant deaths had evolved significantly — so much so that the claims made by the prosecution's medical experts at trial were not scientifically valid. The child's particular brain injuries did not definitively indicate SBS, and the factors such as the reported falls in which the child hit his head, the pneumonia and the sepsis could also have caused the brain injuries and death. The court vacated the conviction, and in 2024 the prosecution dismissed the charges.
Had empirically demonstrable evidence been available when these cases were initially reviewed, Black's family would not have waited seven years for justice, and Butts would not have spent two decades behind bars for a crime that never happened.
Unscientific manner-of-death determinations contribute to wrongful convictions, erode police accountability and deprive families of answers. Prohibiting manner-of-death testimony in court is an essential step toward rebuilding trust in forensic pathology and ensuring the justice system is guided by sound science. Doing so leaves both prosecutors and defense attorneys with evidence that is transparent, testable, and truly within the bounds of a forensic pathologist's expertise, rather than a label that distorts the questions the fact-finder must answer.
Peter Neufeld is a co-founder and special counsel at the Innocence Project at Yeshiva University's Benjamin N. Cardozo School of Law.
Isabelle Cohn is a forensic science policy associate at the Innocence Project.
"Perspectives" is a regular feature written by guest authors on access to justice issues. To pitch article ideas, email expertanalysis@law360.com.
The opinions expressed are those of the author(s) and do not necessarily reflect the views of their employer, its clients, or Portfolio Media Inc., or any of its or their respective affiliates. This article is for general information purposes and is not intended to be and should not be taken as legal advice.
[1] https://www.aclu-md.org/cases/black-et-al-v-webster-iv-et-al/.
[2] State of Ohio v. Alan Butts
, No. 02 CR 001092.[3] https://innocenceproject.org/dna-exonerations-in-the-united-states/.
[4] https://exonerationregistry.org/sites/exonerationregistry.org/files/documents/Medicolegal_Death_Investigation.pdf (This report includes 151 cases. We reached out to the NRE for an updated number and as of May 7, 2025, the number stood at 173.)
[5] https://oag.maryland.gov/News/Documents/pdfs/051525_OCME_audit_report_FINAL.pdf.
[6] State of Ohio v. Alan Butts, No. 22-AP-000763.