The National Academies
10/30/2025 | Press release | Distributed by Public on 10/30/2025 09:10
System that Investigates and Provides Determinations of Cause and Manner of Deaths in Custody Needs Comprehensive Reform, Says New Report
WASHINGTON - The U.S. medicolegal death investigation (MLDI) system is fragmented and lacks the resources, uniformity, enforceable standards, data, and incentives needed to produce consistent cause- and manner-of-death determinations for individuals who die while in custody, finds a new report from the National Academies of Sciences, Engineering, and Medicine. The report recommends actions that Congress, state governments, and others should take to strengthen the nation's MLDI system.
In-custody deaths include those that 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.
Medical examiners and coroners often face major obstacles in investigating these deaths, including outdated and unaccredited facilities and a lack of trained and certified personnel, the report says. The MLDI system as a whole faces inadequate resources and a lack of rigorous and enforceable standards. The report's recommendations to address these deficiencies build on those from a 2009 National Academies report on forensic science .
"Methodological precision is necessary to make accurate cause- and manner-of-death determinations, and the current state of the system undermines the credibility of death-in-custody investigations," said John A. Rich, the inaugural Harrison I. Steans Director of the Rush BMO Institute for Health Equity, Rush University System for Health, and a co-chair of the committee that wrote the report. "In order to understand why a death occurred and hold accountable those responsible for unnatural deaths, it is critically important to get the science right. Our report's recommendations aim to create a robust MLDI system that provides benefits for everyone."
The report recommends Congress allocate funds to states to improve physical infrastructure; increase coordination among the federal, state, and local MLDI systems; develop programs to increase coroner access to medical examiner and forensic pathologist expertise and services; and establish opportunities for cross-disciplinary research and collaborations.
Congress should also direct the U.S. Department of Health and Human Services, in consultation with the National Institute of Justice and the National Institute of Standards and Technology, to convene a panel to define the characteristics of a death in custody that should require an autopsy.
States should require licensure of all medicolegal death investigators. To maintain their license, licensees should meet continuing education requirements. In addition, reciprocity provisions should be developed to recognize licenses from other states. To maintain the quality of forensic pathology services, all medical examiner and coroner offices should arrange for meaningful peer review of no less than 10 percent of cases at least annually.
Data on Deaths in Custody
Comprehensive data on deaths in custody are not available, and there are questions about the reliability of available data, the report finds. Nonetheless, available data raise concerns about the significant numbers of individuals in custody who die by suicide or prior to conviction.
Incomplete or inaccurate data on the cause and circumstances of a death in custody hinder society's ability to protect the health and safety of people who are incarcerated and correctional staff, and to hold accountable those who cause the unnatural deaths of people in custody.
Among other recommendations, the report calls upon Congress to require states to collect and report data on all in-custody deaths. The report also recommends that Congress direct the National Center for Health Statistics to add a checkbox on the U.S. Standard Certificate of Death to indicate whether a death occurred in custody, and authorize and appropriate funding to the Centers for Medicare & Medicaid Services to reimburse state and local governments for the cost of autopsies performed on those who have died in custody.
Testimony Regarding Cause and Manner of Death in Legal Proceedings
Manner of death is an opinion listed on death certificates to inform the public about the circumstances that led to a death. While in some cases there is little doubt about cause and manner of death, in other cases determinations may be less reliable or certain. When called upon as expert witnesses in court, the testimony of those conducting medicolegal death investigations often exerts significant influence on the outcome of a trial or other legal proceeding.
"Because testimony by those who investigate deaths can significantly influence determinations of guilt or innocence, we also recommend new rigorous judicial gatekeeping standards for how this information is presented to courts," added committee co-chair Raymond J. Lohier, a judge on the U.S. Court of Appeals for the Second Circuit.
The report also makes recommendations for federal and state courts and other stakeholders in the criminal justice system to prevent improper testimony on cause and manner of death.
The study - undertaken by the Committee on Advancing the Field of Forensic Pathology: Lessons Learned from Death-in-Custody Investigations - was sponsored by Arnold Ventures, the Just Trust for Education, and Universal Music Group.
The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, engineering, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.
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