WASHINGTON — A new report from the National Academies of Sciences, Engineering, and Medicine warns that the United States’ system for investigating deaths in custody remains deeply inconsistent, under-resourced, and structurally fragmented. According to the study, the nation’s medicolegal death investigation network — known as the MLDI system — lacks the unified standards, reliable data, and professional support required to consistently determine cause and manner of death for individuals who die while in detention or during encounters with law enforcement. The authors call for sweeping action from Congress, state leaders, and federal agencies to strengthen this critical component of the justice and public-health infrastructure.
In-custody deaths occur across a wide spectrum of situations, beginning with a first contact with police and continuing through arrest, pretrial detention, incarceration, and release. The report emphasizes that each of these stages requires accurate and transparent investigation procedures to ensure accountability and public trust. At present, however, many cases confront serious obstacles. Facilities handling these investigations are often outdated or lack formal accreditation, while numerous jurisdictions struggle with shortages of trained forensic pathologists, medical examiners, and qualified investigative personnel.
The national system’s uneven structure is not new. For more than a decade, experts have warned that deficiencies in forensic science and death investigation capacity compromise the accuracy of autopsies and the credibility of criminal justice outcomes. This latest report builds upon earlier findings, reaffirming that precise and scientifically sound methods are essential when determining how a person died while in the custody of the government. Without scientifically defensible processes, the public’s confidence in the justice system erodes, and families are left without clear answers.
Committee co-chair John A. Rich, director of the Rush BMO Institute for Health Equity, underscored the stakes. He noted that getting the science right is fundamental not only for understanding what happened in each death-in-custody case, but also for ensuring accountability when deaths are preventable or involve misconduct. Inaccurate or inconsistent death determinations, he warned, weaken the credibility of investigations and undermine trust in the institutions responsible for safeguarding the lives of people in detention.
To address these challenges, the report calls on Congress to invest in strengthening the physical and organizational infrastructure of the MLDI system. Federal support would help modernize facilities, expand training programs, and increase collaboration among federal, state, and local institutions. The authors also recommend new programs to connect coroners — who often work in smaller or rural jurisdictions — with board-certified forensic pathologists and medical examiners. Such collaboration would help ensure that even resource-limited areas have access to specialized expertise. Additionally, the report advocates for encouraging interdisciplinary research partnerships to advance methods and improve standards.
One recommendation that stands out is the need to define clear criteria for when an autopsy should be mandatory in cases involving deaths in custody. The authors urge Congress to direct the U.S. Department of Health and Human Services to convene experts from the National Institute of Justice and the National Institute of Standards and Technology to develop consistent guidelines. This step, they argue, would help eliminate confusion and ensure that suspicious or unexplained deaths receive appropriate forensic scrutiny.
At the state level, the report calls for mandatory licensing of medicolegal death investigators. Licensing would be paired with continuing education requirements to ensure that personnel remain current on evolving forensic science practices. States should also adopt reciprocity agreements so licensed investigators can work across jurisdictions, reducing staffing limitations. In addition, medical examiner and coroner offices should perform peer review on at least ten percent of their cases every year to reinforce quality and reliability.
A significant portion of the report focuses on the scarcity and unreliability of national data on deaths in custody. Existing data sets are incomplete and sometimes inaccurate, limiting policymakers’ and researchers’ ability to fully understand trends, risk factors, and potential systemic failures. The report notes troubling evidence that many individuals die in custody before trial or as a result of suicide — outcomes that raise urgent questions about conditions inside detention facilities and the care provided to detainees.
To close these data gaps, the report recommends that Congress require all states to systematically collect and report information on deaths occurring in custody. It also proposes adding a checkbox on the national death certificate to indicate whether a death took place in detention. Furthermore, the authors suggest that federal funding should be made available through the Centers for Medicare & Medicaid Services to reimburse state and local agencies for autopsy costs in such cases, ensuring that financial constraints do not deter thorough investigations.
The study also addresses the role of forensic experts in the courtroom. When medical examiners and forensic pathologists testify, their interpretations carry substantial influence over judges, juries, and legal outcomes. In some situations, determining manner of death is straightforward, but in others the available evidence may leave room for uncertainty. Because of this, the report urges courts to adopt more rigorous standards to evaluate expert testimony related to cause and manner of death. The authors emphasize the importance of judicial oversight to prevent misleading or overstated testimony that could unjustly sway verdicts and affect the administration of justice.
Committee co-chair Raymond J. Lohier, a judge on the U.S. Court of Appeals for the Second Circuit, noted that expert testimony in death-in-custody cases has profound implications for whether individuals are found guilty or innocent. Strengthening courtroom standards, he argued, is an essential safeguard to protect fairness and uphold the integrity of the legal system. The report outlines additional guidance for federal and state courts, prosecutors, defense attorneys, and other stakeholders to prevent improper or unsupported conclusions from influencing legal proceedings.
This research was carried out by the Committee on Advancing the Field of Forensic Pathology: Lessons Learned from Death-in-Custody Investigations, with support from philanthropic and private-sector partners. The National Academies, which produced the report, continue to serve as a non-governmental scientific body offering independent analysis on complex public-policy issues affecting science, medicine, and national governance.
With more attention focused on law-enforcement practices, incarceration conditions, and public health in detention environments, the authors argue that reforming the MLDI system is not only overdue but essential. As deaths in custody remain a focal point in national discussions about justice and accountability, the report offers a roadmap toward building a more transparent, scientifically rigorous, and trustworthy system that can meet the demands of modern society.
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