Deaths in custody
Who investigates a death in a Georgia prison: law, practice and GBI declinations
The law and practice for investigating deaths in Georgia prisons, including GBI declinations.
Where this research is used
This page is a research collection: individual facts drawn from the sources listed further down, each traced to where it came from. A research topic brings many collections together into one overview of an issue. The facts on this page feed these 3 topics; open one to see how they fit with the rest of the evidence.
Legal Standards & Case Law
Georgia's prison-conditions litigation runs through a small set of Supreme Court and Eleventh Circuit decisions that set an unusually demanding bar: a plaintiff must prove both an objectively serious deprivation and that officials actually knew of and disregarded it. This page traces that doctrine from Estelle v. Gamble (1976) through Farmer v. Brennan (1994) and the Eleventh Circuit's 2024 en banc reset in Wade v. McDade, then sets it against Georgia's own record — Guthrie, Cason, the Gumm solitary-confinement settlement and its 2024 contempt finding, and the Justice Department's October 2024 conclusion that Georgia's prisons violate the Eighth Amendment. It closes with the people in GPS's death registry whose deaths sit directly on that doctrine.
11,676 data points
Mortality & Deaths in Custody
Georgia's prisons have recorded deaths at a pace unequaled in the state's modern history: 1,928 in Georgia Department of Corrections custody since January 1, 2020, including 333 in 2024 alone, according to GPS's mortality registry. The documented causes — a homicide rate that reached nearly triple the national average, a suicide rate that climbed to 44 per 100,000, and hundreds of overdose deaths — are themselves undercounts, because the Department of Corrections has misclassified at least 44 overdose deaths and stopped publishing cause of death altogether in March 2024. What follows is what the record shows, what it hides, and who decides which is which.
9,363 data points
Oversight & Accountability
Georgia runs one of the nation's largest prison systems with no independent body empowered to inspect it, no ombudsman outside the Department of Corrections, and no public reporting requirement attached to the $600 million it has been voted for prison spending. A six-year federal civil rights investigation found constitutional violations across the system in October 2024 and recommended 82 remedial measures; more than 230 days after its 49-day litigation deadline expired, no one had been arrested, fired, or sued as a result. What remains is a closed loop in which the department investigates its own deaths, codes its own mortality data, disciplines — or does not discipline — its own staff, and classifies its investigative files as confidential state secrets.
20,251 data points
Key Findings
The most impactful data from this research collection. Tap a card for the full finding and its source.
The finding
GBI Director Chris Hosey said the GBI has 19 medical examiner positions, but only 12 of them are filled, mostly because of a nationwide shortage of medical examiners.
The finding
The DOJ's report found that GDC's mortality data categorizes many deaths that were obviously homicides as having an unknown or unknown verified cause of death.
The finding
GBI Director Chris Hosey said national standards ask that an individual medical examiner perform 250 autopsies a year, but the medical examiners in Georgia perform more than 400 a year.
The finding
A court with criminal jurisdiction may order a medical examiner's inquiry upon a filed affidavit attesting that a person's death resulted from foul play, if the court decides the inquiry is essential to the ends of justice.
The finding
As first reported by the Atlanta Journal-Constitution, the GDC in March 2024 stopped including cause-of-death data in its monthly mortality reports, which had typically listed the name, location, age, date, and cause of death of those who died in state custody.
The finding
The Georgia Bureau of Investigation is authorized to perform a post mortem examination and autopsy on a person whose death occurs within a state owned or leased building or on the curtilage of such building, and this GBI authority and jurisdiction supersedes any other authority or jurisdiction otherwise provided under the Georgia Death Investigation Act for a post mortem examination or autopsy.
The finding
The DOJ wrote that in June 2024, Georgia prisons said only six people had been killed inside its facilities, even though the DOJ had obtained reports showing at least 18 people had been murdered that year.
The finding
GDC's June 2024 mortality data still classified at least 2 homicides from 2021 as having an 'unknown' cause of death, excluding them from GDC's official homicide count for that year, even though GDC's incident reports, GBI autopsy records, and EMS records made clear the deaths were homicides (one a stabbing, one asphyxiation via chokehold).
The finding
GDC SOP 507.04.67 requires the Clinical Mortality Peer Review to be completed within 21 working days from the death of the offender, with the Case Abstract form and other mortality review forms mailed to the GDC Office of Health Services within 31 working days of the offender's death.
The finding
GDC reported in its June 2024 mortality data that for the first five months of 2024 there were 6 homicides, even though at least 18 deaths were categorized as homicides in GDC incident reports and GDC assured DOJ investigators these suspected homicides were under investigation.
The finding
The Senate PSI staff report found that in Fiscal Year 2021 alone, DOJ failed to identify at least 990 prison and arrest-related deaths, and 70% of the data DOJ collected was incomplete.
Source
The finding
At Calhoun State Prison, the responding coroner had to wait at the prison gate because no one was there to let him in, and based on the body being stiff the coroner believed the incarcerated person had been dead for seven to eight hours before being found.
The finding
The Senate PSI staff report found that GAO identified at least 990 deaths potentially reportable to BJA in FY 2021 that BJA had not counted, of which 341 were prison deaths disclosed on states' public websites and 649 were arrest-related deaths disclosed in a reliable public database.
Source
The finding
Since a 2024 law went into effect requiring an autopsy after any in-custody death at a state prison facility, Virginia's medical examiner has failed to complete the procedure almost half of the time.
The finding
The AJC found that medical examiner findings were not yet available for 72 of the 73 prisoners who had died that year, nor for more than 50 of the prisoners who died in 2023.
The finding
Coroners shall require an inquest to be conducted when an inmate of a state hospital or a state, county, or city penal institution dies unexpectedly without an attending physician or as a result of violence, and the chief medical examiner or his or her designee, regional medical examiner, or local medical examiner shall perform all medical examiners' inquiries in such cases.
The finding
GDC records show the department labels numerous prison deaths as 'undetermined,' and that was the case with 31 deaths that medical examiners later ruled to be accidental drug overdoses.
The finding
GDC spokesperson Joan Heath said 13 overdose deaths were initially reported by GDC as 'natural' because deaths are labeled that way when not clearly due to trauma, and are later reclassified when death certificates are completed; ten of those 13 overdose deaths have now been reclassified.
The finding
Years after many of the 13 overdose deaths GDC reported as natural, GDC records obtained by the AJC still list them as natural.
All Data Points
350 verified data points extracted from primary sources.
Georgia Senate study committee made no recommendations on GBI death investigations or autopsies Finding
A Georgia Senate study committee's final report recommendations do not include any recommendation on GBI death investigations, autopsies, or medical examiner practice; the report contains no occurrence of the words 'autopsy' or 'medical examiner.'
OCGA § 45-16-24 requires notification of coroner/medical examiner for inmate deaths Legal fact
Georgia law lists death '[w]hen an inmate of a state hospital or a state, county, or city penal institution' among the categories after which 'it shall be the duty of any law enforcement officer or other person having knowledge of such death to notify immediately the coroner or county medical examiner of the county in which the acts or events resulting in the death occurred or the body is found.'
BOP Wardens have discretion to order autopsies under 18 U.S.C. § 4045 Policy
DOJ OIG report describes BOP policy giving Wardens discretion to order an autopsy on a deceased inmate's body under 18 U.S.C. § 4045 if the Warden believes an autopsy is necessary to detect a crime, maintain discipline, protect the health or safety of other inmates, remedy official misconduct, or otherwise as provided by that statute; a non-BOP coroner or medical examiner performs the autopsy.
Source
OCGA 45-16-27 requires coroner inquest for unexpected inmate deaths Legal fact
Official Code of Georgia Annotated § 45-16-27 requires coroners to hold an inquest when an inmate of a state, county, or city penal institution dies unexpectedly without an attending physician or as a result of violence; the chief medical examiner, regional medical examiner, or local medical examiner shall perform all medical examiners' inquiries in such cases.
Maryland medical examiner recordkeeping requirement Legal fact
Maryland Health-General section 5-310 requires the Office of the Chief Medical Examiner to keep complete records on each medical examiner's case, including the date, cause, and manner of death.
Source
GDC SOP 208.03: Autopsy shall be requested but ME has discretion Policy
Under GDC SOP 208.03, 'Death of an Offender,' an autopsy shall be requested for a death under unusual circumstances, but under O.C.G.A. § 45-16-22 the medical examiner has discretion to determine the need for an autopsy.
Oregon requires medical examiner investigation of in-custody deaths Legal fact
Oregon law requires the medical examiner to investigate and certify the cause and manner of death for deaths occurring while incarcerated in any jail, correction facility, or in police custody.
Coroner takes possession of inmate property when no next of kin Legal fact
Under Ga. Comp. R. & Regs. r. 125-2-4-.20 (Death and Interment), in the absence of next of kin, the Coroner takes possession of all property of value found on the deceased inmate, makes an exact inventory, and surrenders the property to the person entitled to custody; the inventory is signed by the Coroner and Warden/Superintendent and becomes a permanent part of the inmate's file.
NCCHC requires psychological autopsy within 30 days for suicides Policy
NCCHC's Procedure in the Event of an Inmate Death standard requires a psychological autopsy, sometimes called a psychological reconstruction or postmortem, within 30 days for all deaths by suicide.
Georgia audit team interviewed 11 of 14 state medical examiners Methodology note
The audit team conducted interviews with 11 of the 14 state medical examiners as part of the review of the State Medical Examiner's Office, and conducted site visits to the headquarters location and the three field locations.
GBI ME Office investigates deaths occurring while incarcerated or in law enforcement custody Legal fact
The GBI Medical Examiner's Office investigates deaths that are apparently homicidal, suicidal, or occurring under suspicious or unknown circumstances; resulting from unlawful use of controlled substances or abuse of chemicals or toxic agents; or occurring while incarcerated or while in the custody of a law enforcement officer. Death cases are reported to the ME's Office by coroners, deputy coroners, and law enforcement, and the ME's Office determines whether an examination will be performed.
OCGA 31-10-15: physician must certify cause of death within 72 hours unless death investigation inquiry required Legal fact
Under OCGA § 31-10-15, the medical certification of cause and circumstances of death must be completed, signed, and returned to the funeral director within 72 hours after death by the physician (or APRN/PA) in charge of the patient's care, except when inquiry is required by the Georgia Death Investigation Act.
GBI Medical Examiner staffing: 12 of 19 positions filled Statistic
GBI Director Chris Hosey said the GBI has 19 medical examiner positions, but only 12 of them are filled, mostly because of a nationwide shortage of medical examiners.
12 filled positions vs. 19 total positions
DCRA minimum reporting elements Legal fact
The Death in Custody Reporting Act requires states to report, at a minimum, the name, gender, race, ethnicity, and age of the deceased; date, time, and location of death; the law enforcement agency involved; and a brief description of the circumstances surrounding the death.
OCGA § 45-16-24 mandates medical examiner's inquiry for inmate deaths Legal fact
A coroner or county medical examiner notified of a death under paragraphs (1) through (10) of the death-reporting statute -- which includes death as an inmate of a state, county, or city penal institution -- shall order a medical examiner's inquiry of that death.
BJA receives widespread underreports of deaths in custody across all three DCRA categories Finding
DOJ's report on DCRA implementation found that BJA is receiving underreports of deaths in custody in all three categories of reporting, and that this underreporting is widespread, not the result of a small number of lagging or uncooperative states.
DOJ found GDC mortality data misclassifies homicides as unknown causes Finding
The DOJ's report found that GDC's mortality data categorizes many deaths that were obviously homicides as having an unknown or unknown verified cause of death.
Massachusetts medical examiner jurisdiction over custody deaths Legal fact
Massachusetts law lists death in custody, in any jail or correctional facility, or in any mental health or mental retardation institution among the deaths that must be investigated by the medical examiner.
GDC SOP 208.03: Body release within 24 hours of demand unless foul play finding Policy
Under GDC SOP 208.03, the body of a deceased offender shall be released to the next of kin or an agent no later than 24 hours after demand for release, and upon release by the Coroner, GBI, or Crime Lab, unless there has been a written finding by the Peace Officer, Medical Examiner, or Coroner that foul play may have been involved.
Pennsylvania coroner statute covers deaths in prison or penal institution Legal fact
Pennsylvania's coroner investigation statute requires investigation to determine cause of death for deaths occurring in prison or a penal institution or while in the custody of the police.
State reimburses county for indigent inmate burial, except county facility deaths Legal fact
Under Ga. Comp. R. & Regs. r. 125-2-4-.20, when an indigent inmate dies in a State institution, the State Board of Corrections reimburses the county governing authority for burial expenditures, but the county is not entitled to reimbursement if the deceased inmate was incarcerated in a county correctional institution or facility at the time of death.
Georgia one of eight states fully accredited by NAME Finding
Georgia is one of only eight states that are fully accredited by the National Association of Medical Examiners (NAME), a professional organization for physicians, investigators, and administrators involved in the field of medical death investigation.
OCGA 31-10-15: 30-day deadline for medical certification when death investigation inquiry required Legal fact
When a death occurs without medical attendance or when inquiry is required under the Georgia Death Investigation Act, the proper person must investigate the cause of death and complete and sign the medical certification portion of the death certificate within 30 days after being notified of the death.
Georgia medical examiners perform over 400 autopsies annually vs 250 national standard Statistic
GBI Director Chris Hosey said national standards ask that an individual medical examiner perform 250 autopsies a year, but the medical examiners in Georgia perform more than 400 a year.
400 autopsies per examiner per year vs. 250 national standard autopsies per examiner per year
DCRA penalty for noncompliance: up to 10% JAG reduction Legal fact
Under the Death in Custody Reporting Act, a state that fails to comply with the reporting requirement may be subject to, at the Attorney General's discretion, not more than a 10-percent reduction of the Byrne Justice Assistance Grant funds otherwise allocated to that state for that fiscal year.
Georgia Death Investigation Act requires notification for inmate deaths Legal fact
The Georgia Death Investigation Act requires notification to the coroner or county medical examiner when an individual dies as an inmate of a state hospital or a state, county, or city penal institution.
Matthew Loflin died of heart failure after officials failed to provide treatment at Chatham County Detention Center Case detail
A report on the federal Death in Custody Reporting Act states that Matthew Loflin died of heart failure after officials failed to provide him treatment at the Chatham County Detention Center in Georgia in 2014, and that his death was highlighted at a Senate Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations hearing on DOJ's failure to implement DCRA.
GDC uses 'unknown causes' pending autopsy, often for months or years Finding
Georgia prison officials regularly claim someone died from 'unknown causes' if an autopsy is pending and update that data when an investigation ends, but according to the DOJ those processes often take months or years to update.
Massachusetts reporting duty for custody deaths Legal fact
Massachusetts General Laws Chapter 38 Section 3 lists death in custody, in any jail or correctional facility, or in any mental health or mental retardation institution, as one of the death categories subject to the reporting duty of that section.
GDC SOP 208.03: FBI no longer accepts fingerprint cards on deceased offenders Policy
Under GDC SOP 208.03, the FBI no longer accepts fingerprint cards on deceased offenders, so fingerprints are not necessary unless explicitly requested by an investigating authority.
Rhode Island requires notification of medical examiners for suspicious deaths Legal fact
Rhode Island General Laws section 23-4-7 requires that where a person dies in a manner suggesting a criminal act, violence, apparent suicide, criminal abortion, or in a suspicious or unusual manner, any person with knowledge must immediately notify police or the office of state medical examiners.
Next of kin and Commissioner receive death certificate for natural-cause deaths Legal fact
Under Ga. Comp. R. & Regs. r. 125-2-4-.20, when an inmate dies from natural causes, the next of kin and the Commissioner of Corrections shall be furnished copies of a Certificate of Death, and the next of kin shall be informed as to the location and procedures for claiming the remains.
ABA: medical examiner should have authority to order autopsy over correctional objection Legal fact
The ABA commentary to its prisoner-death notification standard states the medical examiner should have authority to order an autopsy even over a correctional agency's objection, reasoning that prisoners are vulnerable to abuse and neglect that can culminate in death.
Source
Georgia Death Investigation Act lets medical examiner decline jurisdiction, recorded in PathAssist Legal fact
Under the Georgia Death Investigation Act criteria, the medical examiner decides whether to accept jurisdiction over a case. If jurisdiction is declined, the name of the medical examiner is recorded in the PathAssist database to indicate the case was discussed and declined.
OCGA 45-16-6: annual training required for coroners and deputy coroners Legal fact
Every coroner and deputy coroner must take an approved training course each calendar year in office as a condition of continuing to serve, approved by the Georgia Coroner's Training Council pursuant to OCGA § 45-16-66.
GBI Medical Examiner accreditation downgraded due to caseload Finding
WSB-TV reported that the accreditation of the Georgia Bureau of Investigation's Medical Examiner's Department was downgraded recently, not because of a lack of skill by the state's official forensic pathologists, but because of their large caseload, as GBI Director Chris Hosey told Georgia lawmakers during his budget presentation.
NAME standard A2.6: investigate deaths of persons in custody Legal fact
NAME's Forensic Autopsy Performance Standards (Standard A2, Initial Inquiry) list among the categories of death the forensic pathologist or representative shall investigate: 'A2.6 deaths of persons in custody.'
Court may order medical examiner's inquiry on affidavit of foul play Legal fact
A court with criminal jurisdiction may order a medical examiner's inquiry upon a filed affidavit attesting that a person's death resulted from foul play, if the court decides the inquiry is essential to the ends of justice.
No state penalized under DCRA funding-withholding provision Finding
No state has been penalized under DCRA's funding-withholding enforcement provision because the Department of Justice chose not to apply that provision.
GDC stopped including cause-of-death data in monthly mortality reports in March 2024 Policy
As first reported by the Atlanta Journal-Constitution, the GDC in March 2024 stopped including cause-of-death data in its monthly mortality reports, which had typically listed the name, location, age, date, and cause of death of those who died in state custody.
Michigan medical examiner examination of deceased prisoner Legal fact
Michigan law requires that if a prisoner in a county or city jail dies while imprisoned, the county medical examiner or deputy county medical examiner, upon being notified of the death, shall examine the body of the deceased prisoner.
GDC SOP 208.03: Foreign national death notification to General Counsel next business day Policy
Under GDC SOP 208.03, when a Foreign National offender dies in GDC custody, the Warden or Superintendent or designee must notify the GDC General Counsel of the circumstances on the next business day following the death.
South Carolina requires coroner to order autopsy for deaths in penal institutions Legal fact
South Carolina law requires the coroner to order an autopsy upon the death of persons in penal institutions, under Section 17-7-10.
GBI Division of Forensic Sciences sets uniform fees for death investigation professionals Legal fact
O.C.G.A. § 35-3-151 provides that the Division of Forensic Sciences of the GBI shall provide for and establish uniform fees, as approved by the board, to be paid to medical examiners, dentists, and other professionals for participating in medical examiners' inquiries or coroners' inquests under the Georgia Death Investigation Act.
ABA: correctional official may also order autopsy where authorized by law Legal fact
The ABA's Treatment of Prisoners Standards provide that when a prisoner dies, correctional officials should promptly notify the jurisdiction's medical examiner, and the medical examiner -- not the correctional agency -- should decide whether an autopsy is conducted, though a correctional official may also be permitted to order one where authorized by law.
Source
SMEO autopsy and examination breakdown with 33% jurisdiction declined Statistic
A Georgia state performance audit found that the GBI's State Medical Examiner's Office (SMEO) conducted 2,806 (58%) full autopsies, 271 (6%) limited dissections, and 148 (3%) external examinations, while jurisdiction was declined for the remaining 1,609 (33%) cases.
2,806 full autopsies vs. 1,609 cases with jurisdiction declined
GBI Chief ME reviews autopsy reports in all Use of Force death cases investigated by GBI Policy
Under GBI's custodial death investigations manual, the GBI Chief Medical Examiner or designee reviews the autopsy reports in all Use of Force cases resulting in a death investigated by GBI, including autopsies conducted by GBI Medical Examiners and those conducted by other ME offices on cases investigated by GBI.
OCGA 42-5-50: clerk must notify Corrections Commissioner of sentence within 30 working days Legal fact
The clerk of the court must notify the Commissioner of Corrections of a sentence within 30 working days following receipt of the sentence and send other documents set forth in the Code section.
GBI MEO autopsy reports pending ranged 969-1,154 monthly in FY2024 Statistic
In GBI's April FY2024 Monthly Report, the MEO Backlog chart for FY2024 (reports pending, calculated as more than 90 days from date of examination per NAME accreditation standards) showed reports pending ranging from 969 to 1,154 across the ten months shown, with the percentage released within 90 days ranging from 49.1% to 83.5%.
1,154 reports pending vs. 969 minimum reports pending
NAME standard B3.4: forensic autopsy for non-natural death in custody Legal fact
NAME's Forensic Autopsy Performance Standards (Standard B3, Selecting Deaths Requiring Forensic Autopsies) state the forensic pathologist shall perform a forensic autopsy when 'B3.4 the death is apparently non-natural and in custody of a local, state, or federal institution.'
GBI authorized to perform autopsies for deaths in state buildings, superseding other jurisdiction Legal fact
The Georgia Bureau of Investigation is authorized to perform a post mortem examination and autopsy on a person whose death occurs within a state owned or leased building or on the curtilage of such building, and this GBI authority and jurisdiction supersedes any other authority or jurisdiction otherwise provided under the Georgia Death Investigation Act for a post mortem examination or autopsy.
Arizona requires reporting deaths in custodial agencies Legal fact
Arizona Revised Statutes section 11-593 requires reporting of the death of a person in a custodial agency as defined in section 13-4401.
Susan Burns: GDC frequently categorizes deaths as 'unknown' rather than homicides or suicides Finding
Susan Burns, founder of Georgia prison watchdog group They Have No Voice, said GDC authorities frequently categorize deaths as 'unknown' causes rather than accurately documenting them as homicides or suicides, and that this was central to the misclassification issue.
Michigan statutory requirement for prisoner death examination Legal fact
Michigan law requires a county medical examiner to examine the body of a prisoner who dies while imprisoned in a county or city jail.
GDC SOP 208.03: Consulate notification within five calendar days Policy
Under GDC SOP 208.03, the GDC General Counsel shall notify the appropriate Consulate General, in writing, within five calendar days of a foreign national offender's death.
South Carolina coroner jurisdiction over deaths in holdover facilities and jails Legal fact
South Carolina law states that if any person dies while detained, incarcerated, or under the jurisdiction of a municipal, county, or regional holdover facility, holding cell, overnight lockup or jail, a county correctional facility, the coroner shall address the death as set out in the statute.
Warden must notify Commissioner, Crime Lab, and Coroner of unusual inmate death Legal fact
Ga. Comp. R. & Regs. r. 125-4-4-.11 (Unusual Death) requires that whenever an inmate dies suddenly or under unusual circumstances, the Warden/Superintendent shall promptly notify the Commissioner of Corrections, the Director of the State Crime Lab, and the Coroner of the county in which the death occurs, and furnish the Commissioner a Death Certificate and the findings of the Coroner's inquest.
NAME accreditation checklist: 250 autopsies/year per physician threshold Policy
NAME's Inspection and Accreditation Checklist for Autopsy Facilities asks inspectors to verify item G2h: 'Is the medical staff of sufficient size that no autopsy physician is required to perform more than 250 autopsies/year?' and item G2g, a separate question, asks the same of 'more than 325 autopsies/year.'
GBI ME FAQ: autopsy not always necessary; coroner or ME determines Policy
The GBI Medical Examiner's Office FAQ states that an autopsy is not always necessary and that the coroner or medical examiner will make the determination if an examination is warranted.
GBI manual: jail and prison deaths investigated under use-of-force/custodial death criteria Policy
GBI's Law Enforcement Use of Force and/or Custodial Death Investigations Manual states that investigations of custodial deaths, including jail and prison deaths, will be conducted, reported and reviewed according to the use of force/custodial death case criteria requirements, and the appropriate Inspector will be notified and kept apprised of the investigation status.
Crosby v. Johnson: coroners are county officials for Georgia Tort Claims Act immunity Legal fact
The Georgia Court of Appeals held that for purposes of immunity under the Georgia Tort Claims Act, coroners are county officials, not state officers.
GBI MEO switched to MDI Log database in March 2024, reducing autopsy report releases Methodology note
In GBI's April FY2024 Monthly Report, in March 2024 the Medical Examiner's Office switched from JusticeTrax Laboratory Information Management System (LIMS) to Medicolegal Death Investigator (MDI) Log, a new database system, and fewer reports were released as staff was being trained on new protocols for releasing autopsy reports within the new system.
NAME rationale: custody deaths can engender mistrust of authority Finding
NAME's Forensic Autopsy Performance Standards explain that deaths in the custody of law enforcement agencies or governmental institutions 'can arouse public interest, raise questions, or engender mistrust of authority,' which is part of the rationale for the standard on selecting deaths requiring forensic autopsy.
Coroner/medical examiner must take charge of body upon notice Legal fact
Upon receipt of the required death notice, the coroner or county medical examiner shall immediately take charge of the body.
As of January 2025 GDC had not rectified cause-of-death misclassification Finding
Susan Burns said that as of January 2025, GDC had not rectified the issue of misclassifying cause of death.
Minnesota Protocol: independent reporting of custody deaths Legal fact
The Minnesota Protocol on the Investigation of Potentially Unlawful Death states that where a person has died in custody, this must be reported, without delay, to a judicial or other competent authority that is independent of those implicated, as part of the duty to investigate a potentially unlawful death.
GDC SOP 208.03: Certificate of Death completed by investigating medical authority Policy
Under GDC SOP 208.03, the appropriate investigating medical authority shall complete a Certificate of Death, and the facility shall provide the next of kin with a Certificate of Death.
South Carolina requires autopsy for deaths under jurisdiction of jail or state correctional facility Legal fact
South Carolina law requires the coroner to order an autopsy when any person dies while detained, incarcerated, or under the jurisdiction of a jail or state correctional facility.
Warden must immediately notify Commissioner of all deaths Legal fact
Ga. Comp. R. & Regs. r. 125-4-4-.10 (Injury, Illness and Death) requires that in all cases of death the Warden/Superintendent shall immediately notify the Commissioner of Corrections and provide a copy of the Certificate of Death.
NAME standard: no medical examiner should complete more than 250 exams per year Policy
The National Association of Medical Examiners says no medical examiner should complete more than 250 medical exams per year.
GBI ME FAQ: autopsies performed at request of coroners and officials; public must contact law enforcement or DA Policy
The GBI ME FAQ states that the GBI Medical Examiner's Office performs autopsies at the request of county coroners, local officials, and state officials, and that a person wishing to report a death or raise concerns about a death must contact local law enforcement or the district attorney to request an investigation.
GBI custodial death manual lists records agents must obtain in jail/prison deaths Policy
For jails/prisons, GBI agents must obtain: jail policies and procedures covering handling of inmates who are violent, intoxicated, suicidal, or have other special needs; cell check requirements for regular and for violent/intoxicated/suicidal inmates; records of time checks or cell checks completed by personnel for the shift prior to and up to the time of death; the inmate's jail medical records; jail records including any suicide risk notations; visitation logs; and video/audio surveillance footage if applicable.
Crosby v. Johnson: official-capacity claims against coroner are claims against county with sovereign immunity Legal fact
The Georgia Court of Appeals held that claims against a coroner sued in his official capacity are essentially claims against the county, which is entitled to sovereign immunity absent a showing of waiver.
DCRA Georgia decedents FY2020-2024 total 2,154 Statistic
BJA's DCRA state-reported deaths interactive table lists Georgia decedents of 449 in fiscal year 2020, 445 in FY2021, 437 in FY2022, 394 in FY2023, and 429 in FY2024, totaling 2,154 across all years and manners/location types.
2,154 decedents
Source
UCLA: 60 GDC deaths (5.6%) with unknown circumstances Statistic
The UCLA Law COVID Behind Bars Data Project's Table 3, using Georgia Department of Corrections death records, lists "Unknown" as the general circumstance of death for 60 deaths, 5.6 percent of all deaths.
60 deaths vs. 5.6 percent of all deaths
GAO: 70% of FY2021 death-in-custody records missing required elements Statistic
GAO found that 70 percent of the records on deaths in custody provided by states in fiscal year 2021 were missing at least one element required by DCRA.
70%
Coroner must summon medical examiner and peace officer Legal fact
It is the duty of a coroner who has been notified as required under the death-reporting statute to summon a medical examiner and proper peace officer.
California coroner must investigate deaths in prison or under sentence Legal fact
California Government Code § 27491 requires the coroner to inquire into and determine the circumstances, manner, and cause of death for persons who die in prison or while under sentence, among other categories of death.
June 2024: GDC reported 6 killings while DOJ had evidence of at least 18 murders Statistic
The DOJ wrote that in June 2024, Georgia prisons said only six people had been killed inside its facilities, even though the DOJ had obtained reports showing at least 18 people had been murdered that year.
6 reported killings vs. 18 murders documented by DOJ
Minnesota Protocol scope includes all prison deaths Legal fact
The Minnesota Protocol on the Investigation of Potentially Unlawful Death states that a death falls within the Protocol's scope where the death occurred when a person was detained by, or was in the custody of, the State, its organs, or agents, including all deaths of persons detained in prisons, in other places of detention, and in other facilities where the State exercises heightened control over their life.
DOJ: GBI Office of the Medical Examiner conducts most autopsies; GBI investigates small number at GDC request Finding
DOJ found that for most deaths of incarcerated persons requiring an autopsy, GBI's Office of the Medical Examiner conducts the autopsy, and in a small number of cases GBI handles investigations at GDC's request.
Tennessee medical examiner must investigate deaths of prisoners or persons in state custody Legal fact
Tennessee law includes deaths of prisoners or persons in state custody among the deaths that must be reported and investigated by the county medical examiner.
Coroner's report on Sheqweetta Vaughan death lacked cause and manner Case detail
The coroner's report on Sheqweetta Vaughan's death at Lee Arrendale State Prison did not specify a cause or manner of death, stating a finding was awaiting autopsy and toxicology results and a review of medical records.
GBI has 10 open medical examiner positions Statistic
GBI Director Mike Register said the agency has 10 open medical examiner positions and is struggling to keep up with a growing amount of casework because of a lack of medical examiners.
10 open positions
GBI ME Office state-funded, no charge for autopsies; coroner transports body Policy
The GBI Medical Examiner's Office is funded by the state and does not charge local agencies, coroners, or family members for autopsy services; however, the coroner with jurisdiction over the death is responsible for transporting the body to the Medical Examiner's morgue facility.
GBI Crime Lab backlog: 641 Medical Examiners requests Statistic
The GBI Crime Lab's backlog included 641 requests attributed to Medical Examiners, shown in a backlog chart alongside Toxicology (1,723), Trace Evidence, and Latent Prints/Impressions categories.
641 requests
Crosby v. Johnson: coroner's body-removal decision is discretionary, entitled to official immunity Legal fact
The Georgia Court of Appeals held that the trial court erred in ruling the coroner was not entitled to official immunity for claims predicated on alleged violations of OCGA § 45-16-31, because the coroner's conduct in deciding where to remove the body was discretionary rather than ministerial.
UCLA: 38 GDC deaths (3.54%) undetermined circumstances Statistic
The UCLA Law COVID Behind Bars Data Project's Table 3, using Georgia Department of Corrections death records, lists "Undetermined" as the general circumstance of death for 38 deaths, 3.54 percent of all deaths.
38 deaths vs. 3.5 percent of all deaths
GAO: nearly 1,000 unreported deaths in custody in FY2021 Statistic
GAO compared fiscal year 2021 state-submitted records to publicly available data and identified nearly 1,000 deaths that potentially should have been reported to DOJ but were not.
1,000 deaths
GDC SOP 507.04.67 natural death notification chain Policy
GDC SOP 507.04.67 requires that following a natural death the Medical Director or designee immediately notify the Warden/Superintendent, the facility duty officer, and the Health Services Administrator, and that the Warden/Superintendent or designee notify the County Coroner and, through the State Communication Center, notify the GDC Commissioner, Regional Director, and the GDC Health Services Director.
California Commission on State Mandates confirms coroner jurisdiction over prison deaths Legal fact
A California Commission on State Mandates decision states that the types of death over which the coroner has jurisdiction under Government Code section 27491 include deaths 'In prison or while under sentence.'
Source
OCGA 45-16-32 requires medical examiner/coroner reports and permanent records Legal fact
Official Code of Georgia Annotated § 45-16-32 requires the medical examiner and coroner to complete a report of each medical examiner's inquiry and coroner's investigation and to maintain permanent records of such reports.
Minnesota reportable death categories include inmates Legal fact
Minnesota law makes deaths of inmates of public institutions and persons in custody of law enforcement officers who have not been hospitalized primarily for organic disease a reportable death subject to medical examiner investigation.
DOJ: Apparent homicides may be reported as undetermined/unknown pending autopsy; final reports can take months or years Finding
GDC officials told DOJ investigators that apparent homicides may be reported as undetermined or unknown deaths pending autopsy results or other pending investigative activities, and it can take months or years before GDC receives a final autopsy report for deaths.
Tennessee notification duty for deaths of prisoners in state custody Legal fact
Tennessee law requires any physician, undertaker, law enforcement officer, or other person having knowledge of the death of a prisoner or person in state custody to notify the county medical examiner.
GDC OPS investigated Vaughan death as undetermined and believed natural Finding
GDC spokesperson Joan Heath told the Atlanta Journal-Constitution that the Office of Professional Standards was investigating Sheqweetta Vaughan's death 'as undetermined and believed to be natural' pending autopsy results.
DCRA requires quarterly reporting of custody deaths to Attorney General Legal fact
The Death in Custody Reporting Act (DCRA) requires that each state receiving Byrne JAG funds report to the Attorney General on a quarterly basis information regarding deaths of persons detained, under arrest, in the process of being arrested, en route to incarceration, or incarcerated.
Source
BJS: 163 prisoner deaths in Georgia in 2018, 93 in 2001 Statistic
BJS recorded 163 prisoner deaths in Georgia state and federal facilities in 2018 and 93 deaths in 2001.
163 deaths vs. 93 deaths in 2001
Governor's budget recommendation: $1.4M design funds for GBI ME Office expansion Statistic
GBI's Joint Budget Hearing presentation to the Georgia legislature listed, among Governor's Budget Recommendation GO Bond Projects, design funds of $1.4 million for expansion of the GBI Medical Examiner's Office (Headquarters), alongside $7.24 million for construction of a new Region 1 Investigative Office.
$1.4M
GDC SOP 102.01: deceased offender identity withheld until next of kin notified; cause withheld until autopsy Policy
Under GDC SOP 102.01 (Media Relations), regarding information released to media about a deceased offender, the offender's identity is withheld until next of kin is notified, and cause of death is withheld until autopsy results are available.
UCLA: 1 GDC death (0.09%) pending circumstances Statistic
The UCLA Law COVID Behind Bars Data Project's Table 3, using Georgia Department of Corrections death records, lists "Pending" as the general circumstance of death for 1 death, 0.09 percent of all deaths.
1 death vs. 0.1 percent of all deaths
BJA DCRA guidance: use of force manner of death regardless of ME ruling Policy
BJA's DCRA reporting guidance instructs that for deaths during the process of arrest attributable to use of force, the manner of death 'should be entered as "Use of Force by Law Enforcement or Corrections Officer," regardless of the ruling of the medical examiner.'
GDC SOP 507.04.67 unusual death notification and scene preservation Policy
GDC SOP 507.04.67 requires that if a death occurs as a result of suicide, homicide, or accidental or suspicious circumstances, the GDC Commissioner and GDC Statewide Medical Director be notified immediately, and the Warden/Superintendent or designee is responsible for notifying the GBI, with the body not to be removed without permission of the GBI and the County Coroner.
Colorado requires investigation of deaths in custody or incarceration Legal fact
Colorado law requires investigation of deaths while in the custody of law enforcement officials or while incarcerated in a public institution.
OCGA 45-16-32 requires evidence transmission to forensic lab in suspected foul play Legal fact
Under OCGA § 45-16-32, in cases where a report indicates a suspicion of foul play, the medical examiner and peace officer in charge shall transmit any specimens, samples, or other evidence to a forensic laboratory for analysis; where foul play is verified, the laboratory shall provide a completed lab report to the appropriate prosecuting attorney.
Minnesota Protocol: independent authority requirement Legal fact
The Minnesota Protocol states that where a State agent has caused the death of a detainee, or where a person has died in custody, this must be reported without delay to a judicial or other competent authority that is independent of the alleged perpetrator.
DOJ: At least 2 homicides from 2021 still classified 'unknown' in June 2024 mortality data Statistic
GDC's June 2024 mortality data still classified at least 2 homicides from 2021 as having an 'unknown' cause of death, excluding them from GDC's official homicide count for that year, even though GDC's incident reports, GBI autopsy records, and EMS records made clear the deaths were homicides (one a stabbing, one asphyxiation via chokehold).
2 homicides
Texas medical examiner inquest required for deaths in prison or jail Legal fact
Texas law requires a medical examiner or deputy to hold an inquest when a person dies within twenty-four hours after admission to a hospital or institution or in prison or in jail.
Clinical Peer Review meetings scheduled within 10 days, held within 30 Policy
GDC SOP 508.03 (Death Notification, Critical Incident Notification, and Investigation) requires Central Office Clinical Peer Review Team meetings to be scheduled within ten working days and to occur within thirty days after the incident.
DCRA minimum data elements for death reports Legal fact
The DCRA report must contain at minimum the name, gender, race, ethnicity, and age of the deceased; the date, time, and location of death; the law enforcement agency involved; and a brief description of the circumstances surrounding the death.
Source
BJS cumulative cause-of-death breakdown for Georgia state prisoners Statistic
BJS's cumulative cause-of-death breakdown for Georgia state prisoners shows 2,212 deaths from all causes, including 735 from heart disease, 559 from cancer, 284 suicides, and 75 homicides.
2,212 deaths
GBI budget presentation includes ME Office caseload slide CY17-CY22 Methodology note
GBI's Joint Budget Hearing presentation includes a slide titled 'GBI Medical Examiners Office Caseloads CY17, CY22' showing Total Caseload by Year and Autopsies per Doctor. The underlying figures are not reproduced in the document.
GDC SOP 102.01: specific cause of death not released unless officially determined by medical examiner Policy
Under GDC SOP 102.01 (Media Relations), information that may not be released in connection with an investigation of an event or crime, unless authorized by the Director of Professional Standards or designee, includes the specific cause of death unless officially determined by the medical examiner.
UCLA: 5 GDC deaths (0.47%) not listed circumstances Statistic
The UCLA Law COVID Behind Bars Data Project's Table 3, using Georgia Department of Corrections death records, lists "Not listed" as the general circumstance of death for 5 deaths, 0.47 percent of all deaths.
5 deaths vs. 0.5 percent of all deaths
BJA DCRA guidance: required data fields for PMT Policy
BJA's DCRA guidance states that for each death in custody, states must enter into the PMT 'The decedent's name, date of birth, sex, race, and ethnicity,' along with 'The date, time, and location of the death,' and 'The law enforcement or correctional agency that detained, arrested, or was in the process of' detaining or arresting the decedent.
GDC SOP 507.04.67 Clinical Mortality Peer Review deadline Policy
GDC SOP 507.04.67 requires the Clinical Mortality Peer Review to be completed within 21 working days from the death of the offender, with the Case Abstract form and other mortality review forms mailed to the GDC Office of Health Services within 31 working days of the offender's death.
Colorado coroner must inquire into cause and manner of custodial deaths Legal fact
Colorado Revised Statutes section 30-10-606 requires the coroner to make inquiry to determine cause and manner of death if the death occurs from the action of a peace officer or while in the custody of law enforcement officials or while incarcerated in a public institution.
OCGA 45-16-28 authorizes physician autopsy with consent when ME inquiry not required Legal fact
Official Code of Georgia Annotated § 45-16-28 provides that in the case of death under circumstances that would not require a medical examiner's inquiry under the death-reporting statute, a licensed physician is deemed legally authorized to perform an autopsy when consented to by the person assuming custody of the body for burial purposes.
Minnesota Protocol scope includes prison detainees Legal fact
The Minnesota Protocol's definition of custody deaths within its scope includes deaths where a person was detained by, or was in the custody of, the State, its organs, or agents, including all deaths of persons detained in prisons.
DOJ: GDC reported 6 homicides for first five months of 2024 vs. at least 18 in incident reports Statistic
GDC reported in its June 2024 mortality data that for the first five months of 2024 there were 6 homicides, even though at least 18 deaths were categorized as homicides in GDC incident reports and GDC assured DOJ investigators these suspected homicides were under investigation.
6 homicides vs. 18 homicides in incident reports
Psychological autopsy required for suicides and unusual deaths of mental health patients Policy
GDC SOP 508.03 requires that for any unusual deaths of offenders receiving mental health services, or any offender (Level 1-6) who commits suicide, a Psychological Autopsy or review of the circumstances surrounding the death shall occur.
DCRA noncompliance penalty up to 10% Byrne JAG reduction Legal fact
A state that fails to comply with DCRA's quarterly reporting requirement may, at the Attorney General's discretion, face up to a 10-percent reduction of the funds otherwise allocated to it under the Byrne JAG program for that fiscal year.
Source
BJA DCRA example of sufficient manner-of-death description includes prone restraint asphyxiation Policy
BJA's DCRA guidance on reporting prison-based deaths gives, as a 'sufficient' example of brief circumstances describing manner of death, an account of a death 'due to being placed in prone position while restrained.'
Death certificate findings missing for several 2022 prison deaths; nine 2023 deaths pending Data gap
Death certificate findings for Georgia prison deaths are still missing for several 2022 prison deaths, and for 2023, coroners have said that findings on how nine prisoners died are still pending investigation.
GDC SOP 102.01: identity of critically injured or deceased withheld prior to next-of-kin notification Policy
Under GDC SOP 102.01 (Media Relations), information that may not be released in connection with an investigation includes the identity of any critically injured or deceased person prior to notification of next of kin.
UCLA: GDC recorded 1,072 deaths at ~59 facilities Statistic
In these records, the Georgia Department of Corrections recorded 1,072 deaths at approximately 59 different facilities.
1,072 deaths
DCRA scope: all custodial settings including state prisons Legal fact
The Death in Custody Reporting Act (DCRA; Pub. L. No. 113-242) requires states to report to the Attorney General information regarding the death of any person who is detained, under arrest, in the process of being arrested, en route to be incarcerated, or incarcerated at a municipal or county jail, state prison, state-run boot camp prison, boot camp prison contracted out by the state, or any state or local contract facility or other local or state correctional facility (including any juvenile facility).
GDC SOP 507.04.67 Administrative Mortality Review deadlines Policy
GDC SOP 507.04.67 requires an Administrative Mortality Review to be conducted by the Office of Health Services for all offender deaths in custody, with the Administrative Mortality Review form completed within fifteen working days of an offender's death by the Health Services Administrator and mailed within twenty days of the offender's death.
Connecticut requires scene preservation for custodial deaths until Chief Medical Examiner authorizes Legal fact
Connecticut General Statutes section 19a-407 provides that in cases of apparent homicide or suicide, or of accidental death the cause of which is obscure, or any other death not clearly the result of natural causes, that occurs while the deceased person is in the custody of a peace officer or a law enforcement agency or the Commissioner of Correction, the scene of the event shall not be disturbed until authorized by the Chief Medical Examiner.
Reuters identified 22 CCDC deaths 2009-2019, 50% due to illness Statistic
Reuters identified 22 people who died at CCDC from 2009 through 2019, of which 50% were due to illness, as cited in the Senate PSI staff report's Georgia case study.
22 deaths vs. 50 percent due to illness
Source
Minnesota Protocol: independent investigation mandate Legal fact
The Minnesota Protocol states that where a State agent has caused the death of a detainee, or where a person has died in custody, this must be reported without delay to a judicial or other competent authority that is independent of the detaining authority and mandated to conduct prompt, impartial and effective investigations into the circumstances and causes of such a death, and that this responsibility extends to persons detained in prisons.
DOJ: 2023 GDC $5 million settlement in mattress-fire death ruled homicide Case detail
In 2023, GDC agreed to a $5 million settlement in a case in which an incarcerated person died after correctional officers left him locked in his cell with his mattress on fire; the medical examiner ruled the death a homicide.
Texas medical examiner duty to hold inquest for prison/jail deaths Legal fact
Texas law makes it the duty of the medical examiner to hold an inquest when a person dies within twenty-four hours after admission to a hospital, institution, prison, or jail.
Clinical Peer Review confidential and non-discoverable under O.C.G.A. § 31-7-133 Policy
GDC SOP 508.03 provides that Clinical Peer Review of suicides and unusual deaths is confidential and non-discoverable per O.C.G.A. § 31-7-133, and is to be conducted in an open and honest manner with contributions encouraged from all staff involved in the clinical care of the deceased offender.
Javion Benham death at Valdosta State Prison ruled homicide by strangulation Case detail
Lowndes County Coroner Austin Fiveash said his office responded to Valdosta State Prison and ruled the death of 21-year-old Javion Benham a homicide caused by strangulation, after the coroner's office estimated Benham had been dead for about two days before being found.
BJA DCRA training uses Georgia Diagnostic and Classification State Prison as example agency Finding
BJA's DCRA training presentation on reporting prison-based deaths uses 'Georgia Diagnostic and Classification State Prison' as the custodial agency in its illustrative decedent-record example.
GDC stopped providing information on how prisoners are dying (March) Policy
In March, the Georgia Department of Corrections said it would no longer provide information on how prisoners are dying. That forced the AJC to seek out other sources to try to identify homicides. Death certificates are the definitive record, but autopsy findings can take months.
GDC SOP 102.01: employees barred from commenting on pending investigations absent authorization Policy
Under GDC SOP 102.01 (Media Relations), when an investigation is pending, employees shall make no comment about matters under investigation unless authorized by the Director of the Office of Professional Standards, Director of Public Affairs, or their designees.
GDC media policy withholds death ID until next of kin notified, cause until autopsy Policy
GDC's own media policy states that for an inmate death, ID is withheld until next of kin is notified, and cause is withheld until autopsy results are available.
BJA DCRA guidance: pending investigation manner of death Policy
BJA's DCRA reporting guidance states that for cases that remain under investigation, the manner of death should be reported as 'Unavailable, Investigation Pending,' and the state should specify when it anticipates obtaining the information.
GDC SOP 507.04.67 autopsy via GBI when cause unclear Policy
GDC SOP 507.04.67 states that in cases where the cause of an offender's death is unclear or an undiagnosed communicable disease is suspected, all reasonable attempts will be made to obtain a complete autopsy via the GBI.
Connecticut Chief Medical Examiner must investigate all violent deaths Legal fact
Connecticut General Statutes section 19a-406 requires the Chief Medical Examiner to investigate all violent deaths, whether apparently homicidal, suicidal or accidental.
DOJ failed to identify at least 990 prison and arrest-related deaths in FY2021 Statistic
The Senate PSI staff report found that in Fiscal Year 2021 alone, DOJ failed to identify at least 990 prison and arrest-related deaths, and 70% of the data DOJ collected was incomplete.
990 deaths vs. 70 percent of data incomplete
Source
Minnesota forensic pathologist review for DOC facility deaths Legal fact
Minnesota Statutes section 390.11 requires that for deaths occurring within a facility licensed by the Department of Corrections, the coroner or medical examiner shall ensure that a forensic pathologist certified by the American Board of Pathology reviews each death and performs an autopsy on all unnatural, unattended, or unexpected deaths.
Source
DOJ: Calhoun State Prison coroner waited at gate; body believed dead 7-8 hours before found Case detail
At Calhoun State Prison, the responding coroner had to wait at the prison gate because no one was there to let him in, and based on the body being stiff the coroner believed the incarcerated person had been dead for seven to eight hours before being found.
Virginia law requires autopsy after in-custody death at state prison since 2024 Legal fact
Since a 2024 Virginia law went into effect, an autopsy is required after any in-custody death at a state prison facility.
GDC Criminal Investigations Division investigates criminal allegations with GDC nexus Policy
GDC's Office of Professional Standards Fact Sheet states that the Criminal Investigations Division (CID) is charged with investigating any criminal allegation with a nexus to the GDC, and that its Special Agents and Criminal Investigators possess police powers and statewide jurisdiction.
Clayton County Sheriff did not follow up on detainee autopsy Finding
Clayton County Sheriff Levon Allen said he did not follow up on the autopsy of detainee Martinez to find out the cause of death, saying the man had fallen while in the jail's medical care.
GBI declined to open investigation into Cobb County jail death of Martin Floyd Case detail
The Georgia Bureau of Investigation was notified of Martin Floyd's death at the Cobb County jail but declined to open its own investigation, while the Cobb County Sheriff's Office's Criminal Investigations Unit and Cobb County Medical Examiner's Office proceeded with a review and autopsy. The Sheriff's Office said its Criminal Investigations Unit looks into every in-custody death as standard protocol.
GDC SOP 227.02: non-compliant grievances alleging physical force referred to OPS Criminal Investigation Division Policy
Under GDC SOP 227.02 (Statewide Grievance Procedure), grievances with physical force allegations deemed non-compliant are referred to the Office of Professional Standards, Criminal Investigation Division by Region.
Sen. Randy Robertson suggests routine GBI involvement in prison death investigations Quote
Study committee chairman Sen. Randy Robertson said it might make sense to routinely rely on the GBI for prison death investigations, saying "One thing that it does is it takes the suspicion out of the mix and the conspiracy theories tend to go away when that happens," though the committee did not plan to include the suggestion in its report.
NAME 2025 standard B1.4: forensic autopsy for unexpected/non-natural death in custody Legal fact
NAME's Forensic Autopsy Performance Standards (Standard B1) list 'the death is unexpected or apparently non-natural and occurs in the custody of a local, state, or federal institution' as one of the circumstances requiring a forensic autopsy.
GDC SOP 507.04.67 Clinical Mortality Peer Review committee composition Policy
GDC SOP 507.04.67 requires a Clinical Mortality Peer Review for all deaths in custody, performed by a committee chaired by the Health Service Administrator, the institutional Medical Director, the Responsible Physician, and the Regional Medical Director or designee.
NAME defines deaths in custody broadly to include direct or indirect law enforcement contact Finding
The NAME position paper on deaths in custody defines 'deaths in custody' as 'those deaths in which the circumstances of the death place the decedent in either direct or indirect contact with law enforcement such as incarceration, apprehension, and pursuit.'
Source
GAO identified 990 uncounted deaths in FY2021: 341 prison, 649 arrest-related Statistic
The Senate PSI staff report found that GAO identified at least 990 deaths potentially reportable to BJA in FY 2021 that BJA had not counted, of which 341 were prison deaths disclosed on states' public websites and 649 were arrest-related deaths disclosed in a reliable public database.
990 deaths
Source
Mississippi medical examiner jurisdiction over prison deaths Legal fact
Mississippi's medicolegal death investigation law, Miss. Code Ann. § 41-61-59, lists death of a person confined in a prison, jail or correctional institution as a death affecting the public interest that must be investigated.
DOJ: Calhoun coroner said 'some shit that ain't right about this inmate' Finding
The coroner investigating a death at Calhoun State Prison told emergency dispatch there was 'some shit that ain't right about this inmate.'
Virginia medical examiner failed to complete required autopsies almost half the time Finding
Since a 2024 law went into effect requiring an autopsy after any in-custody death at a state prison facility, Virginia's medical examiner has failed to complete the procedure almost half of the time.
GDC partners with GBI on joint investigative training Policy
GDC's Office of Professional Standards Fact Sheet states that GDC partners with the Georgia Bureau of Investigation in a joint training initiative to ensure all GDC Special Agents receive the nation's highest quality investigative training.
No Georgia GBI rules found on medical examiner jurisdiction declination Data gap
Searches of Georgia Rules and Regulations Department 92 (Georgia Bureau of Investigation) for 'Medical Examiner,' 'Medical Examiner's Inquiry,' 'Death Investigation,' and 'Coroner' returned no match, indicating no published GBI rule on medical examiner jurisdiction declination criteria was located.
No state law requires Georgia's nearly 800 agencies to report in-custody deaths to CJCC Legal fact
Georgia's Criminal Justice Coordinating Council states there is currently no state law requiring the nearly 800 different agencies to report death in custody information to CJCC.
AJC: GDC released almost no information on Daughtry's death six months later Case detail
The AJC reported that GDC released almost no information on former SMU prisoner Daughtry's death, even to his attorneys, citing a pending autopsy and ongoing investigation; six months later his death remained a mystery.
Jackson v. State: no warrant or consent required for medical examiner autopsy Legal fact
The Georgia Court of Appeals held that no search warrant or consent from the decedent's family was required for the medical examiner to conduct the autopsy and blood test on the stillborn fetus.
NAME 2025 standard B1.3: forensic autopsy for death associated with law enforcement action Legal fact
NAME's Forensic Autopsy Performance Standards also require a forensic autopsy when 'the death is associated with law enforcement action' (Standard B1.3).
GDC SOP 507.04.67 body release to funeral home Policy
GDC SOP 507.04.67 provides that after proper medical examination by a physician and consent of the County Coroner, the body will be released to a funeral home, which will document receipt of the body.
NAME recommends homicide certification for law enforcement firearm deaths Finding
The NAME position paper's committee recommends that deaths in which law enforcement discharges a firearm upon an individual who caused officers to perceive a threat 'be certified as homicide as suggested by the National Association of Medical Examiners position paper A Guide for Manner of Death Certification.'
Source
OCGA 42-5-7 requires warden to notify commissioner and coroner of inmate death Legal fact
Official Code of Georgia Annotated § 42-5-7 requires that whenever any inmate dies suddenly or under unusual circumstances in any correctional institution, the warden or superintendent shall immediately notify the commissioner and the coroner of the county in which the death occurs, and furnish the department with a copy of the findings of the coroner's inquest.
Mississippi mandatory autopsy for deceased prisoners Legal fact
Mississippi law makes it mandatory for the State Medical Examiner to cause an autopsy to be performed on the body of a deceased prisoner once notified of a prisoner's death, and the State Medical Examiner must also investigate any case where a person is found dead on correctional-system premises.
DOJ: Smith State Prison EMS not admitted until 1:11 p.m.; coroner waited at gate Case detail
The DOJ report describes a death investigation at Smith State Prison where EMS personnel were not let into the prison gates until 1:11 p.m., and upon arriving the coroner also had to wait at the prison gate because no one was there to let him in.
Virginia Code section 32.1-285 pertains to OCME autopsies for DOC custody deaths Legal fact
A Virginia Department of Health spokesperson stated that Virginia Code section 32.1-285 pertains to the Office of the Chief Medical Examiner performing autopsies on individuals who are in custody of the Department of Corrections.
OPS combines administrative and criminal investigative functions Policy
GDC's Office of Professional Standards Fact Sheet states that OPS incorporates administrative and criminal investigative functions to provide oversight for GDC's leadership and staff while coordinating and collaborating with external local, state, and federal agencies and entities.
GBI Medical Examiner FAQ lacks declination criteria Data gap
Searches of the GBI Division of Forensic Sciences Medical Examiner's Office FAQ for 'examination by this office is not necessary,' 'decline jurisdiction,' 'criteria for acceptance,' and 'will not accept' returned no match, indicating the FAQ does not publish criteria for declining jurisdiction.
All eight DCRA target agencies have reported since 2019; Gwinnett County ME Office not reporting Finding
Georgia's CJCC states that since starting DCRA data collection in 2019, all eight target reporting agencies have provided data to the SAC, but turnover has caused delays in reporting for almost all agencies, and currently the Gwinnett County Medical Examiner's Office is not reporting.
OCGA 45-16-23: local medical examiner must be licensed physician appointed by state medical examiner Legal fact
Under OCGA § 45-16-23, a local medical examiner must be a licensed physician appointed by the state medical examiner to perform scene investigations, external examinations, limited dissections, autopsies, or any combination of such duties.
Jackson v. State: exclusionary rule applies only to law enforcement, not medical examiner Legal fact
The Georgia Court of Appeals held that the exclusionary rule used to suppress evidence seized in illegal searches applies only to Fourth Amendment violations involving law enforcement officers, and that a medical examiner's investigation under the Death Investigation Act is not conducted by a law enforcement officer.
NAME 2025 standard A2.6: investigate deaths in custody of institution Legal fact
NAME's Forensic Autopsy Performance Standards (Standard A2) list investigation of 'deaths of persons in custody of a local, state, or federal institution' as a required investigative category, A2.6.
GDC SOP 507.04.67 family notification responsibility Policy
GDC SOP 507.04.67 assigns the Warden/Superintendent or designee responsibility for contacting the offender's family or next of kin following a natural death, with the Responsible Health Authority available to discuss the incident surrounding the death.
NAME recommends lower autopsy threshold for deaths in custody Finding
The NAME position paper on deaths in custody recommends 'a lower threshold than normal to perform autopsy examinations on deaths in custody, when possible,' and that 'an external and internal examination of the body should be performed by, or be directly supervised by' an experienced forensic pathologist.
Source
OCGA 35-3-153 establishes chief medical examiner and qualifications Legal fact
Official Code of Georgia Annotated § 35-3-153 establishes within the Division of Forensic Sciences an office of chief medical examiner, appointed by the director, who must at the time of appointment be a pathologist certified in forensic pathology by the American Board of Pathology.
Mississippi penalty for failure to notify medical examiner Legal fact
Under Mississippi law, any prison officer or employee who fails to immediately notify the medical examiner of a prisoner's death is guilty of a misdemeanor, punishable by a fine of not less than $100 nor more than $500 and confinement in the county jail.
DOJ recommendation: quality assurance program with morbidity/mortality reviews Policy
DOJ recommended that GDC implement a quality assurance program that includes complete, interdisciplinary morbidity/mortality reviews of all deaths, attempted suicides, and other critical incidents, that is adequately maintained, examines for patterns and trends, and identifies and corrects systemic deficiencies.
Virginia medical examiner investigation statute covers deaths in jail, prison, or police custody Legal fact
Virginia's medical examiner investigation statute, Va. Code Ann. § 32.1-283, requires investigation of deaths of persons in jail, prison, other correctional institution or in police custody.
Death of a penal institution inmate qualifies as a coroner case Legal fact
Under Georgia law as described in a state performance audit, a death of a person who 'is an inmate of a state hospital or a state, county, or city penal institution' qualifies as a coroner case requiring investigation.
GBI Medical Examiner's Office page lacks acceptance criteria Data gap
Searches of the GBI Division of Forensic Sciences Medical Examiner's Office page for 'examination by this office is not necessary,' 'decline,' and 'acceptance criteria' returned no match, indicating the page does not publish acceptance criteria.
CJCC Statistical Analysis Center assists agencies with DCRA reporting Policy
Georgia's DCRA State Implementation Plan states that the Criminal Justice Coordinating Council (CJCC), via its Statistical Analysis Center (SAC), assists agencies with reporting DCRA. The Research Analyst assigned to DCRA sets up meetings with agencies to discuss the data collection process and reporting requirements.
OCGA 45-16-23: medical examiner's investigator has same authority at scene but cannot arrest or perform autopsies Legal fact
Under OCGA § 45-16-23, a medical examiner's investigator performs the duties of the medical examiner with the same authority while at the scene of death and during subsequent investigation, except that no investigator is authorized to make an arrest or perform official external examinations, limited dissections, or autopsies.
Jackson v. State: medical examiner inquiry defined Legal fact
The Georgia Court of Appeals described a medical examiner's inquiry under the Death Investigation Act as an investigation into the circumstances surrounding a death, which may include an autopsy and other tests and examinations to determine the cause of death.
BOP Warden authority to order autopsy Policy
The Federal Bureau of Prisons Program Statement on Autopsies states the Warden may order an autopsy on a deceased inmate's body in the event of homicide, suicide, fatal illness or accident, or unexplained death, when necessary to detect a crime, maintain discipline, protect the health or safety of other inmates, remedy official misconduct, or defend the United States or its employees from civil liability.
GDC SOP 507.04.67 Mortality Peer Review Packet retention Policy
Under GDC SOP 507.04.67, upon completion all mortality review forms shall be maintained together as the Mortality Peer Review Packet at the Office of Health Services for ten years, and copies of the mortality review forms are not to be maintained or retained at the facility.
NAME position paper covers six recommendation areas Finding
The NAME deaths-in-custody position paper provides recommendations in six areas including categorization, investigation information, enhanced autopsy procedures, death certification guidance, statistical reporting parameters, and release of information to the public.
Source
OCGA 35-3-153 duties: death investigation regions, records, guidelines Legal fact
Under OCGA § 35-3-153, the chief medical examiner must establish death investigation regions, appoint regional medical examiners, maintain permanent death investigation records for all jurisdictions in the state, and establish death investigation guidelines for coroners and medical examiners.
Mississippi prompt reporting requirement for prison deaths Legal fact
Mississippi law requires a person's death affecting the public interest, including the death of a person confined in a prison, jail or correctional institution, to be promptly reported to the medical examiner by the physician in attendance, any hospital employee, any law enforcement officer, the embalmer, any emergency medical technician, or any relative or other person present.
DOJ: February 2023 Calhoun death timeline: found dead in restrictive housing, EMS delayed Case detail
In February 2023, an incarcerated person was found dead in his restrictive-housing cell at Calhoun State Prison, leaning against the door and wrapped in mattress padding. About thirty minutes after a GDC officer noticed the man had not moved for hours, emergency responders were called. They arrived at 1:04 p.m. but were not inside until 1:11 p.m. due to delays waiting for staff to open the gates. They confirmed the death and reported the coroner was needed; the coroner also had to wait at the gate.
Virginia OCME must be notified and investigate cause and manner of death in custody Legal fact
Virginia law requires the Office of the Chief Medical Examiner to be notified and to investigate the cause and manner of death of any person who dies in jail, prison, other correctional institution, or in police custody.
SMEO declined jurisdiction in 1,354 cases in FY2009 Statistic
In fiscal year 2009, Georgia's State Medical Examiner's Office was consulted and ultimately declined jurisdiction in 1,354 cases statewide.
1,354 cases
Senate PSI report contains no Georgia-specific prison death data Data gap
Searches of the 2022 Senate PSI Staff Report 'Uncounted Deaths in America's Prisons and Jails' for 'Georgia Department of Corrections,' 'GDC,' and 'Georgia prison' returned no match, indicating the report does not contain Georgia-specific prison death data.
Source
GBI performs autopsies for custody deaths but investigations usually left to GDC internal investigations Finding
The GBI now performs autopsies for deaths in custody, but investigations are most often left up to GDC internal investigations, unless the death involves an officer or corrections officials request the agency's involvement.
AJC: most GDC facility deaths investigated by GDC Office of Professional Standards, GBI occasionally involved Finding
The AJC reported that most deaths inside GDC facilities are investigated by the agency's Office of Professional Standards, although the GBI is occasionally involved as well.
Jackson v. State: stillborn fetus is a deceased person under Death Investigation Act Legal fact
The Georgia Court of Appeals held that an unborn fetus, when stillborn, becomes a deceased person within the meaning of the Death Investigation Act.
BOP Warden must consult Clinical Director for medical death autopsy recommendation Policy
BOP's autopsy policy requires the Warden to consult with the Clinical Director for an autopsy recommendation for any death related to medical conditions, including unexpected deaths and deaths of unknown cause.
OCGA § 45-16-22 medical examiner discretion on autopsy Legal fact
Except as otherwise provided in the article, it is in the sole discretion of the medical examiner to determine whether or not an autopsy or limited dissection is required, though the medical examiner must give due consideration to the opinions of the coroner and the peace officer in charge.
CDC assessed coroner and medical examiner laws across all states and DC Finding
CDC's Public Health Law Program assessed coroner and medical examiner laws across the 50 states and the District of Columbia at the request of the National Center for Health Statistics, and each state sets its own standards for what kinds of deaths require investigation.
GDC SOP 208.03: next-of-kin notification by Warden or Superintendent Policy
GDC's SOP on Death of an Offender requires that notification of the Next of Kin following an offender's death be made by the Warden or Superintendent or Designee.
New Jersey medical examiner jurisdiction over prison deaths Legal fact
New Jersey statute lists deaths of inmates of prisons among the deaths subject to the medical examiner's jurisdiction.
DOJ: GDC mortality data categorizes obvious homicides as 'unknown' pending death certificate Finding
DOJ found that GDC's mortality data categorizes many deaths that obviously were homicides as having an unknown reason or unknown verified cause of death, and according to GDC this unknown category reflects deaths for which GDC has not yet received a copy of the death certificate to verify the cause of death.
Virginia OCME investigation required for deaths in jail, prison, or police custody Legal fact
Virginia law requires an investigation by the Office of the Chief Medical Examiner into the cause and manner of death whenever a person dies in jail, prison, other correctional institution, or police custody.
SMEO declined jurisdiction in 33% of 4,834 death notifications in FY2010 Statistic
Of 4,834 cases reported to Georgia's State Medical Examiner's Office in fiscal year 2010, jurisdiction was declined for 1,609 cases, representing 33% of the total; SMEO conducted 2,806 (58%) full autopsies, 271 (6%) limited dissections, and 148 (3%) external examinations.
1,609 cases vs. 4,834 total death notifications
Senate PSI report contains no Clayton or Fulton County jail data Data gap
Searches of the 2022 Senate PSI Staff Report 'Uncounted Deaths in America's Prisons and Jails' for 'Clayton County,' 'Fulton County,' 'Clayton County Jail,' and 'Fulton County Jail' returned no match, indicating the report does not contain data on these Georgia jails.
Source
Sen. Bearden suggested recommending GBI investigate all Georgia prison deaths Case detail
After the committee had discussed recommendations but before it took a vote, Republican state Sen. Timothy Bearden of Carrollton suggested recommending that the Georgia Bureau of Investigation be brought in to investigate all deaths within Georgia prisons.
FY26 Medical Examiner Fellowship Program began July 1 with 2 participants Policy
GBI Director Hosey reported the FY26 Medical Examiner Fellowship Program began on July 1st with 2 participants beginning their training, who had just finished 2 lectures on firearm-related injuries.
Source
Commissioner Oliver: GDC waits for medical examiner findings before releasing manner of death Finding
GDC Commissioner Tyrone Oliver said that even if a person is found dead with multiple stab wounds, GDC will wait for a medical examiner's findings before releasing manner-of-death information.
Jackson v. State: quasi-property interest in decedent's body not constitutional Legal fact
The Georgia Court of Appeals held that the common-law quasi-property concept protecting surviving relatives' interests in a decedent's body is not of constitutional dimension.
BOP requires post-mortem toxicology even if autopsy unnecessary Policy
BOP's autopsy policy requires Wardens to order post-mortem toxicology tests even if a complete autopsy is determined to be unnecessary.
OCGA § 45-16-22 county funding for external examinations Legal fact
The fee for a medical examiner's external examination is to be paid from funds of the county in which the act was committed, or, if that county is unknown, from funds of the county in which the body was found.
Florida medical examiner must determine cause of death in prison or penal institution Legal fact
Florida law requires the district medical examiner to determine the cause of death and perform such examinations, investigations, and autopsies as deemed necessary when a death occurs in any prison or penal institution or in police custody.
GDC SOP 208.03: body release within 24 hours of demand, subject to Coroner/GBI/Crime Lab Policy
GDC's SOP on Death of an Offender requires that the body of a deceased offender be released to the next of kin or an agent thereof no later than 24 hours after the demand for release, and only upon release by the Coroner, GBI, or Crime Lab, unless there has been a written finding that foul play may have been involved.
New Jersey mandatory autopsy for inmate deaths Legal fact
New Jersey's mandatory-autopsy rule requires autopsy for all deaths of inmates of jail, prison, or penitentiary and all prisoners and suspects who were in the process of being detained, arrested or transported by guards, police and law enforcement or court officers, unless the suspected cause of death is a known condition.
O.C.G.A. § 45-16-80: Medical examiner may replace coroner but cannot impanel inquest jury Legal fact
Under O.C.G.A. § 45-16-80, the office of coroner may be abolished by local law and replaced with an office of medical examiner, who shall be authorized to perform all functions prescribed for a coroner under the Georgia Death Investigation Act except that the medical examiner has no authority to summon and impanel a jury to hold inquests.
Washington coroner jurisdiction over deaths in jail or prison Legal fact
Washington's coroner statute, RCW 68.50.010, vests jurisdiction over the body in the county coroner or medical examiner where death occurs in a jail or prison.
Chief Medical Examiner decides whether to accept jurisdiction Policy
When a death case is reported to the State Medical Examiner's Office, the Chief Medical Examiner or designee determines whether to accept jurisdiction based on information provided by the coroner and additional information collected by SMEO investigators.
DOJ medicolegal death investigation page lacks custody death guidance Data gap
Searches of the DOJ National Center for Forensic Science medicolegal death investigation page for 'deaths in custody,' 'custody,' and 'detainee' returned no match, indicating the page does not address custody death investigation.
Bearden GBI proposal omitted from final recommendations; Oliver opposed Case detail
Sen. Timothy Bearden's suggestion that the GBI be brought in to investigate all deaths within Georgia prisons did not make it into the Senate study committee's final list of recommendations, and GDC Commissioner Tyrone Oliver said he wouldn't be amenable to that recommendation becoming law.
Coroners must complete basic training within 180 days of election or appointment Legal fact
Under Georgia Coroner's Training Council rules, a qualified coroner must successfully complete the next scheduled basic training course provided by the Georgia Police Academy no longer than 180 days after election or appointment, and no coroner may charge or collect any fee for services unless properly certified.
AJC: medical examiner findings unavailable for 72 of 73 prisoner deaths that year Statistic
The AJC found that medical examiner findings were not yet available for 72 of the 73 prisoners who had died that year, nor for more than 50 of the prisoners who died in 2023.
72 deaths without medical examiner findings vs. 73 total prisoner deaths that year
GBI Forensic Scientific Services appropriation includes medical examiner autopsy services Policy
The Governor's Budget Report for Amended FY2025 and FY2026 states the purpose of the Forensic Scientific Services appropriation is, among other things, to provide medical examiner (autopsy) services as part of the Georgia Bureau of Investigation's forensic analysis and testimony functions.
BOP autopsy does not require next-of-kin authorization Policy
Under BOP's autopsy policy, where the Warden has authority to order an autopsy, no next-of-kin authorization is required; the autopsy proceeds with or without the next-of-kin's consent, though an attempt should always be made to inform the next-of-kin.
OCGA § 45-16-27 inquest required for unexpected inmate death or death by violence Legal fact
Coroners shall require an inquest to be conducted when an inmate of a state hospital or a state, county, or city penal institution dies unexpectedly without an attending physician or as a result of violence, and the chief medical examiner or his or her designee, regional medical examiner, or local medical examiner shall perform all medical examiners' inquiries in such cases.
ACA standards require immediate coroner notification and postmortem under certain conditions Policy
ACA's Performance-Based Standards and Expected Practices for Adult Correctional Institutions (5th ed.) states, as commentary to its death-procedure standard: 'The medical examiner or coroner should be notified of the offender's death immediately. A postmortem examination should be performed if the cause of death is unknown, if the death occurred under suspicious circumstances, or if the' [condition continues].
GDC SOP 208.03: facility must provide next of kin a Certificate of Death Policy
GDC's SOP on Death of an Offender requires the facility to provide the next of kin with a Certificate of Death.
New Jersey regulation on mandatory autopsy for inmate deaths Legal fact
New Jersey's State Medical Examiner regulations list among categories requiring mandatory autopsy: all deaths of inmates of jail, prison, or penitentiary and all prisoners and suspects in the process of being detained, arrested or transported, unless the suspected cause of death is a known condition for which the inmate was hospitalized and being treated at the time of death.
O.C.G.A. § 45-16-80: General Assembly may abolish coroner by local law and establish medical examiner Legal fact
Under O.C.G.A. § 45-16-80, the General Assembly by local law may abolish the office of coroner in a county and establish in lieu thereof the office of medical examiner, with qualifications, powers, and duties provided in the Code section.
Wisconsin requires autopsy for inmate deaths in correctional facilities Legal fact
A CDC compilation of Wisconsin coroner/medical examiner law states that if an individual dies while in the legal custody of the department and confined to a correctional facility located in Wisconsin, the coroner or medical examiner of the county where the death occurred shall perform an autopsy on the decedent.
Declined jurisdiction recorded in PathAssist database Methodology note
If the State Medical Examiner's Office declines jurisdiction over a case, the name of the medical examiner who made that decision is recorded in the PathAssist database to indicate the case was discussed and declined.
Belinda Maley Senate testimony lacks autopsy/medical examiner content Data gap
Searches of the Testimony of Belinda Maley submitted to the Senate for 'autopsy' and 'medical examiner' returned no match, indicating the testimony does not address autopsy or medical examiner issues.
Oliver: GDC investigators receive same training as GBI investigators Quote
GDC Commissioner Tyrone Oliver told the Georgia Recorder he wouldn't be amenable to a recommendation that GBI investigate all prison deaths becoming law, and said his department's investigators go through the same training as GBI investigators.
Certified coroners and deputy coroners must complete 24 hours annual training Legal fact
Under Georgia Coroner's Training Council rules, for each calendar year following initial certification, each certified coroner and deputy coroner must complete 24 hours of additional annual training in approved courses to maintain certification.
AJC: medical examiner findings unavailable for more than 50 prisoners who died in 2023 Statistic
The AJC found that medical examiner findings were not yet available for more than 50 of the prisoners who died in 2023.
50 deaths without medical examiner findings (more than)
GAO: DCRA data missing deaths for 11 states' prisons and 12 states' jails Finding
GAO-22-106033 states that the DCRA data collected from states did not capture any deaths in state prisons for 11 states or deaths in local jails for 12 states, despite evidence that such deaths occurred while individuals were in custody.
OCGA § 45-16-27 inquest requirement for deaths under paragraphs (1)-(11) Legal fact
Coroners shall require an inquest to be conducted in their respective counties when any individual dies under any circumstances specified in paragraphs (1) through (11) of subsection (a) of the death-reporting Code section, subject to listed exceptions where an inquest is not required to be held.
ACA standards require internal review of all deaths in custody Policy
ACA's Performance-Based Standards and Expected Practices for Adult Correctional Institutions require, as one element of the health authority's mandatory internal review system, 'reviewing all deaths in custody, suicides or suicide attempts, and illness outbreaks.'
GDC SOP 208.03: CID Inspector decides whether to notify GBI in natural death cases Policy
GDC's SOP on Death of an Offender requires that in natural death cases the Warden/Superintendent or designee notify the Criminal Investigations Division, with the Inspector of the Criminal Investigations Division determining whether or not to notify the Georgia Bureau of Investigation (GBI) based on any unusual circumstances of the offender's death, and the Criminal Investigations Division also contacting the Medical Examiner.
New York autopsy requirement for inmate deaths Legal fact
New York County Law § 674 requires the coroner, coroner's physician or medical examiner to promptly perform or cause to be performed an autopsy with respect to any death occurring within the county to an inmate of a correctional facility, whether or not the death occurred inside the facility.
Rule 125-2-4-.20: Warden must notify GBI Director or district SAC of sudden/violent/unusual death Legal fact
Georgia Board of Corrections Rule 125-2-4-.20 (Death and Interment) requires that when an inmate dies suddenly or violently or under unusual circumstances without an attending physician, the Warden/Superintendent or representative shall notify the Director of the Georgia Bureau of Investigation or his appointed representative (Special Agent in Charge of District) in the district where the death occurs.
Wisconsin statute 979.025 requires autopsy of correctional inmate Legal fact
Wisconsin law requires that if an individual dies while in the legal custody of the department and confined to a correctional facility located in Wisconsin, the coroner or medical examiner of the county where the death occurred shall perform an autopsy on the decedent.
Georgia one of eight states fully accredited by NAME Finding
Georgia is one of only eight states fully accredited by the National Association of Medical Examiners (NAME), a professional organization for physicians, investigators, and administrators in medical death investigation; accreditation includes an on-site inspection and review.
DOJ FY23 DCRA implementation report contains no Georgia noncompliance finding Data gap
Searches of the U.S. Department of Justice FY23 DCRA Implementation Report for 'Georgia,' 'noncompliant,' and 'found noncompliant' returned no match, indicating the report does not identify Georgia as noncompliant with DCRA.
Committee chair Robertson indicated openness to GBI investigating all prison deaths Finding
Sen. Timothy Bearden's suggestion that the GBI be brought in to investigate all deaths within Georgia prisons didn't make it into the Senate study committee's list of recommendations, but committee chair Sen. Randy Robertson indicated he may be open to the idea.
ME inquiry required for unexpected or violent deaths of penal institution inmates Legal fact
The Georgia Coroner In-Service training manual teaches that when an inmate of a state hospital or a state, county, or city penal institution dies unexpectedly without an attending physician or as a result of violence, the chief medical examiner or designee, regional medical examiner, or local medical examiner shall perform all medical examiners' inquiries.
$5,184,500 for Medical Examiner Annex furniture and equipment in Decatur Statistic
The Governor's Budget Report for Amended FY2025/FY2026 lists $5,184,500 for furniture, fixtures, and equipment for the Medical Examiner Annex at Headquarters, Decatur, DeKalb County, under the Georgia Bureau of Investigation.
$5.2M USD
OCGA § 45-16-27 coroner investigation fees Legal fact
On and after January 1, 2007, coroners are entitled to an investigation fee of $175.00 where no jury is impaneled or a fee of $250.00 where a jury is impaneled, paid from the county treasury.
Illinois Coroner's Act requires reporting of deaths in custody or state institutions Legal fact
Illinois' Coroner's Act requires that all deaths occurring while being pursued, apprehended, or taken into custody of any law enforcement agency be reported to the coroner, and that all deaths in any State institution be reported to and investigated by the county coroner.
GDC SOP 208.03: CID Inspector decides GBI notification in sudden/violent death cases Policy
GDC's SOP on Death of an Offender requires that in cases of sudden or violent death or unusual circumstances, the Warden or Superintendent notify the Inspector of the Criminal Investigations Division and request that an investigator be sent to the facility, with the Inspector responsible for determining whether to notify the GBI.
New York State Commission of Correction death investigation duty Legal fact
New York Correction Law section 47 gives the State Commission of Correction's board the power and duty to investigate and review the cause and circumstances surrounding the death of any incarcerated individual of a correctional facility, and to cause the body to undergo examinations including an autopsy as the board deems necessary.
Rule 125-2-4-.20: Warden must notify Coroner/ME and request autopsy in all instances Legal fact
Georgia Board of Corrections Rule 125-2-4-.20 requires that in cases of an inmate's sudden, violent, or unusual-circumstance death, the Warden/Superintendent shall notify the Coroner of the county (or medical examiner in counties without a coroner), and that an autopsy will be requested in all instances.
Independent autopsy in Lashawn Thompson death found severe neglect Case detail
An independent autopsy for Lashawn Thompson, who died in a bedbug-infested cell in Fulton County Jail's psychiatric wing, found he died due to severe neglect, contradicting an earlier Fulton County medical examiner's report.
NAME ideal caseload 250 autopsies per medical examiner per year, max 325 Statistic
NAME standards indicate the ideal caseload per medical examiner is 250 autopsies per year, though a medical examiner can conduct as many as 325 per year without adversely affecting public health and safety.
250 autopsies per year vs. 325 maximum standard caseload
Senate PSI report lacks autopsy/medical examiner content Data gap
Searches of the 2022 Senate PSI Staff Report 'Uncounted Deaths in America's Prisons and Jails' for 'autopsy,' 'autopsies,' and 'medical examiner' returned no match, indicating the report does not address autopsy or medical examiner practices.
Source
Georgia law requires autopsy for inmate deaths in state, county, or city penal institutions Legal fact
The GBI's autopsy FAQ document states that under Georgia law an autopsy is required in deaths that are those of an inmate of a state hospital or a state, county, or city penal institution.
Coroner investigation fees: $175 without jury, $250 with jury Legal fact
The Coroner In-Service training manual states that on and after January 1, 2007, coroners are entitled to an investigation fee of $175.00 where no jury is impaneled or $250.00 where a jury is impaneled, paid upon receipt of a monthly statement to the county treasury.
GBI FY2023 MEO backlog of unworked reports rose from 387 (July) to 545 (October) Trend
In GBI's FY2023 October Monthly Report to the Board of Public Safety, the Medical Examiner's Office backlog of unworked reports (calculated as more than 90 days from the date of examination per National Association of Medical Examiner accreditation standards) was 387 in July, 397 in August, 476 in September, and 545 in October.
GBI Division of Forensic Sciences maintains NAME accreditation for Medical Examiner's Office Finding
The GBI Division of Forensic Sciences maintains NAME accreditation for the Medical Examiner's Office.
Illinois coroner must investigate suspected sudden or violent deaths Legal fact
Illinois law directs every coroner to take charge of the body and make a preliminary investigation whenever a death is suspected to be sudden or violent, whether apparently suicidal, homicidal, or accidental.
GDC SOP 208.03: autopsy shall be requested; ME has discretion under OCGA 45-16-22 Policy
GDC's SOP on Death of an Offender states that an autopsy shall be requested in death-under-unusual-circumstances cases, and notes that the medical examiner has discretion under O.C.G.A. § 45-16-22 to determine the need for an autopsy.
New York autopsy authorization for deceased incarcerated individuals Legal fact
New York Correction Law section 47 authorizes the State Commission of Correction board to cause the body of a deceased incarcerated individual to undergo examinations, including an autopsy, as in the opinion of the board are necessary to determine the cause of death.
Rule 125-2-4-.20: Body release within 24 hours of demand unless foul play finding or legality dispute Legal fact
Georgia Board of Corrections Rule 125-2-4-.20 requires that the body of a deceased inmate be released to the next of kin or an agent thereof no later than 24 hours after the demand for release, unless there has been a written finding that foul play may have been involved or there is a dispute over the legality of release.
Fulton County medical examiner initially ruled Thompson death undetermined Case detail
An earlier report from the Fulton County medical examiner's office on Lashawn Thompson's death found no obvious signs of trauma on his body but noted a 'severe bed bug infestation,' and listed his cause of death as 'undetermined.'
FY2009 medical examiner caseloads within NAME maximum Statistic
In fiscal year 2009, of 13 medical examiners, 10 performed 250 or fewer examinations during the year, and the remaining three performed between 250 and 300 examinations; no medical examiner had a caseload of more than 325.
13 medical examiners
Statute allowing untrained physicians as local medical examiners not modified since original audit Finding
A follow-up state audit review found that the Georgia statute allowing any licensed physician to be appointed as a local medical examiner, even without training in forensic pathology, had not been modified since the original audit, though forensic pathology training is a prerequisite for county, regional and state medical examiners.
GBI Division of Forensic Sciences maintains NAME accreditation for ME Office Finding
The GBI Division of Forensic Sciences currently maintains NAME (National Association of Medical Examiners) accreditation for the Medical Examiner's Office.
GBI Division of Forensic Sciences had 398 positions (363 state, 35 grant) as of October 2022 Statistic
In GBI's FY2023 October Monthly Report to the Board of Public Safety, the Division of Forensic Sciences had 363 state-funded positions and 35 grant-funded positions, for a total of 398 positions, as of October 2022.
398 positions
GDC press release: Anthony Hann death cause undetermined pending autopsy Case detail
A GDC press release on the death of inmate Anthony Hann at Valdosta State Prison stated that the cause of death was undetermined pending investigation and autopsy results.
Senator Ossoff letter: 70% of FY2021 DCRA records missing required information Statistic
A letter from Senator Ossoff to Attorney General Garland states that GAO reporting revealed that 70% of records on deaths in custody that states submitted in fiscal year 2021 were missing at least one category of information DCRA required DOJ to collect.
70%
Source
Kentucky coroners must perform post-mortem examinations for deaths in custody or penal institutions Legal fact
Kentucky law requires coroners to require a post-mortem examination when a death occurs while the person is in police custody, a jail or penal institution, or a state mental institution when there is no previous medical history to explain the death.
GDC SOP 208.03: Communications Center notifies Commissioner and Assistant Commissioner Chief of Staff Policy
Under GDC SOP 208.03, for deaths under unusual circumstances the Communications Center additionally notifies the Commissioner (as directed) and the Assistant Commissioner Chief of Staff (as directed).
New York County Law autopsy and toxicology report requirement Legal fact
New York County Law requires the coroner, coroner's physician or medical examiner to promptly perform or cause to be performed an autopsy and prepare an autopsy report including a toxicological report with respect to any death occurring within the county to an incarcerated individual of a correctional facility.
Rule 125-2-4-.20: Natural-cause death: notify next of kin and Commissioner; furnish Certificate of Death Legal fact
Georgia Board of Corrections Rule 125-2-4-.20 requires that when an inmate dies from natural causes and has designated a next of kin, the Warden/Superintendent shall notify the next of kin and the Commissioner of Corrections promptly, and both shall be furnished copies of a Certificate of Death.
Independent autopsy ruled Thompson death homicide due to severe neglect Case detail
The independent autopsy of Lashawn Thompson, written by Dr. Roger A. Mitchell Jr., a former chief medical examiner in Washington D.C., listed the cause of death as 'Complications due to Severe Neglect,' with 'Untreated Decompensated Schizophrenia' as a contributing cause, and ruled the manner of death a homicide.
Four largest counties operate their own medical examiner offices Finding
Cobb, DeKalb, Fulton and Gwinnett counties have abolished their coroner offices and operate their own medical examiner offices, each headed by a forensic pathologist appointed by the county commission with no reliance on the SMEO.
Ohio statute lacks prison/custody death provisions Data gap
Searches of the Ohio Revised Code Section 313.12 for 'prison,' 'custody,' 'penal,' 'jail,' and 'inmate' returned no match, indicating the statute does not address deaths in custody.
Coroners not reporting required deaths to GBI; GBI took no action Finding
A follow-up state audit review found that coroners were not reporting certain deaths to the GBI as required by law, GBI acknowledged such cases may not be reported as required, and GBI had not taken action to address the issue.
OCGA definition: medical examiner's inquiry may but need not include autopsy Legal fact
OCGA § 45-16-21 defines 'medical examiner's inquiry' as an inquiry made by a medical examiner into the circumstances surrounding a death required to be reported under Code Section 45-16-24, which inquiry may include, but is not required to include, a scene investigation, an external examination, a limited dissection, an autopsy, or any combination thereof.
GBI DOFS total vacant positions 41-44 and vacant scientist positions 15-19, Jul-Oct 2022 Statistic
In GBI's FY2023 October Monthly Report, total vacant positions in the Division of Forensic Sciences were 41 (July), 44 (August), 43 (September), and 43 (October); vacant scientist positions were 15, 18, 19, and 19 for the same months.
43 vacant positions (October)
Macon Medical Examiner's Office autopsies redistributed to Decatur and Pooler Policy
GBI announced that any autopsies previously performed at the GBI's Central (Macon) Medical Examiner's Office location would be redistributed between the headquarters location in Decatur, Georgia and the Pooler, Georgia lab, after the Macon office ceased performing postmortem examinations.
Georgia county jail deaths in 2023-2024 cited in Ossoff letter Statistic
A letter to Attorney General Garland states that in just the first six months of 2024, at least six individuals died in custody in Clayton County Jail, and three more died in custody in the Fulton County Jail that year, following the death of 10 individuals in custody in Fulton County in 2023.
Source
GDC SOP 208.03: death scene secured and left undisturbed until authorized Policy
Under GDC SOP 208.03, the death scene shall be secured and left undisturbed until the Warden or Superintendent and the investigating authority authorizes clean-up or removal.
North Carolina medical examiner jurisdiction over jail/prison deaths Legal fact
North Carolina law gives the medical examiner jurisdiction upon the death of any person occurring in a jail, prison, correctional institution or in police custody.
Rule 125-2-4-.20: Full notification chain for sudden/violent/unusual death Legal fact
Under Georgia Board of Corrections Rule 125-2-4-.20, when an inmate dies suddenly, violently, or under unusual circumstances without an attending physician, the Warden/Superintendent or representative must notify the Commissioner of Corrections, the county Coroner (or medical examiner if no coroner) and request an autopsy in all instances, the Director of the State Crime Laboratory, the Director of the GBI or appointed representative in the district, and the Internal Investigation Section (or after hours, the Communications Center at Central Office), and must notify the next of kin.
GDC failed to report 7 deaths to BJS in 2015 Statistic
UCLA's Law COVID Behind Bars Data Project reports that the Georgia Department of Corrections did not report 7 deaths, 5% of annual agency deaths, to BJS in 2015.
7 deaths vs. 5 percent of annual agency deaths
SMEO served 152 of 159 counties; three contracted private pathologists Statistic
The SMEO provided services to 152 of Georgia's 159 counties, while the state's four largest counties (Cobb, DeKalb, Fulton, and Gwinnett) operated medical examination services at their own expense, and at least three additional counties contracted with private pathologists for services.
152 counties vs. 159 total Georgia counties
GBI: forensic pathology training for Local Medical Examiners 'not necessary' due to pathologist scarcity Finding
GBI stated in response to a state audit follow-up review that it is the opinion of the GBI Medical Examiner's Office that forensic pathology training for Local Medical Examiners 'is not necessary,' because the scarcity of pathologists in Georgia makes it extremely rare that a Local Medical Examiner is actually a pathologist.
OCGA definition: inquest is judicial inquiry before coroner and jury Legal fact
OCGA § 45-16-21 defines 'inquest' as an official judicial inquiry before a coroner and coroner's jury for the purpose of determining the cause of death.
GBI medical examiner ruled Thomas Henry Giles' death a homicide after smoke-filled cell at Augusta State Medical Prison Case detail
A GBI medical examiner ruled the death of Georgia prisoner Thomas Henry Giles a homicide after he was left for hours in his smoke-filled cell at Augusta State Medical Prison in October 2020, though officers moved inmates of nearby cells; he died of smoke inhalation, and the case resulted in a $5 million settlement in 2023.
New Central Lab for Forensic Science and Chief Medical Examiner completed December 2025 Finding
The new Central Lab building for Georgia's Department of Forensic Science and Office of the Chief Medical Examiner was completed in December 2025.
DOJ FY2023 report: DCRA JAG reduction discretionary Legal fact
DOJ's FY2023 report to Congress states that the DCRA statute does not require a state's JAG award to be reduced for the state's failure to comply but makes such an award reduction subject to the discretion of the Attorney General.
Maine defines custodial deaths as medical examiner cases Legal fact
Maine law defines a medical examiner case to include a death when the person is in custody pursuant to an arrest, confined in a state correctional or detention facility, county jail, other county correctional or detention facility, or local lockup, or is on the way to or from a courthouse or any of these places while in the custody of a law enforcement officer.
GDC SOP 208.03: Warden posts officer to log all crime scene entrants Policy
Under GDC SOP 208.03, the Warden or Superintendent is responsible for posting an officer at the crime scene who must log, in writing, every individual who enters the crime scene area.
North Carolina notification requirement for custody deaths Legal fact
North Carolina law requires that the medical examiner of the county be notified upon the death of any person occurring in a jail, prison, correctional institution, or in police custody.
Rule 125-2-4-.20: Suicide/accidental/suspicious death: medical records to Health Services; written report to Commissioner Legal fact
Under Georgia Board of Corrections Rule 125-2-4-.20, in the event of a suicide, accidental death, or death under suspicious circumstances, the inmate's medical records must be copied and sent to the Health Services Unit at Department of Corrections' central office for review, and a written report with details of the death and the Coroner's or Medical Examiner's report must be submitted to the Commissioner of Corrections.
GDC failed to report 10 deaths to BJS in 2018 Statistic
UCLA's Law COVID Behind Bars Data Project reports that the Georgia Department of Corrections did not report 10 deaths, 6% of annual agency deaths, to BJS in 2018.
10 deaths vs. 6 percent of annual agency deaths
SMEO failed NAME 90-day autopsy completion standard: 78% of 300 cases Finding
A state audit review found the SMEO was not meeting the NAME standard that 90% of autopsies be completed within 90 days of receipt of the body; a review of 300 cases found only 78% (234) were completed within that 90-day timeframe.
No assurance all cases that should be reported to a medical examiner are actually reported Data gap
A follow-up audit found that under the current system there is no assurance that all cases that should be reported to a medical examiner for a determination of whether an autopsy is necessary are actually reported.
ME performing coroner duties may sign death certificate except when inquest held Legal fact
Under OCGA § 45-16-26, when the medical examiner is performing the duties of the coroner in such cases, the medical examiner may sign the death certificate except when an inquest is held.
GBI investigated in-custody death of Shaqwan Warren, 33, at request of Houston County Sheriff's Office Case detail
GBI announced that, at the request of the Houston County Sheriff's Office, GBI agents were investigating the in-custody death of Shaqwan Warren, age 33, of Macon, Georgia.
BJA developing DCRA compliance plan expected May 2023 Policy
DOJ's FY2023 DCRA report states that BJA was developing a DCRA compliance plan, expected to be final and made public in May 2023, consistent with a recommendation made by GAO in its report released in September 2022.
Maine requires examination and inquest for deaths in custody Legal fact
Maine law requires that when a person in custody dies, an examination and inquest must be held and a medical examiner must be immediately notified.
GDC SOP 208.03: crime-scene log must include entry and exit times Policy
Under GDC SOP 208.03, the crime-scene log must also contain the times that individuals entered and left the crime scene area.
Oklahoma medical examiner jurisdiction over DOC/county jail deaths Legal fact
Oklahoma law lists deaths of persons detained or occurring in custody of the Department of Corrections or a county jail as a category requiring investigation under the medical examiner statutes.
NCCHC Standard A-09 requires health authority review of all in-custody deaths Policy
NCCHC Standard A-09 (Procedure in the Event of an Inmate Death) states: 'The responsible health authority conducts a thorough review of all deaths in custody in an effort to improve care and prevent future deaths.'
SMEO FY2010 activity totals: 4,834 notifications, 1,609 declined Statistic
The State Medical Examiner's Office recorded 2,806 (58%) full autopsies, 271 (6%) limited dissections, 148 (3%) external examinations, and 1,609 (33%) cases with jurisdiction declined, totaling 4,834 death notifications, in Fiscal Year 2010.
4,834 death notifications
GBI: cannot enforce coroner reporting requirement until Death Investigation Act amended Legal fact
GBI stated in its audit response that until the Death Investigation Act is legislatively amended to require coroners to report all appropriate cases to the GBI Medical Examiners' Office, it is impossible to enact and enforce such a requirement, and it is not possible for GBI to independently act to implement the recommendation.
GBI ME Office accredited by NAME; autopsies at Decatur HQ and Macon, Pooler labs Finding
The Georgia Bureau of Investigation Medical Examiner's Office is accredited by the National Association of Medical Examiners. Autopsies are conducted by GBI medical examiners at the Headquarters Laboratory in Decatur (Atlanta) and in the regional laboratories in Macon and Pooler (Savannah); staff consists of forensic pathologists, death investigation specialists, and administrative staff.
GDC SOP 203.03: offender death or suicide defined as Major Incident Policy
Under GDC SOP 203.03 (Incident Reporting), the death or suicide of an offender is an example of a Major Incident, defined as an activity outside normal routine that might cause public concern or notoriety and affects the health, safety, custody, control, or management of the offender or staff.
FY2027 budget raises medical examiner starting salary to $300,000 Statistic
HB 974, Georgia's FY2027 budget, provides $1 million to the GBI for a salary increase for medical examiners, bringing their starting salary from $270,000 to $300,000 and introducing two additional salary steps.
$300,000 USD starting salary vs. 270,000 previous starting salary
BOP requires Multilevel Mortality Review within 30 days of inmate death Policy
BOP policy requires institution personnel (Mortality Review Committee members) to complete a Multilevel Mortality Review (MLMR) within 30 days of any inmate death and submit their report to the Office of Quality Management in the BOP Central Office's Health Services Division.
Source
GDC SOP 208.03: Administrative Duty Officer obtains photographs/videotape of death scene Policy
Under GDC SOP 208.03, the Administrative Duty Officer or Designee, if not on scene, shall immediately obtain still photographs (and videotape if possible) of the death scene and body.
Oklahoma medical examiner jurisdiction over penal incarceration deaths Legal fact
Oklahoma law lists deaths of any persons detained or occurring in custody of penal incarceration as one of the types of deaths that shall be investigated.
NCCHC requires psychological autopsy within 30 days for suicides Policy
NCCHC guidance states a psychological autopsy 'is required within 30 days for all deaths by suicide' and is a written reconstruction of the decedent's life emphasizing factors that may have led to or contributed to the death, usually conducted by a psychologist or other qualified mental health professional.
SMEO accepted jurisdiction in 3,225 cases; 37% accidental Statistic
Of the 4,834 death notifications received in FY2010, jurisdiction was accepted in 3,225 cases; the SMEO determined the manner of death to be accidental in 37% (1,179 of 3,225) of all deaths under its jurisdiction.
3,225 cases vs. 1,179 accidental deaths
Original audit found coroners not reporting suspected suicides to GBI as required Finding
The original audit found that coroners were not reporting certain deaths to GBI, such as suspected suicides, which are required by law to be reported.
Coroners elected to four-year terms Legal fact
Under OCGA § 45-16-1, coroners are elected, commissioned, and removed as are clerks of the superior courts, and coroners hold their offices for four years.
GDC SOP 203.03: immediate telephone report to Regional Director after Major Incident, especially offender death Policy
Under GDC SOP 203.03 (Incident Reporting), after any Major Incident, especially in the event of the death of an offender, a telephone report shall be made immediately to the Regional Director and, upon authorization, to the Communications Center.
GBI Headquarters Medical Examiner's Office new construction scheduled mid-September 2025 Finding
GBI's July Monthly Report for FY2026 states that GBI Headquarters' Medical Examiner's Office new construction was scheduled to begin in mid-September 2025, and that a new Central Medical Examiner's Building was then in the programming phase of design.
BOP all deaths undergo Multilevel Mortality Review Policy
The DOJ OIG report states that all deaths in BOP facilities (except legal executions) undergo a Multilevel Mortality Review (MLMR), a process conducted by a multidisciplinary team of institution Health Services employees and executive leadership, as a quality improvement process.
Source
NCCHC three-pronged death review approach Policy
NCCHC's guidance on its inmate-death standard describes a three-pronged approach to every inmate death: 'an administrative review, a clinical mortality review and a psychological autopsy if the death is by suicide. These three processes comprise a death review.'
GBI made no effort to re-establish statutory requirement for coroners to report all deaths Finding
GBI acknowledged that cases requiring a medical examiner's inquiry may not be reported as required, but GBI has not taken action to address the issue and has made no effort to re-establish the statutory provision requiring coroners to provide information on all deaths under their jurisdiction.
Coroner candidate must complete Georgia Police Academy basic training within 180 days Legal fact
Under OCGA § 45-16-1, a coroner candidate must have successfully completed, no later than 180 days after election or appointment, the next scheduled class of a basic training course provided by the Georgia Police Academy.
GDC SOP 203.03: Central Communications Center notifies Division Director, Communications, OPS, Special Operations Policy
Under GDC SOP 203.03 (Incident Reporting), the GDC Central Communications Center shall notify the Division Director, the Office of Communications, the Office of Professional Standards, and the Director of Special Operations.
Georgia Coroner's Training Council composition Legal fact
Georgia's Coroner's Training Council is composed of five coroners, a licensed physician, and the superintendent of the Georgia Police Academy or his designee, with the five coroners appointed by the Board of Public Safety.
BOP After Action Reviews required for suicides but discretionary for other deaths Policy
The DOJ OIG report found that BOP's review requirements differ by manner of death: a Psychological Reconstruction Report (a type of After Action Report) is required for every inmate suicide, but After Action Reviews are discretionary for other death types such as homicides and accidental drug overdoses.
Source
NCCHC clinical mortality review required within 30 days Policy
NCCHC guidance states the clinical mortality review is 'to be conducted within 30 days to determine the appropriateness of the clinical care provided and the effectiveness of the clinical policies and procedures relevant to the circumstances surrounding the death.'
SMEO supervisory review of cases rose from 25% in 2009 to ~45-50% by 2013 Trend
The State Medical Examiner's Office staff estimated the percentage of cases subject to supervisory review increased from 25% in 2009 to approximately 45-50% at the time of the follow-up review.
RW Page Corp. v. Kilgore: coroner who opens public inquest waives right to claim transcript is not public record Legal fact
The Supreme Court of Georgia held that when a coroner, a public official, makes an inquest and opens it to the public, and the testimony given at the public inquest is recorded and transcribed at public expense, the coroner has waived any right to contend that the transcript is not a public record.
Georgia Coroner's Basic Course definition Legal fact
Georgia defines the Coroner's Training Council's "Basic Course" as curriculum covering the knowledge and skills needed to complete an inquiry into the cause and circumstances of a death caused by foul play, accident, or that is unexplained or suspicious.
DOJ OIG: 48% of BOP inmate deaths had deficiencies in emergency response Statistic
The DOJ OIG report found that in 48 percent (166 of 344) of inmate deaths within its evaluation scope, there were deficiencies in connection with BOP staff's response to the inmate's medical emergency.
48%
Source
NCCHC 2018 standards eliminated 30-day administrative review requirement Policy
NCCHC guidance notes that in previous versions of the standard the administrative review was required within 30 days, but in the 2018 Standards for Health Services for jails and prisons that 30-day requirement was eliminated, though NCCHC still recommends a preliminary administrative review occur as soon as possible.
Brandon Burrell autopsy suggests hours passed before guards found body at GDCP Case detail
The autopsy for 31-year-old Brandon Burrell suggests hours went by until guards found his body at the Georgia Diagnostic and Classification State Prison earlier this year.
RW Page Corp. v. Kilgore: court declined to decide coroner's right to withhold closed-inquest transcript Legal fact
The Supreme Court of Georgia expressly declined to decide whether a coroner has the right to withhold a transcript of a closed inquest.
Coroner basic training required within 180 days of election or appointment Legal fact
A Georgia coroner must successfully complete the basic training course provided by the Georgia Police Academy no later than 180 days after election or appointment, and no coroner may charge a fee for services unless properly certified.
Brandon Burrell autopsy found roughly 60 lacerations Statistic
The autopsy found roughly 60 lacerations on Brandon Burrell's body.
60 lacerations
Kilgore v. R.W. Page Corp.: no Open Meetings Act exception for pending criminal investigations Legal fact
The Supreme Court of Georgia concluded there is no exception to the Open Meetings Act for meetings concerning a pending criminal investigation, including a coroner's inquest.
GBI administrative rules lack medical examiner death-investigation criteria Data gap
GBI's administrative rules consist of six chapters covering general applicability, nonprofit bingo games, implied consent, independent scientific examination of evidence, limited disclosure of crime scene photographs/videos, and secondary metals recyclers -- none titled or addressed to medical examiner death-investigation criteria.
GDC labeled 31 overdose deaths as 'undetermined' before ME ruled accidental overdose Finding
GDC records show the department labels numerous prison deaths as 'undetermined,' and that was the case with 31 deaths that medical examiners later ruled to be accidental drug overdoses.
Kilgore v. R.W. Page Corp.: coroner is not a law enforcement agency under Open Meetings Act Legal fact
The Supreme Court of Georgia held that a coroner does not constitute a law enforcement agency for purposes of the Open Meetings Act's exemption for GBI and other law-enforcement-agency meetings.
GDC initially reported 13 overdose deaths as 'natural'; 10 later reclassified Finding
GDC spokesperson Joan Heath said 13 overdose deaths were initially reported by GDC as 'natural' because deaths are labeled that way when not clearly due to trauma, and are later reclassified when death certificates are completed; ten of those 13 overdose deaths have now been reclassified.
Kilgore v. R.W. Page Corp.: coroner's inquest verdict is merely advisory Legal fact
The Supreme Court of Georgia stated that the verdict of a coroner's inquest is merely advisory to officers charged with the execution of public laws and does not amount to a formal charging or indictment as does a grand jury's true bill.
GDC records still list 13 overdose deaths as natural years later Finding
Years after many of the 13 overdose deaths GDC reported as natural, GDC records obtained by the AJC still list them as natural.
Kilgore v. R.W. Page Corp.: coroner's inquest is a 'meeting' under Open Meetings Act Legal fact
The Supreme Court of Georgia held that a coroner's inquest constitutes a 'meeting' within the meaning of § 50-14-1(a)(2) of Georgia's Open Meetings Act.
Wallace v. State: O.C.G.A. § 45-16-27(d) excludes autopsy photographs from Open Records Act disclosure Legal fact
The Georgia Supreme Court in Wallace v. State held that O.C.G.A. § 45-16-27(d) excludes autopsy photographs from required disclosure under the Open Records Act, with exceptions including medical purposes or the public interest.
Source
Wallace v. State: autopsy photographs at issue not subject to Open Records Act disclosure Legal fact
The Georgia Supreme Court in Wallace v. State concluded that the autopsy photographs at issue were not subject to disclosure under the Open Records Act.
Source
O.C.G.A. § 45-16-27(d) allows court-ordered disclosure of autopsy photos on public-interest findings Legal fact
O.C.G.A. § 45-16-27(d), as described in Wallace v. State, allows the superior court to order disclosure of autopsy photographs upon findings in writing that disclosure is in the public interest and that it outweighs any privacy interest that may be asserted by the deceased's next of kin.
Source
Sources
156 cited sources backing this research.
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Key Entities
Organizations, people, facilities, and other named entities referenced in this research.
American Bar Association
[organization]
American Correctional Association
[organization]
Anthony Hann
[person]
Arizona
[organization]
Arkansas
[organization]
Atlanta Journal-Constitution
[organization]
Augusta State Medical Prison
[facility]
Austin Fiveash
[person]
Baldwin State Prison
[facility]
Belinda Maley
[person]
Board of Public Safety
[organization]
Brandon Burrell
[person]
Bureau of Justice Assistance
[organization]
Bureau of Justice Statistics
[organization]
Calhoun State Prison
[facility]
California
[organization]
California Commission on State Mandates
[organization]
CCDC
[facility]
CDC
[organization]
Central Lab
[facility]
Central Medical Examiner Building
[facility]
Chatham County Detention Center
[facility]
Chris Hosey
[person]
Clayton County Jail
[facility]
Cobb County Medical Examiner's Office
[facility]
Cobb County Sheriff's Office
[organization]
Colorado
[organization]
Connecticut
[organization]
Criminal Justice Coordinating Council
[organization]
Crosby v. Johnson
[case]
Daughtry
[person]
Death in Custody Reporting Act
[legislation]
DOJ
[organization]
DOJ findings report investigation of Georgia prisons
[case]
Executive Order 14074
[legislation]
Federal Bureau of Prisons
[organization]
Florida
[organization]
Fulton County Jail
[facility]
Fulton County Medical Examiner's Office
[organization]
Ga. Comp. R. & Regs. r. 125-2-4-.20, Death and Interment
[legislation]
GAO
[organization]
GBI Crime Lab
[organization]
GBI Division of Forensic Sciences
[organization]
GBI Medical Examiner's Office
[organization]
GBI Office of the Medical Examiner
[organization]
GBI State Medical Examiner's Office
[organization]
GDC
[organization]
GDC Office of Health Services
[organization]
GDC Office of Professional Standards
[organization]
Georgia Board of Corrections
[organization]
Georgia Bureau of Investigation
[organization]
Georgia Coroner In-Service training manual
[program]
Georgia Coroner's Training Council
[organization]
Georgia Court of Appeals
[organization]
Georgia Death Investigation Act
[legislation]
Georgia Department of Corrections
[organization]
Georgia Diagnostic and Classification State Prison
[facility]
Georgia General Assembly
[organization]
Georgia Police Academy
[organization]
Georgia Senate Study Committee on Corrections
[organization]
Gines v. State
[case]
Government Accountability Office
[organization]
Gwinnett County Medical Examiner's Office
[facility]
HB 974
[legislation]
Hosey
[person]
Houston County Sheriff's Office
[organization]
Illinois
[organization]
Jackson v. State
[case]
Javion Benham
[person]
Joan Heath
[person]
Kentucky
[organization]
Kilgore v. R.W. Page Corp.
[case]
Lashawn Thompson
[person]
Lee Arrendale State Prison
[facility]
Levon Allen
[person]
Louisiana
[organization]
Macon Medical Examiner's Office
[facility]
Maine
[organization]
Martin Floyd
[person]
Maryland Office of the Chief Medical Examiner
[organization]
Massachusetts Medical Examiner
[organization]
Matthew Loflin
[person]
Medical Examiner Fellowship Program
[program]
Michael Reno
[person]
Michigan County Medical Examiner
[organization]
Mike Register
[person]
Minnesota Department of Corrections
[organization]
Minnesota Medical Examiner
[organization]
Minnesota Protocol
[legislation]
Mississippi State Medical Examiner
[organization]
National Association of Medical Examiners
[organization]
National Center for Health Statistics
[organization]
National Commission on Correctional Health Care
[organization]
New Jersey State Medical Examiner
[organization]
New York State Commission of Correction
[organization]
North Carolina Medical Examiner
[organization]
O.C.G.A. § 45-16-22
[legislation]
O.C.G.A. § 45-16-24
[legislation]
O.C.G.A. § 45-16-27(d)
[legislation]
O.C.G.A. § 45-16-80
[legislation]
OCGA § 45-16-1
[legislation]
OCGA § 45-16-21
[legislation]
OCGA § 45-16-26
[legislation]
Office of Professional Standards
[organization]
Office of the Chief Medical Examiner
[organization]
Oklahoma Department of Corrections
[organization]
Oklahoma Office of the Chief Medical Examiner
[organization]
Oregon
[organization]
PathAssist
[program]
Pennsylvania
[organization]
Randy Robertson
[person]
Reuters
[organization]
Rhode Island
[organization]
Roger A. Mitchell Jr.
[person]
RW Page Corporation v. Kilgore
[case]
Sen. Timothy Bearden
[person]
Senator Jon Ossoff
[person]
Shaqwan Warren
[person]
Sheqweetta Vaughan
[person]
Smith State Prison
[facility]
SOP 208.03
[program]
SOP 507.04.67
[program]
South Carolina
[organization]
State Medical Examiner's Office
[organization]
Susan Burns
[person]
Tennessee
[organization]
Texas
[organization]
They Have No Voice
[organization]
Thomas Henry Giles
[person]
Tyrone Oliver
[person]
U.S. Department of Justice
[organization]
U.S. Department of Justice Office of the Inspector General
[organization]
U.S. Senate Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations
[organization]
UCLA Law COVID Behind Bars Data Project
[organization]
United States Senate Permanent Subcommittee on Investigations
[organization]
United States Senate PSI Staff Report
[organization]
Virginia
[organization]
Virginia Department of Health
[organization]
Wallace v. State
[case]
Washington
[organization]
Watkins v. State
[case]
Wisconsin
[organization]