Nearly 20 years ago, I stepped into the downtown Baltimore office of an obscure state official named Dr. David Fowler. He was lanky, affable, with an Afrikaner accent that alluded to his South African roots. He was also the state’s chief medical examiner, the man who determined the fate of all cases of suspicious deaths across the state.
I had no idea at the time, but roughly two decades later, he would become one of the most infamous pathologists in the world, his work and reputation fodder for national headlines after his stunning testimony on behalf of Derek Chauvin, the cop accused and eventually convicted of murdering George Floyd on camera in May of 2020.
Perhaps I should have expected it based on what transpired that day in Fowler’s office.
I had no idea at the time, but roughly two decades later, he would become one of the most infamous pathologists in the world, his work and reputation fodder for national headlines after his stunning testimony on behalf of Derek Chauvin, the cop accused and eventually convicted of murdering George Floyd on camera in May of 2020.
I was visiting to question him about the death of a man in police custody that occurred after he was struck with a Taser. Fowler had ruled the cause of death the result of a condition called “excited delirium.” I had never heard of it, so I wanted an explanation.
The autopsy had listed cardiac arrhythmia as a key contributor to the victim’s death, so I was curious why the Taser wasn’t identified as the primary cause. It seemed logical that the shock of thousands of volts of electricity emanating from the allegedly non-lethal weapon could have been definitively responsible for the victim’s demise. Fowler, however, didn’t think so. He was adamant that the now-discredited excited delirium theory, not the Taser, was key to explaining the fatal incident. In fact, he gave me a book on it.
The theory seemed absurd. And, indeed, it was.
That was the beginning of what would turn into decades of often contentious coverage of Fowler by me and my reporting partner, Taya Graham. Reporting that included stories concerning the massive number of unclassified deaths Fowler’s office left undetermined, the death of young men in police custody that an audit showed were wrongly decided, and women caught in the throes of addiction whose suspicious deaths were overlooked.
Along the way, we found cases that still haunt us. Mysterious deaths with gaping holes of missing evidence and unexplained circumstances. Tragic tales of innocent people who expired under dubious circumstances that—in light of a scathing audit that found Fowler’s office was plagued by investigative lapses and discredited science—might have otherwise been resolved.
That’s why we have compiled relevant facts of each case in the story that follows.
Much of this reporting is personal for us; though, as always, we do our best to remain objective. But it’s our exactitude as reporters and our need for truthful answers that also drives our conviction that the cases we recount here—cases we’ve spent years investigating and reporting on ourselves—might have had different outcomes if someone other than Fowler was in charge.
And that is the point of this piece: to reveal what happens when a bureaucrat weaponizes incompetence. To reckon with how the government can be an unwitting accomplice to murder, not by acts of commission, but through many mundane and concerted acts that entrench a state-sanctioned system of willful indifference.
— Stephen Janis, 2026
In May 2011, a young woman named Emily Hauze attended a party in Fells Point, a waterfront neighborhood in Baltimore known for its lively bars and cobblestone streets.
The recent Loyola College graduate had been living with her parents in Pennsylvania, but she often returned to the city to spend time with her college friends. She even had something to celebrate—a new job as a teacher.
At the party, she met a young man. He was a Johns Hopkins Medical School student who, attendees later told us, was not a friend of anyone at the party. In fact, no one could recall who invited him.
The pair left together and ended up at a Mount Vernon apartment.
The next day, police received a call that a maintenance worker at the same apartment building had made a gruesome discovery: A body was lying in a dumpster attached to a compactor at the bottom of the building’s trash chute.
Police arrived to find a naked female corpse in the dumpster. The position of the body indicated that it had traveled down the chute and into the compactor. At the time, the deceased could not be identified.
Minutes later, an officer stopped a young man in the lobby who was carrying a bag of clothes. He explained they belonged to a young woman who had vanished from his apartment early in the morning and had never returned.
He identified the woman as 23-year-old Emily Hauze.
One would think, given the questions raised by circumstantial evidence alone, Hauze’s death would require an extensive investigation.
But that’s not what happened.
Instead, an inconspicuous government agency quizzically ruled Hauze’s death an accident—a determination that ended the investigation, according to police records we reviewed. According to the Office of the Chief Medical Examiner (OCME), the official conclusion was that Hauze ended up naked and dead at the bottom of that trash chute by some fatally unlucky accident she caused herself.
But how could she have thrust herself through a roughly 24-inch-wide trash chute? What would prompt anyone to crawl into a stinking metal contraption attached to a shaft traveling 25 stories? And why was a young man carrying her clothes through the lobby instead of calling the police?
It was a process we had become accustomed to after reporting on death investigations over the past two decades: A mysterious death in Baltimore, a cursory look by police, and an even more questionable ruling from the OCME that shuts down the investigation entirely.
At the time, that determination marked the end of the road for Hauze’s case. Until now.
In recent years, the Office of the Chief Medical Examiner has come under renewed scrutiny for lax and often questionable practices. Much of that scrutiny has focused on one man who played a central role in shaping how the office operated: former Chief Medical Examiner Dr. David Fowler.
Fowler’s work remained largely obscure until he testified in the murder trial of Derek Chauvin, the Minneapolis police officer whose knee pressed into George Floyd’s neck for over 8 minutes. The downward pressure caused asphyxiation and ultimately killed him. Floyd’s death prompted national outcry and widespread protests.
In recent years, the Office of the Chief Medical Examiner has come under renewed scrutiny for lax and often questionable practices. Much of that scrutiny has focused on one man who played a central role in shaping how the office operated: former Chief Medical Examiner Dr. David Fowler.
Called by Chauvin’s defense, Fowler testified that Floyd’s death was caused not by police restraint, but by underlying heart disease, drug use, and carbon monoxide exposure—conclusions sharply at odds with the jury’s verdict and later medical consensus.
Even with Chauvin’s conviction, the world erupted in outrage at Fowler’s manifest incompetence. Roughly 450 doctors penned a letter calling for his work to be examined. The Maryland attorney general responded with an extensive audit of police custody deaths for which the OCME conducted autopsies. It found Fowler had ruled incorrectly on 41 deaths involving police restraint.
Many in the public were shocked at these findings; we were not.
That’s because we had covered Fowler’s work on a variety of mysterious cases for almost two decades, including police-involved deaths, questionable suicides, murky drug overdoses, and even a home invasion that Fowler ruled did not contribute to the death of the homeowner.
We wrote stories on all of these cases, calling into question the rulings of the OCME. But nothing happened. His role as an obscure bureaucrat went unexamined by the government that appointed him.
But much has changed since Fowler’s testimony. A formerly inscrutable agency is in the spotlight. And families who believe Fowler erred in cases involving their loved ones are speaking out.
That’s why we are going to explore in detail some of the most vexing cases we covered during Fowler’s tenure. In each case, we will compare the findings of the audit with gaps and failures in the investigative process that seem to raise more questions than answers.
Rey Rivera
“Routine deficiencies in case files—including missing photographs, absent scene analyses, and inadequate investigative follow-up—compromised accuracy across the board.” — Maryland OAG Audit, 2025
The highest profile case from the Fowler era is the alleged suicide of Rey Rivera. The 26-year-old aspiring filmmaker’s mysterious death became a national story after a Netflix reboot of Unsolved Mysteries highlighted the case.
Rivera was found on the floor of an empty office in May 2006. The space was the home of a former storefront church, which had recently been vacated, behind the historic Belvedere Hotel in Baltimore’s Mount Vernon neighborhood.
A hole in the ceiling over Rivera’s body suggested he had jumped from the roof of the Belvedere with the intent to commit suicide. But a series of bizarre and seemingly contradictory facts belied those conclusions, all of which became even more questionable when the Unsolved Mysteries episode aired.
“Routine deficiencies in case files—including missing photographs, absent scene analyses, and inadequate investigative follow-up—compromised accuracy across the board.”— Maryland OAG Audit, 2025
The highest profile case from the Fowler era is the alleged suicide of Rey Rivera. The 26-year-old aspiring filmmaker’s mysterious death became a national story after a Netflix reboot of Unsolved Mysteries highlighted the case.
Like many of the cases we covered, it wasn’t just the medical evidence that made Rivera’s suicide tough to accept for his family and friends. It was also the narrative bolstered by police and accepted without pushback by the OCME that somehow Rivera—just married and planning to move to Los Angeles—suddenly decided to jump off the top of a building.
The case files do little to explain why he would have made such a fateful and out-of-character decision.
Instead, what we know about Rivera’s final hours reveals less of a path to a spontaneous suicide than a series of mysteries that don’t evince a simple explanation.
The morning he disappeared was routine. He kissed his wife, Alison, goodbye before she departed on a business trip to Richmond, Virginia. He made a last-second visit to an Apple store to rent some equipment for an editing project he was wrapping up for a client.
According to a guest who was visiting the couple, Rivera returned home briefly, then suddenly left again shortly after receiving a mysterious phone call. He departed with just his keys, a credit card, and a cellphone. He was wearing shorts, flip-flops, and a T-shirt.
And then he just disappeared.
When Rivera failed to check in, friends frantically searched Mount Vernon, where his car was found in the parking lot next to the Belvedere Hotel. Three employees of the firm where Rivera worked ventured to the top of a nearby parking garage adjacent to the building. There they spotted a hole in the roof, and eventually police found Rivera’s body underneath.
Since the case was featured on Netflix, an entire subreddit has emerged, filled with theories about how Rivera ended up on the floor of that empty conference room. Fueling that speculation is a bizarre note found taped behind his computer shortly after he died. It was written in florid prose, heavy on metaphor. It mentioned his high school friend, Porter Sansbury, and the firm where they worked together, Agora.
The FBI concluded it was not a suicide note. It was certainly a message of sorts, though difficult to dissect. Something about it always felt like a cry for help, like Rivera had gotten in over his head and didn’t know what to do.
Rivera’s friends described him as a larger-than-life personality, a hero to many, a stalwart companion who would bend over backwards for even a casual acquaintance. Perhaps he just didn’t know how to ask for assistance.
But there is one aspect of certainty in the case: the flimsy work of the homicide unit and the similarly incomplete autopsy.
The case file released by the Baltimore Police Department is amazingly bereft of details. No witness statements, for example, from the people who found the hole. No interviews with the employees of the firm where he worked. Nothing about the hotel or the people who may have been present when he allegedly jumped.
In the files made available to us, there were no photos of the scene or statements from family and friends about when they had last seen Rivera. Nothing about a possible motive for him to run from his house, without saying a word, to apparently jump to his death.
That doesn’t mean the evidence doesn’t exist; it just wasn’t in the files released by police after the case received international attention.
Similarly, the autopsy report itself is vague and seems incomplete, though it also reveals that
the medical examiner who examined Rivera’s body, Melissa Brassell, had doubts. “Injuries at the time of the autopsy were consistent with the fall from a height,” Brassell wrote in her May 2006 report. “Because the circumstances surrounding the incident are unclear, and it is not known how the deceased came to have precipitated from such a height, the manner of the death is best classified as UNDETERMINED.”
But there were plenty of investigative opportunities to answer that question, none of which made it into the case files.
Marie Dauenheimer, an accredited medical illustrator who depicts catastrophic injuries for wrongful death cases, told us that, when a person falls from a height, generally injuries are bilateral—meaning they occur on both sides of the body. That was not the case with Rivera’s corpse.
“There’s really nothing that happened to that left leg. Nothing happened to the pelvis on that side. It’s really just very perplexing,” she said
“Usually, you’d see a lot more lower limb injuries—and, again, they would be bilateral.”
Investigators could have also tried to trace Rivera’s cell phone to learn where he had been prior to his death. But they didn’t. They could have mapped the room where he was found and the location of his body to determine the vantage points from where he could have actually fallen. But they didn’t.
And there is no indication in any of the documents from the medical examiner’s autopsy and the homicide case files that anyone was interviewed, though we know police spoke to Rivera’s widow, Alison. It seems that investigators, without any conclusive evidence, abandoned a methodical search for clues. That’s because, again, the case was essentially closed after Fowler’s office ruled Rivera’s death undetermined.
According to the autopsy report and the case files, no one in the OCME’s homicide unit pursued any potential leads after the OCME’s ruling. In fact, both the autopsy and police report provide few, if any, examples of anyone involved in the case asking questions of anyone. The testimonies of people who worked in the Belvedere, as well as friends and family, simply were not included in the files we reviewed.
Investigators could have also tried to trace Rivera’s cell phone to learn where he had been prior to his death. But they didn’t. They could have mapped the room where he was found and the location of his body to determine the vantage points from where he could have actually fallen. But they didn’t.
This lack of curiosity about the circumstances surrounding Rivera’s alleged suicide also reflects one of the most pointed criticisms of the 2025 audit.
The outside auditors noted that Fowler’s office often failed to answer basic questions, and seemed to lean on the ‘undetermined’ classification instead of drilling down into the details to answer critical mysteries, like where exactly Rivera would have jumped from to end up where he was found.
When Stephen spoke to Fowler about this case back in 2007, he portrayed the ruling as a favor to the family. He believed classifying Rivera’s death as undetermined left the door open to further investigation.
But, of course, the undetermined ruling produced the exact opposite effect. It left his death in a post-mortem purgatory for eternity.
Pete Peltesmes
“Deaths occurring in the course of another person’s actions should be certified as homicides; OCME failed to apply this ‘but-for’ standard in numerous cases.” — Maryland OAG Audit, 2025
If there is a case that reveals the impact of Fowler’s unconventional overreliance on ‘undetermined’ as a manner of death, it is the untimely demise of 77-year-old Pete Peltesmes. Although his case received little attention, it is perhaps the most striking example of how much damage an unorthodox medical examiner can do to a suspicious death investigation before it even starts.
Peltesmes was born in Greece and immigrated to the US in 1967. He opened and managed a successful restaurant in the Baltimore area before retiring.
He was home in July 2013 when a group of men banged on the door. What happened next is a matter of dispute between his family and OCME.
“Deaths occurring in the course of another person’s actions should be certified as homicides; OCME failed to apply this ‘but-for’ standard in numerous cases.”— Maryland OAG Audit, 2025
When Peltesmes’ wife returned home, she found her husband lying on the floor unconscious. His pants were pulled down to his ankles. His wallet was stolen. There was a large bruise on the left side of his head.
There were other injuries as well: his ribs were fractured on the left side of his body; there was extensive bruising on his arms and neck. All signs of a violent home invasion.
Doctors later determined Peltesmes had a massive stroke. Police arrested several suspects, but they were not charged with murder. No charges were filed against the home invaders save for robbery.
That’s because Fowler’s office refused to rule Peltesmes’ death a homicide. The OCME argued that the timing of his stroke was too murky to definitively blame his death on the intruders. Thus, the case was ruled undetermined.
But the OCME theory that the timing of his death could not be determined is problematic at best. It contradicts a very simple fact: police believe Peltesmes was at the door when the invaders attacked. His body was found behind said door. In other words, he was alive when the thieves entered the home.
The evidence for this theory is compelling. For example, the extensive list of injuries suggest Peltesmes initially fought back. The bruising, the broken ribs, and head injuries all allude to a violent struggle.
Secondly, the fact that Peltesmes was found behind the open door suggests he suffered the stroke after the intruders entered. It seems improbable he would rise from his nap, venture to the front of the house, then have a stroke at the front door prior to home invaders entering and looting the place.
It’s possible, of course, but not probable.
This evidence would normally lead to what’s known as a ‘but/for’ analysis. (In this case, but/for the burglary, Peltsemes would probably be alive.) However, Fowler’s office ruled it was impossible to reach that conclusion and ruled his death undetermined.
For Fowler, such rulings were not unusual, but what makes Peltesmes’ case unusual is the fact that the family fought back. They tried to overturn Fowler’s ruling. They sued the OCME in administrative court, seeking to convince a judge to void the undetermined ruling. What happened during the proceedings shows just how bizarre the agency’s approach to pathology was.
Both Fowler and an assistant medical examiner were grilled on the stand by the family’s lawyer, exposing startling lapses. At one point, an unnamed pathologist was asked to explain the broken ribs Peltesmes sustained during the attack. She told the court she was not aware of the injury.
“I didn’t know that the ribs were broken, I didn’t confirm that the ribs were broken during the autopsy,” she testified.
This is precisely the type of shoddy work that the audit of OCME during Fowler’s tenure highlights. It’s truly remarkable that a medical examiner in a potential homicide case was completely unaware of a significant injury.
Both Fowler and an assistant medical examiner were grilled on the stand by the family’s lawyer, exposing startling lapses. At one point, an unnamed pathologist was asked to explain the broken ribs Peltesmes sustained during the attack. She told the court she was not aware of the injury.
Fowler also testified, and his explanation for dissociating the stroke with the robbery was even more problematic. “This would not be the first time in our experience as medical examiners we’ve seen an individual collapse and there has been scavenging of the body for valuables,” Fowler opined.
Perhaps. But the “scavenging” occurred in Peltesmes’ home during a robbery in his living room. How Fowler could conclude that the stroke and the attack were unrelated is almost as difficult to understand as his testimony on George Floyd’s cause of death.
In this case, though, Fowler received pushback from someone other than a reporter or distraught relative. That’s because the family hired an outside pathologist, Virginia’s former Chief Medical Examiner Dr. Marcella Fierro, to testify. She told the court that the evidence clearly supported a determination of homicide as the manner of death.
“He opened that door, and something bad happened to him. He had a massive stroke, and he died. And he would be alive and well today in his usual state of miserable health were it not for that event,” Fierro testified.
She also took issue with Fowler’s use of the “undetermined” designation. “Death should not be certified undetermined until you have exhausted every last piece of the investigation.”
The judge ultimately ruled he did not have jurisdiction over the OCME. Questions about Peltesmes’ case remain unanswered and his cause of death remains undetermined.
Still, Peltsemes’ family has not given up their quest to have the case re-examined. His daughter Eleni has sent letters to both the Maryland attorney general’s office and OCME requesting the case be re-opened and the classification changed to homicide.
The medical examiner turned down her request, and she has yet to hear back from the attorney general’s office. But she remains undeterred.
“I will never stop fighting, never,” she told us. “My father deserved better.”
Emily Hauze
“Case reviewers found key investigative details routinely absent, and determinations issued without sufficient justification or documentation.” — Maryland OAG Audit, 2025
One of the consistent critiques from the outside pathologists who reviewed the OCME’s work was that it was often incomplete or bereft of critical details. And no case embodies that lack of thoroughness more than the death of Emily Hauze, the recent Loyola College graduate who was found naked and dead at the bottom of a trash chute in a Mount Vernon apartment building in 2011.
“Case reviewers found key investigative details routinely absent, and determinations issued without sufficient justification or documentation.” — Maryland OAG Audit, 2025
The OCME‘s autopsy report does little to explain how Hauze ended up naked in a trash compactor. Nothing in the case files even attempts to posit a theory about how someone weighing roughly 100 pounds could thrust themselves through a metal box roughly two feet across, restricted by a metal spring. Especially a young woman whose friends say she was not inclined to put herself in danger.
Trash chute designs vary widely, but climbing into one, let alone pushing your body into the shaft, would not be easy. The case files do not describe the chute’s design, or how Hauze would have climbed into it.
The compactor, which literally compresses the material thrown down the chute, also erases injuries. In this case, it is again astounding how readily the OCME accepted the theory that someone could actually end up in it by accident.
The story the medical student shared with police to explain this improbable sequence of events only adds to that mystery.
He told police that he and Hauze had sex. Shortly afterwards, he claimed, Hauze said she was going to the bathroom, left the room, and he fell asleep. The next morning, he woke up to the sound of her phone ringing.
She simply disappeared.
He also explained that the phone call was from Hauze’s friend trying to find her. Then, he told police, he fell back asleep until 11 AM. Coincidentally, that was the time police were knocking on doors in nearby apartments seeking information about the unidentified body.
The OCME‘s autopsy report does little to explain how Hauze ended up naked in a trash compactor. Nothing in the case files even attempts to posit a theory about how someone weighing roughly 100 pounds could thrust themselves through a metal box roughly two feet across, restricted by a metal spring. Especially a young woman whose friends say she was not inclined to put herself in danger.
It’s worth noting that Hauze’s body was unclothed, and that all her jewelry was left in his room. So, apparently, she stripped down completely naked before venturing into the hall and eventually ending up in the trash chute.
But a separate case that occurred in the same building makes the conclusions about her death even more difficult to fathom.
One year prior to Hauze’s passing, a man named Harsh Kumar ended up in the same trash chute. Kumar’s death was also ruled an accident by OCME. Police attributed it, in part, to his use of the sleep aid Ambien, which they concluded led him to wander aimlessly and, perilously, into the chute. Within one year of each other, two people apparently climbed into the same constricted steel shaft and thrust themselves towards a horrifying death.
Nowhere in any of the documents we reviewed did any member of law enforcement or OCME interrogate how and why someone would make such a consequential mistake. In fact, the only explanation we have been able to conjure for this apparent lack of investigative insight comes from a private investigator.
Hauze’s family hired former homicide detective Stephen Tabeling to investigate. Tabeling was a former lieutenant in Baltimore’s murder investigations unit during the 1970s.
Tabling reached out to the detectives assigned to the case, but they refused to help him. However, they did share their theory of what happened: Hauze, they told him, mistook the trash chute for a pet door; she crawled in thinking it was an entrance to the medical student’s apartment. Tabeling was shocked.
“I couldn’t believe it,” he told us. “But that’s what they thought.”
Tabeling also had a run-in with Fowler’s office about the case, but he said the chief medical examiner wouldn’t budge.
“I can’t understand how they could come to that conclusion,” Tabeling added.
The case is, of course, dormant. The family has not responded to our emails, and the homicide case files show no investigative work over several months after her body was found.
Robert Clay
“OCME’s conclusions frequently relied on unsupported or discredited scientific rationales, resulting in manner-of-death rulings judged not reasonable.” — Maryland OAG Audit, 2025
The death of Baltimore activist and business leader Robert Clay in May of 2005 prompted one of our first—and, perhaps, the most politically fraught—encounters with the OCME.
Clay was a larger-than-life Black business contractor who exerted political power behind the scenes both in Baltimore and outside of the city. He was a frequent contributor to political campaigns and a noted adversary of then-Mayor Martin O’Malley, whose campaign for governor had just kicked off when Clay died.
Clay was found dead on the first floor of his office in Reservoir Hill, a neighborhood on the city’s west side—the victim of a gunshot wound. His body was splayed across the floor, but his feet were resting on the bottom of a staircase. A stolen .38 Special was found underneath his body.
The OCME didn’t immediately rule on Clay’s death because there was so much contradictory evidence. The primary pathologist, Anne Rubio, said at the time she had concerns that made her reluctant to deem it a suicide, even as homicide detectives were urging her to do so.
The evidence was decidedly ambiguous.
Clay was right-handed, for instance, but the gun was found in his left hand. The bullet that killed him traveled from the left side of his head out the front of his right side, meaning he would have had to aim the gun over his left ear with his left hand—a highly unusual and awkward way to commit suicide for someone who is right-handed.
The bullet that killed Clay was never found. Police explained to us that unrecovered bullets were routine. But it still made definitively connecting the gun found on Clay to his death nearly impossible.
The gun, in fact, was stolen during a burglary in Frederick, Maryland, 10 years before Clay died. Police refused to release details of a trace conducted through the National Crime Information Center database. How Clay acquired the weapon that apparently killed him remains a mystery.
The bullet that killed him traveled from the left side of his head out the front of his right side, meaning he would have had to aim the gun over his left ear with his left hand—a highly unusual and awkward way to commit suicide for someone who is right-handed.
It is also unclear if Clay’s hands were checked for gunshot residue—a test that can be done post-mortem to confirm if a person fired a weapon. The files don’t contain any evidence a GSR test was administered; however, it’s worth noting that testing for gunshot residue has also been scrutinized for methods that can produce false positives.
Lastly, Clay did not leave a suicide note.
Rubio finally ruled Clay’s death a suicide, to the dismay of his family. The FBI confirmed this ruling by citing what legal experts now consider to be questionable forensic science: blood spatter analysis. They argued the blood spatter made it impossible for someone to sneak up behind Clay and shoot him. The spatter, they argued, would have been disturbed.
However, blood spatter analysis has been widely discredited. In 2009, a report by the National Academy of Sciences found blood spatter analysis lacked rigor.
“The uncertainties associated with bloodstain pattern analysis are enormous,” the report noted. “Some experts extrapolate far beyond what can be scientifically supported by bloodstain pattern analysis.” Authors of the report also note that “the opinions of bloodstain pattern analysts are more subjective than scientific.”
We’ve examined some photos from the scene. The blood spatter extends outward from Clay’s body, projecting perhaps three to four feet onto the first floor lobby of the building. The blood trail snakes around a divider leaving no trace on the wall itself.
Even more intriguing is that there is very little blood spatter on the wall adjacent to his body. Minimal. Much less, in fact, than the residue on the floor depicted in the scene photos. Investigators noted more blood stains on the wall than the photos depict. But that discrepancy is left unresolved, and it raises questions about whether the existing bloodstain evidence can actually support the level of certainty investigators later claimed.
The case file does not document the methodology used to analyze the bloodstain evidence, the assumptions underlying that analysis, or how particular patterns were interpreted. This absence makes it difficult to assess how investigators came to the irrefutable conclusion that there was no foul play.
Still, the FBI used the blood spatter evidence to say it would have been impossible for someone else to have killed Clay. Their official reason was that the distribution of the spatter ruled out another person being at the scene when Clay died.
In 2008, then-Baltimore City Inspector General Hilton Green decided to re-examine the case. He re-interviewed witnesses, spoke to officers involved in the investigation, and even talked to Fowler.
Green, who has since passed away, conducted his probe based upon the theory that Clay was murdered and the investigation was botched. He uncovered some intriguing details about events both before and after Clay’s body was found.
In a report Green issued in 2009, he recounted business disputes between Clay and two individuals who were both eventually imprisoned: Wilkins McNair Jr., a Baltimore accountant who was charged with embezzlement, and LaVan Hawkins, a successful businessman who spent time in federal prison for withholding taxes from employees but not paying them to the government.
McNair claimed that Clay’s death was tied to a dispute over contracts and that somehow Hawkins was involved. However, it was McNair who had been entangled in Clay’s personal business.
After Clay’s death, his wife Gerietta retained McNair as a financial adviser. McNair convinced her to put proceeds from the couple’s Howard County home into a fund he managed. He then redirected the money into his own accounts, according to an FBI press release.
McNair eventually pled guilty to embezzlement, his second set of charges for financial crimes. This means he had both motive and opportunity.
But, again, the possibility of further investigation was shut down by OCME’s suicide ruling. When Green spoke to Fowler, he pressed him on the fact that Clay was right-handed. The report quotes Fowler as saying, “Although it was unusual that a right-handed man would shoot himself on the left side of the head, people in that state do unusual things when contemplating death.”
Fowler also cited the aforementioned questionable blood spatter analysis, claiming an unidentified “expert” had concluded the evidence made murder impossible. “Dr. FOWLER further advised that a blood splattering expert had reviewed the case, and he too had agreed it was suicide,” Green’s report notes.
Green ultimately concluded in the report that Clay had likely committed suicide; however, he urged law enforcement to interview both McNair and Hawkins.
Fowler also clashed with Clay’s family. “He wasn’t open to the fact we believed Robert’s case needed more investigation,” Cheryl Clay, Robert’s cousin, told us. She also shared a letter written by Fowler shortly after the family had met with him to raise concerns about the autopsy findings and request that Clay’s case be re-opened. The missive was direct and to the point:
Dear Ms. Clay,
I am responding to your letter to Dr. Rubio regarding the death of Robert Lee Clay, Sr. Dr. Rubio has retired and is no longer available.
The issues raised in your letter were all considered during the forensic investigation of Mr. Clay’s death. In the ten years since his death, no new information has been produced to suggest that it was anything but a suicide. In light of these facts, requests to reopen the investigation or change the manner of death determination in this case are denied.
Sincerely,
David R. Fowler
Cheryl hopes questions about Fowler’s work might lead to police taking another look at her cousin’s case. “I truly believe Robert did not commit suicide,” she told us.
She also recalls, with some bitterness, Fowler’s dismissiveness about the family’s concerns. An attitude, she says, that comports with his approach to investigating other suspicious deaths in Baltimore.
Tyra McClary
“The OCME exhibited an aberrant and unjustified reliance on the ‘undetermined’ manner of death, often substituting uncertainty for investigation.” — Maryland OAG Audit, 2025
Tyra McClary was a Baltimore resident who struggled with addiction. Her body was found in 2006 under a pile of mulch in Northwest Baltimore with a plastic bag tied around her legs.
The toxicology report found heroin and cocaine in her system. So, initially, despite the strange circumstances surrounding the disposition of her body, her death seemed destined to be swept into Fowler’s vast “undetermined” category as hundreds of overdose deaths were happening across the city.
But the autopsy also revealed that both McClary’s adrenal gland and her thyroid gland had hemorrhaged. Cyril Wecht, a famous pathologist who conducted autopsies of John F. Kennedy and Anna Nicole Smith, told us that this could be an indication of injuries associated with more nefarious manners of death.
“The OCME exhibited an aberrant and unjustified reliance on the ‘undetermined’ manner of death, often substituting uncertainty for investigation.”— Maryland OAG Audit, 2025
“Adrenal hemorrhage can be the result of someone suffering prolonged stress, meaning an hour of stress, not minutes. Being left out in the cold, for example, or being in an extremely stressful situation for a very long period of time. Very rarely, it is sometimes caused by blunt force trauma to the stomach,” he said in an interview for the Baltimore Examiner. “Thyroid hemorrhage can indicate manual strangulation, being strangled with the hands, not ligature, meaning a rope. It can also be the result of blunt force trauma to the neck.”
These injuries prompted the medical examiner to write that “homicide could not be ruled out.” Still, due to the fact that McClary’s body was partially decomposed and there was no evidence of injury, her cause of death was ruled undetermined.
McClary’s family told us she was an addict who, for years, struggled to overcome her reliance on opioids. But treatment was hard to come by in the city during the 2000s. To support her habit, she often sold her body on the streets of Northwest Baltimore.
Unfortunately, there was no attempt to investigate her death further, according to homicide records. Ultimately, it was an example of how an undetermined ruling leads to stasis.
Perhaps it was that uncertainty that pushed McClary’s death into the middle of another controversy. Shortly after she died, a protest was held in Northwest Baltimore to call out police for not responding to community concerns about a possible serial killer. McClary’s picture was printed on a placard and hoisted above the crowd as one of the yet-unknown murderer’s victims.
Stephen wrote a story for the Baltimore Examiner about the outcry, quoting some of the activists who alleged there were more bodies, perhaps a dozen. The police told him that was untrue. He included both sides in a 300-word report.
Stephen’s former employer, the Baltimore City Paper, accused him of manufacturing a serial killer in 2006, criticizing him for quoting the protesters and blasting the Baltimore Examiner for hyping the story with alarming headlines.
Needless to say, tensions were high. But the experience left us with a big question: Why would members of a community hold a protest, attended by over 100 residents, over a nonexistent serial killer?
In 2008, though, suspicions about a serial killer in the community erupted again—this time after a series of strangulations. Five women were asphyxiated over four months in the same Northwest Baltimore neighborhood where the protests occurred in 2006.
Along with his former colleague Luke Broadwater, Stephen delved into similar cases stretching back a decade. After their findings were published, police arrested William Vincent Brown, whom they connected to at least two murders and one attempted murder and rape during the 2000s. However, Brown was never charged in connection with the 2008 strangulation murders.
At the time, Stephen hoped BPD would reinvestigate McClary’s case. He interviewed Wecht about the evidence, who said it was worth pursuing. But the police ignored it. In fact, even though the city formed a task force to investigate the five cases, four were never solved and remain open today.
It seems unlikely, based on the cases we reviewed here, that Fowler’s questionable approach to pathology as Maryland’s chief medical examiner was limited to the type of police-involved restraint cases that were reviewed by the 2025 audit. More than likely, there are many additional suspicious deaths that warrant review.
In a city that systematically, routinely, and notoriously buried the true scope and scale of racial injustice, economic inequality, and police abuse, Fowler was a critical cog in the state machine of organized indifference.
Whether or not all of Fowler’s dubious rulings are ultimately reexamined, the bureaucracy that allowed Fowler to chart this course is due for a reckoning as well. His ability to operate without scrutiny for decades needs to be fully grasped, especially because the activists and families who challenged Fowler’s outlier tendencies were generally ignored.
In a city that systematically, routinely, and notoriously buried the true scope and scale of racial injustice, economic inequality, and police abuse, Fowler was a critical cog in the state machine of organized indifference.
For example, when Fowler ruled the police-custody death of Eastern Shore resident Anton Black an accident despite evidence to the contrary, few politicians questioned his decision.
Black had been chased by three white officers to his Greensboro, Maryland, home after a 911 caller made a false accusation that he had kidnapped his cousin.
Just a few feet from his doorstep, an officer laid on top of the 160-pound track star for minutes. Eventually, Black lost consciousness. En route to the hospital, he was declared dead.
The body camera footage showed the officer sitting on top of him during the arrest. The downward pressure on his back was a classic case of positional asphyxia. But Fowler ruled it an accident attributable to a heart abnormality and bipolar disorder.
We asked Wecht to review the case—he called Fowler’s ruling “blatantly wrong”—but we were the only media organization to do so. Every other outlet trumpeted Fowler’s ruling as definitive.
Only a lawsuit filed by the ACLU on behalf of his family prompted the state to respond. That suit was settled for $5 million, but Fowler’s ruling that Black’s death was an accident still stands.
And that’s the dilemma facing state and city leaders in the aftermath of Fowler’s fall from grace. What should be done to fix 16 years of injustice resulting from questionable science and flawed postmortem investigations? Should the officers involved in Black’s death now be prosecuted? Should the AG’s office expand the scope of the audit of Maryland’s OCME and review other rulings on other deaths not involving police?
Presumably, they will not. Instead, we expect the audit to be touted as an adequate response to a bureaucratic failure that has since been fixed.
What’s worse, if Fowler had not testified in Derek Chauvin’s defense on national television, the current (but still limited) process of re-examining past police restraint cases would not have occurred. Only his very public and widely criticized testimony on behalf of Chauvin forced state officials to respond, not the decades of dubiously classified in-custody deaths under his watch.
Perhaps it’s time to delve deeper into not just how Fowler was allowed to continue wreaking havoc on death investigations, but also why. Why were public officials so incurious? Why was OCME impervious to accountability? Who should have been watching? And does the office itself need reform in light of the audit’s findings?
What’s worse, if Fowler had not testified in Derek Chauvin’s defense on national television, the current (but still limited) process of re-examining past police restraint cases would not have occurred. Only his very public and widely criticized testimony on behalf of Chauvin forced state officials to respond, not the decades of dubiously classified in-custody deaths under his watch.
Answering these questions is, in some sense, even more important than reviewing past autopsies, if only to ensure that a tenure similar to Fowler’s is simply impossible.
Before publication, we asked the Maryland attorney general’s office if they planned to re-open the specific cases included in this report. We also inquired into the scope of any future audits. Here is their response:
“The Office of the Attorney General was granted the authority to perform a comprehensive review of the 36 cases where the reviewers – unanimously – concluded the manner of death should have been homicide. While that review is active and ongoing, our office will have no additional comment.”
We also reached out to Dr. David Fowler several times via the email listed on his curriculum vitae with specific questions related to reporting contained in this report. He had not responded prior to publication.
Finally, we asked the current management of the Maryland Office of the Chief Medical Examiner for comment on our conclusions, outlining the facts of each case so they could respond. Here is what they said:
Pete Peltsemes
“The injuries described could be due to a fall or a strike, as noted in the autopsy report. Additionally, as the autopsy report states: “It is possible that the spontaneous hemorrhage was brought about by the agitation and shock of being robbed, or alternatively, that he had a spontaneous intracerebral hemorrhage and fell to the ground as he was getting out of the house, and he was robbed once he was unresponsive. Thus, the manner of death is best certified as Undetermined.” Possible ribfractures which were described on pre-mortem radiology were not confirmed at autopsy.”
Emily Hauze
“Investigative circumstances reported by the investigating agency, coupled with
injuries described by the medical examiner as being “consistent with a fall from a height, with impacts within the metal chute, terminal impact into the compactor portion and
peri/postmortem compression injuries from activation of the trash compactor”, is why the case was certified as Accident. Toxicology testing (which would include lidocaine) was negative for Drugs.”
Rey Rivera
“Scene diagrams may be in the possession of the investigating police agency. Scene photographs are not public record.
“Unilateral injuries may be seen with precipitation from a height, as it is dependent on how the body comes in contact with the ground and/or any other objects during descent. As stated in the autopsy report: Because the circumstances surrounding the incident are unclear, and it is not known how the deceased came to have precipitated from such a height, the manner of death is best classified as Undetermined.”
Robert Clay
“No blood spatter analysis was performed by OCME.”
Tyra McClary
“These questions should most appropriately be directed to the investigating police agency.”
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