Determining Cause of Death of Incarcerated Prisoners in America

How Experts Uncover the Cause and Manner of Death

A medicolegal death investigation is a complex puzzle. When someone dies under unclear circumstances, especially in a place like a prison, forensic pathologists are tasked with assembling a vast collection of seemingly disconnected clues—medical records, witness statements, video footage, and minute biological evidence—into a coherent and truthful narrative. Their work is a methodical pursuit of the final word on how and why a life ended.

This article follows a real-world investigation into the death of a 24-year-old man in a tribal prison, a case that illustrates the meticulous process experts use. Every such investigation has two primary goals, which are distinct yet deeply connected: determining the Cause of Death, which is the specific injury or disease that started the lethal chain of events, and the Manner of Death, which classifies the circumstances surrounding that cause into one of five categories (Homicide, Suicide, Accident, Natural, or Undetermined). To understand this intricate process, we will follow the path of the investigation, starting with the very first steps taken after the body is discovered.

1. The Investigation Begins: Gathering the First Clues

An investigation doesn’t begin with the scalpel; it begins with context. Using the case of the young man who died in custody, presented by Deputy Medical Examiner Dr. Deland Weyrauch, we can see how an expert’s first task is to build a comprehensive picture of the decedent’s life and final days before even entering the autopsy suite.

The critical first steps include:

1. Body Transport In this case, the decedent’s body had to be transported on a 4.5-hour drive from the remote tribal prison to the medical examiner’s facility. This highlights the logistical challenges investigators face, especially in rural or underserved areas where access to forensic pathology services is limited.
2. Pre-Autopsy Information Crucially, a skilled investigator gathers extensive information before the first incision is made. Dr. Weyrauch collected law enforcement reports and the decedent’s pre-incarceration medical records. This background information helps form initial hypotheses and guides the physical examination, ensuring the pathologist knows what specific signs of injury or disease to look for.
3. Reviewing Medical History The initial records provided a vital foundation for the case. Dr. Weyrauch learned that the decedent had a history of schizophrenia and methamphetamine use. Most importantly, just before his 2.5-day incarceration, he had been to the emergency room for a suspected overdose of his psychiatric medications, haloperidol and olanzapine.
4. This raised a critical question: why was he cleared for incarceration? The ER records held the answer. While there, he “showed no clinical, diagnostic testing, or laboratory findings concerning serious intoxication or physiological derangement” and was subsequently discharged to law enforcement. This detail reveals the insidious nature of delayed toxicity; even medical professionals initially missed the severity of his condition, making Dr. Weyrauch’s subsequent investigation all the more critical.

With this preliminary information in hand, the investigator was prepared to begin the physical examination, looking for evidence that could confirm or challenge the story told by the records.

2. Beneath the Surface: The Autopsy and the Lab

The autopsy is a systematic process of examining the body both externally and internally to find the physical evidence of what caused death. Dr. Weyrauch’s examination was a methodical search for clues that were invisible to the naked eye.

2.1. The Physical Examination

The death investigation began with a detailed external examination. Dr. Weyrauch found no obvious signs of a struggle, traumatic injury, or self-harm. The next step was a meticulous internal examination. To rule out traumatic asphyxia (death from a lack of oxygen due to neck or chest compression), he dissected every neck muscle individually to look for subtle bleeds or other signs of neck compression. The examination revealed no such injuries, deepening the mystery. With no obvious disease or trauma present, the answer had to lie at a much smaller scale.

2.2. The Microscopic Deep Dive

The pivotal clue emerged from the microscopic tissue examination. In the decedent’s kidneys, Dr. Weyrauch discovered myoglobin casts—a clear sign of a serious medical condition. This finding pointed to a specific mechanism of death:

Rhabdomyolysis is a condition where muscle tissue breaks down and releases harmful substances, including a protein called myoglobin and high levels of potassium, into the bloodstream. This flood of toxins can damage the kidneys and, critically, the excess potassium can trigger a fatal cardiac arrest by arrhythmia. Symptoms of rhabdomyolysis “may be vague or absent in up to 50 percent of patients,” making it a silent but deadly condition.

This microscopic discovery provided a plausible mechanism—a cascade of events inside the body that led to the heart stopping. But a crucial question remained: what triggered this catastrophic muscle breakdown in the first place?

3. Connecting the Dots: From Mechanism to Cause

With a mechanism of death established, the investigator’s next task was to synthesize all available evidence to pinpoint the underlying cause. This required connecting the biological findings with the decedent’s history and the circumstances of his final days.

First, toxicology results provided a crucial link. Laboratory tests confirmed that haloperidol and olanzapine were the only active drugs in the decedent’s system. Critically, medical literature has associated this class of antipsychotic drugs with rhabdomyolysis. Although methamphetamine was detected in his urine, it was absent from his blood, indicating it had been fully metabolized before his death in prison and was not a factor. Crucially, records showed the decedent “had not been administered any medication while in prison,” confirming the fatal dose was self-administered before he ever entered the facility.

Second, Dr. Weyrauch had to investigate and eliminate alternative explanations. Because rhabdomyolysis can be caused by extreme physical exertion, and given his knowledge of deaths in custody, Dr. Weyrauch knew he had to rigorously investigate the possibility of a struggle with prison staff. To do this, he “crucially obtained all the video the prison had.” The footage showed the decedent sitting calmly in a restraint chair, “not struggling,” with his “legs dangling, shoulders relaxed.” This powerful visual evidence allowed Dr. Weyrauch to confidently rule out physical restraint as a contributing factor.

The evidence now pointed strongly toward the psychiatric medications as the cause of the fatal rhabdomyolysis. With the cause of death clarified, the investigation turned to its final, and often most complex, question.

4. The Final Question: Determining the Manner of Death

Determining the manner of death goes beyond medical science; it requires an assessment of the decedent’s intent and the overall circumstances. Was the drug ingestion an accident, or was it a deliberate act?

The final piece of the puzzle came from a source gathered in the first stage of the investigation: the emergency medical services report from his ER visit. In it, Dr. Weyrauch discovered the decedent’s own words. He had stated to ambulance staff that he had taken “all four bottles of” his medication and that this was his “first attempt of suicide.” Medical staff had documented that he was alert and fully oriented during this conversation and, significantly, “did not describe any active psychosis,” which preempted any argument that his statement was unreliable due to his schizophrenia diagnosis.

This statement of intent provided the last piece of necessary evidence. Dr. Weyrauch could now make his final, official determination:

• Cause of Death: “complications including rhabdomyolysis due to recent olanzapine, haloperidol, and methamphetamine intoxication”
• Manner of Death: “suicide”

The manner of death is a classification that provides crucial context for public health and legal purposes. The five possible manners of death are defined as follows:

While this case came to a clear conclusion, many others are plagued by systemic challenges that can obscure the truth and lead to contested findings.

5. When the Truth is Contested: Systemic Challenges

Not every investigation benefits from the clarity of evidence seen in the case study. The U.S. medicolegal death investigation system faces significant, systemic challenges that can compromise the accuracy and objectivity of its findings.

• Resource Scarcity: A nationwide shortage of board-certified forensic pathologists severely limits the ability of the system to conduct thorough investigations. In remote areas, the time and cost required to transport a body may determine whether a case receives an autopsy at all.
• Controversial Diagnoses: In contentious in-custody deaths, especially those involving physical restraint, certain terms have been used as a cause of death despite lacking a firm scientific basis. These include “excited delirium,” which is not a recognized medical diagnosis, and “sickle cell trait,” a genetic condition that does not cause death on its own. The use of “excited delirium” is particularly concerning; one study found that of 166 such deaths in police custody from 2010 to 2020, 43.3 percent involved Black individuals, transforming a questionable diagnosis into an alarming racial trend.
• Cognitive Bias: Investigators are human and susceptible to cognitive bias—unconscious errors in thinking that influence judgment. Contextual information is vital, but knowledge that a death occurred in police custody, for example, can unintentionally sway a determination if an investigator is not actively working to remain objective.
• Undue Influence: To ensure neutral and objective assessments, medical examiners and coroners must operate independently. Pressure from law enforcement, prosecutors, or other parties with a stake in an investigation can compromise the integrity of the findings.

These challenges threaten the core mission of death investigation, but a series of checks and balances exist to promote accuracy and accountability.

6. Ensuring Accuracy: Checks, Balances, and the Pursuit of Justice

To counteract systemic challenges and human error, the field of forensic pathology relies on several quality assurance mechanisms designed to ensure that determinations are as accurate and reliable as possible.

1. Peer Review This is a process where experts evaluate their peers’ work to identify potential errors or differences of opinion before a conclusion is finalized. In Ontario, Canada, for example, peer review is mandatory for all deaths in custody that involve a physical altercation between the decedent and staff, providing an essential layer of oversight in high-stakes cases.
2. Second Autopsies When a death is disputed, a second autopsy by an independent pathologist can be crucial for uncovering errors or offering a new interpretation of the evidence. The Autopsy Initiative, a group that provides free second autopsies for families of those who die in custody, found a different cause of death in every one of its 20 completed case reviews. The discrepancies can be shocking: in one case, an initial autopsy listed the cause of death as dehydration/bronchopneumonia, while the second pathologist ruled the death was caused by asphyxia by manual strangulation. In another instance, a second autopsy discovered a bullet that was missed during the initial examination.
3. Independent Audits System-wide audits can reveal patterns of error or bias. A major audit of in-custody death cases handled by Maryland’s former chief medical examiner, Dr. David Fowler, produced stunning results. For over half of the 87 audited cases, a panel of independent experts disagreed with the original manner of death. Reviewers noted that the original autopsy reports often failed to acknowledge restraint as a potential contributing factor or, when it was acknowledged, failed to certify the death as a homicide, violating the “but-for” standard. The audit also identified a pattern of using the controversial “excited delirium” diagnosis and potential racial bias.

The real-world impact of these mechanisms can be profound. The case of LaShawn Thompson, who died in the Fulton County Jail in Atlanta, is a powerful example. His death was initially ruled “undetermined.” However, a second autopsy commissioned by his family revealed evidence of severe neglect, including an extreme insect infestation and malnutrition. The second pathologist changed the manner of death to “homicide,” a determination that triggered a full civil rights investigation by the U.S. Department of Justice into the jail’s inhumane conditions.

Why Rigorous Death Investigation Matters

Determining the cause and manner of death is not a simple medical procedure but a meticulous, multi-faceted investigation that sits at the intersection of science, medicine, and law. It is a process that demands precision, objectivity, and a relentless commitment to uncovering the truth.

The final word written on a death certificate is far more than a bureaucratic formality. It is a powerful tool with profound societal consequences. When executed with rigor and independence, this final word can expose systemic neglect, as in the case of LaShawn Thompson; it can identify public health threats and prevent future deaths; and it can serve as the ultimate check on the justice system, holding power accountable. A well-resourced, transparent, and fiercely independent death investigation system is not just a scientific tool; it is a pillar of a just society.

Contact A Wrongful Death Lawyer Near You

Even if a loved one is incarcerated, they still retain fundamental rights, including the right to safety and humane treatment. If they pass away while in jail, it is crucial that their death is thoroughly investigated to ensure accountability. Authorities must examine the circumstances surrounding the incident, and if negligence or misconduct is found, those responsible should be held accountable to uphold justice. If you have lost a loved one who was in prison at the time of their death and feel that their death was avoidable we urge you to reach out to the team here at the Lovely Law Firm. We will do all we can to get you the answers you’re looking for and fight for justice. Contact our office to book a free case consultation with one of our wrongful death attorneys in Myrtle Beach.