Accounting for Medical Examiners in Historical Autopsies of the Carceral State

By Will Tchakirides

Following three nights of unrest in the Twin Cities last May, Hennepin County Attorney Mike Freeman charged Minneapolis patrolman Derek Chauvin with third-degree murder and second-degree manslaughter of George Floyd. Minnesota Attorney General Keith Ellison upgraded the charges to second-degree murder and charged the other three officers who watched Floyd’s killing with aiding and abetting second-degree murder. Yet he did so only after Hennepin County’s medical examiner officially determined Floyd’s death to be a homicide. In a preliminary ruling, Dr. Andrew Baker found “no physical findings that support a diagnosis of traumatic asphyxia or strangulation.”

In originally suggesting that “the combined effects” of Floyd “being restrained by the police, his underlying health conditions, and any potential intoxicants in his system likely contributed to his death,” Dr. Baker corroborated the Minneapolis Police Department’s statement that Floyd died from a “medical incident” — not police use of force. Independent medical examiners hired by Floyd’s family contested this claim, finding “asphyxiation from sustained pressure” as the primary cause of death. As criminal proceedings in the Chauvin case play out today, Hennepin County’s initial autopsy judgment continues to raise questions about whether justice will be done.

Such disputes reveal how much medical examiner assessments matter in cases of deadly police violence. Their reports shape public understandings of events and inform decisions made by prosecutors, judges, and juries, especially when determining the validity of criminal charges and whether cases warrant trial. However, their accounts are also heavily shaped by the perspectives of police and other criminal justice workers who benefit from fixed assumptions of legitimacy. This can lead to decisions that safeguard a biased system that diminishes law enforcement culpability. Therefore, it is important that scholars of the carceral state pay attention to authorized medical examinations in police brutality cases. While they may seem detached from the on-the-ground work of policing, state-sanctioned medical examiners are, in fact, part and parcel of the carceral apparatus. And, their decisions have helped to uphold its unchecked monopoly on racialized state violence.

Nowhere was this clearer than in the little remembered case of Ernest Lacy, who Milwaukee police killed nearly forty years ago in an incident eerily similar to Floyd’s murder. Lacy’s killing highlights the under-appreciated role that state pathologists can play in maintaining the criminal-legal system’s predisposition towards police, while supporting wider racist perceptions of Black criminality.

Milwaukee police killed Lacy on the night of July 9, 1981. He had taken a break from helping his cousin paint an apartment. While en route to a convenience store, three members of the Milwaukee Police Department’s (MPD) all-white Tactical Enforcement Unit stopped, questioned, and arrested Lacy on suspicion of a rape he did not commit. Each of the officers carried pending police brutality complaints.[i]

People Hold Vigil. Rick Wood, July 9, 1983, Milwaukee Historic Photos, Milwaukee Public Library.

The MPD had a long history of over policing and under protecting Black citizens. At least a dozen African Americans lost their lives in police confrontations between 1958 and 1981. MPD brass had even covered up the first murder in that span, Daniel Bell, shielding it from the public until a complicit officer revealed the truth in 1978. And so, Lacy was probably justifiably terrified when the officers approached, having articulated unease to his parents about interacting with Milwaukee police.[ii]

A brief altercation ensued during the arrest, where the unarmed Lacy tried to flee the officers’ grasp. The police wrestled him to the ground, restraining him face down on the Wisconsin Avenue pavement.

An eyewitness testified to the “police murder” of Lacy, noting how Officer Thomas Eliopul pinned him down with his leg. Eliopul pressed his knee into Lacy’s upper back, then lifted his arms perpendicularly behind his torso for handcuffing, further inhibiting the flow of oxygen to his brain. Two other officers held down Lacy’s legs. His body convulsed, then went limp. The officers placed Lacy, motionless, on the floor of a police van, apparently to be driven to the home of the woman who registered the sexual assault complaint for verification. Police said they realized Lacy was not breathing when they arrived. They had ignored warnings from a second Black arrestee picked up along the way. The officers then drove Lacy to a hospital, where he was pronounced dead on arrival.

After conducting an autopsy, Milwaukee County Medical Examiner Chesley Erwin reported “shallow cuts,” but no “deep injuries.” A deputy medical examiner, Warren Hill, told the press they believed “fright” may have killed Lacy, pointing to his known dread of law enforcement and “being confined in enclosed places.”[iii] Associate Medical Examiner Elaine Samuels reinforced Hill’s narrative, citing six incidents in five years where she suspected people died from “excessive fright.”[iv]

Such debate over the cause of death allowed speculation about Lacy’s mental health and drug use to come to the forefront of the public conversation of the incident. The result? Blame shifted from the police to the man they killed, allowing Police Chief Harold Breier to readily justify exonerating his officers. Having completed the MPD’s internal inquiry within a week, Breier reasoned medical examiner analysis “showed no particular injury that would have caused death.”[v] Police were “guilty of no wrongdoing.” As was his custom, the chief refused to cooperate in any further investigations.

Regardless, District Attorney E. Michael McCann authorized an independent examination to make the family “feel comfortable” as the county finished its analysis. The outside medical expert chosen by the Lacy’s attorney reached a very different conclusion, finding that force applied by police to Lacy’s lower neck caused “compression suffocation,” cutting off air supply and inducing seizures.[vi] Doubts about the independent examiner’s credentials, however, led to a third autopsy, whereby another outside medical expert, county officials, and a police union-hired pathologist denied the “compression suffocation” claim.[vii]

Nonetheless, Black activists understood the role racism played in medical examinations of African American police brutality victims. In fact, community leaders had protested a 1972 ruling by Warren Hill that the death of Jacqueline Ford, a 19-year-old Black woman “accidentally” shot by police in her own home, was an “excusable homicide.” When police “accidentally” shot and killed 16-year-old Jerry Brookshire in 1974, irate civil rights and Black Power groups asked the U.S. Attorney’s office to bar county medical examiners from conducting an inquest pending federal investigation.

Justice for Ernie Lacy Parade. Sherman Gessert, July 9, 1981, Milwaukee Historic Photos, Milwaukee Public Library.

Following Lacy’s death, a multi-organizational coalition formed to demand suspensions, criminal prosecutions, and, later, firings of the officers.[viii] About four thousand people marched in the then largest protest demonstration against police brutality in Milwaukee’s history, with the coalition staging more actions –– marches, rallies, boycotts, and sit-ins –– through 1982.

To settle confusion over Lacy’s cause of death and determine the necessity of prosecution, District Attorney McCann called for an inquest hearing. Again, Hill was scheduled to preside, until he stated there was not enough evidence to justify criminal indictments. Activists demanded his removal and called for a racially integrated panel.

McCann appointed a retired county judge as special examiner for the inquest hearing, which recommended homicide and misconduct charges. However, McCann had the charges dropped because his special examiner had chosen a jury “partially by race,” ostensibly violating the officers’ “constitutional rights.” The Lacy family was devastated, especially Ernest’s mother, Myrtle (below); she had taken on a visible leadership role in the Coalition for Justice for Ernest Lacy, alongside prominent activists Michael McGee and Howard Fuller. McCann issued new charges, but the Circuit Court dismissed them citing “a lack of probable cause.”[ix]

Ernie Lacy Protestors. Benny Sieu, c. 1982-1983, Milwaukee Historic Photos, Milwaukee Public Library.

But there was still some modicum of justice. The Milwaukee Fire and Police Commission fired Officer Eliopul in 1983 –– a first for a Black police brutality complaint –– and the state legislature passed a new law mandating police seek medical attention for arrestees in need.

In the end, the county medical examiner ruled “respiratory insufficiency, exact mechanism not determined, with aspiration of vomitus” as the cause of death. There were “factors” they “had not been able clearly to define,” namely police use of force.

Medical examiner rulings that minimize police responsibility in deaths caused by restraint are not limited to Milwaukee, as epidemiologists have found. Indeed, state medical examiner offices have long played a role in county officials excusing police accused of wrongfully killing citizens.

This pattern lasted in Milwaukee until video recordings prompted change. The 2011 case of Derek Williams — another young Black man who died out of breathe in police custody — signaled a turn. County medical examiners revised their initial ruling from natural death to homicide after a previously unreleased “dash-cam” video showed the officers ignoring his pleas of “I can’t breathe.” Even so, no police faced criminal charges or discipline.

In at least one high profile case, medical examiner findings contributed to the removal of an officer accused of using lethal force. A New York City examiner found that Staten Island officer Daniel Pantaleo’s application of an illegal chokehold “set into motion” the “lethal sequence” that killed Eric Garner in 2014. While it did not persuade a grand jury to criminally indict, her expert testimony contributed to Pantaleo’s eventual firing and pension loss.

Black mistrust of county medical examiners is well founded, given the historical proliferation of state reports and rulings that have removed police actions as primary causes of deaths. While it’s unclear if the context of a violent weekend encouraged the Hennepin County Medical Examiner to adjust their own findings, one thing is certain: The Floyd family and the movement at their backs must not let up on demanding the truth and reaping justice.


Will Tchakirides completed his PhD in U.S. History at the University of Wisconsin-Milwaukee in 2020. His dissertation, “‘Accountable to No One’: Confronting Police Power in Black Milwaukee,” explores local underpinnings of police legitimacy and the limits of reform advocacy in one of America’s most racially punitive cities. He will soon begin work as a Research Assistant on the Smithsonian’s “Our Shared Future: Reckoning with Our Racial Past.”

Featured image (at top): Milwaukee Demands Justice for Those Murdered by Police. Joe Brusky, May 30, 2020, Flickr.

[i] Patricia Worth, The Milwaukee Sentinel, “Brutality Complaint Dismissed,” October 26, 1981. The Tactical Enforcement Unit was Milwaukee’s version of the Special Weapons and Tactics (SWAT) division established by the Los Angeles Police Department after the 1965 Watts rebellion. See Max Felker-Kantor, Policing Los Angeles: Race, Resistance, and the Rise of the LAPD (Chapel Hill: University of North Carolina Press, 2018), 52-53.

[ii] Joe Manning and John Fauber, “Family Says Lacy Thought He Was Inferior to Others,” Milwaukee Sentinel, July 11, 1981.

[iii] Bruce Gill and Karen Rothe, “Fright May Have Caused Man’s Death after His Arrest,” Milwaukee Sentinel, July 11, 1981.

[iv] Manning and Fauber, “Family Says Lacy Thought He was Inferior to Others.”

[v] Gill and Rothe, “Fright May Have Caused Death.”

[vi] Kevin Merida, “2nd Autopsy Clouds Case,” Milwaukee Journal, July 12, 1981.

[vii] Marilyn Kucer, “New Autopsy Fails to Reveal Cause of Lacy’s Death,” Milwaukee Sentinel, July 13, 1981.

[viii] On the Coalition for Justice for Ernest Lacy, see Laura R. Woliver, From Outrage to Action: The Politics of Grass-roots Dissent (Urbana: University of Illinois Press, 1993).

[ix] Margaret Hoyos, “DA Ponders Lacy Options,” Milwaukee Journal, January 30, 1982.

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