When they carried the body of a 32-year-old Black man named Lamont Perry out of the woods in Wadesboro, North Carolina, there were no protests over his sudden death in police custody.
No reporters camped at the scene. No lawyers filed suit.
Instead, the final mark in the ledger of Perry’s life was made by a state medical examiner who attributed his death in large part to sickle cell trait, a genetic characteristic that overwhelmingly occurs in Black people. The official word was that he had died by accident.
But the examiner’s determination belied certain facts about that night in October 2016, public records and interviews show. Accused of violating probation in a misdemeanor assault case, Perry was chased by parole and police officers through the dark into a stand of trees, where only they could witness what happened next.
He had swelling of the brain, and a forensic investigator reported that he had an open fracture of his right leg. He was covered in dirt, and residents of a nearby housing complex told his family that when the officers emerged from the woods, their shoes and the bottoms of their pants were spattered in blood.
Perry’s case underscores how willing some American pathologists have been to rule in-custody deaths of Black people accidents or natural occurrences caused by sickle cell trait, which is carried by 1 in 13 Black Americans and is almost always benign. Those with the trait have only one of the two genes required for full-blown sickle cell disease, a painful and sometimes life-threatening condition that can deform red blood cells into crescent shapes that stick together and block blood flow.
As recently as August, lawyers for Derek Chauvin, the Minneapolis police officer convicted last month of murdering George Floyd, invoked sickle cell trait in an unsuccessful motion to dismiss the case against him, saying that the condition, along with other health problems and drug use, was the reason Floyd had died.
The New York Times has found at least 46 other instances over the past 25 years in which medical examiners, law enforcement officials or defenders of accused officers pointed to the trait as a cause or major factor in deaths of Black people in custody. Fifteen such deaths have occurred since 2015.
In roughly two-thirds of the cases, the person who died had been forcefully restrained by authorities, pepper-sprayed or shocked with stun guns. The determinations on sickle cell trait often created enough doubt for officers to avert criminal or civil penalties, the Times found.
In three cases, deaths linked to sickle cell trait that were deemed natural or of indeterminate cause were later ruled homicides — as occurred when Martin Lee Anderson, 14, died at the hands of his jailers at a northwest Florida juvenile detention camp in January 2006.
“You can’t put the blame on sickle cell trait when there is a knee on the neck or when there is a chokehold or the person is hogtied,” said Dr. Roger Mitchell Jr., the former chief medical examiner for the District of Columbia and now chair of pathology at the Howard University College of Medicine. “You can’t say, ‘Well, he’s fragile.’ No, that becomes a homicide.”
Not every death that is tied to the condition is inherently questionable. Medical experts say sickle cell trait has caused deaths in rare cases of extreme overexertion, especially among military trainees and college athletes. Three of the in-custody deaths identified by the Times involved people who were exercising vigorously in jail yards or running hard before they collapsed — and law enforcement officers said that at most they put handcuffs on them.
In none of the deaths examined by the Times did the person have actual sickle cell disease.
In interviews, Mitchell and other medical experts agreed that the trait warranted mention in autopsies but said any natural or accidental death attributed to it, even in part, should be scrutinized if the person died during or after a struggle with law enforcement.
Many said they suspected some sickle cell determinations might reflect a pattern of bias or conflicts of interest among medical examiners and police officials.
Forensic pathologists, the doctors who conduct autopsies for coroners and medical examiners, were singled out in a hotly disputed study published in a scientific journal in February suggesting that racial bias could influence their rulings, though it did not address sickle cell trait.
And coroners and medical examiners have entrenched relationships with law enforcement in many areas, functioning as part of police departments or working closely with them.
In Perry’s case, agents with the North Carolina State Bureau of Investigation sealed his body in a bag before a forensic investigator inspected it. Officers at the scene could not say for sure how he had suffered his injuries but said it appeared he had tripped and fallen into a ravine. The officers said he had been talkative when they found and handcuffed him, but then he lost consciousness. No efforts were made to revive him with lifesaving equipment when paramedics arrived, records and interviews show, and the “open fracture” documented by the forensic investigator was described in the autopsy as a “laceration.”
Perry had alcohol and a small amount of cocaine in his bloodstream when he died, and the medical examiner ruled that he had succumbed to “cocaine toxicity in the setting of sickle cell trait,” effectively ending any deeper inquiry. The local district attorney declined to bring charges.
For Perry’s relatives, who could not afford a lawyer to challenge the ruling, all that was left was a series of unanswered questions. What had happened in the woods? Why would the investigators not let them view the body before the autopsy?
“The only people who know what happened are that probation officer and the officers who ran out there,” said Perry’s half-brother, Mario Robinson. “I don’t believe what they said.”
A nationwide pattern
To gain a sense of how often medical examiners have used sickle cell trait to explain in-custody deaths, the Times reviewed thousands of pages of autopsy records, court filings and police reports. It examined data on suspicious deaths from more than 30 of the U.S.’ largest counties, whose jurisdictions cover nearly 1 in 3 Black Americans.
The review identified dozens of cases dating to the 1970s and was almost certainly an undercount.
Many of the deaths received little outside scrutiny at the time, in part because the families did not have the resources to challenge official determinations or because the detained people were not seen as particularly sympathetic. Many had histories of arrests on drug use, domestic violence or other charges, and additional evidence that might point to police misconduct, such as video footage, was often not made public.
The results of the review offer a vivid glimpse into deaths in custody. In the past 25 years, 19 cases involved Black people who died after being restrained in ways that could hinder breathing. Twelve deaths occurred after the police or sheriffs’ deputies used stun guns. Nine happened after they used pepper spray. Two followed bites from police dogs.
Five of the cases were initially ruled homicides.
The rest were labeled undetermined, accidental or natural.
In communities from California to Pennsylvania, officials cited the rulings in closing investigations into the deaths, ensuring that police agencies provided the last word on what had occurred.
David Campbell, 25, stopped breathing in Allentown, Pennsylvania, in October 2011 after resisting his jailers’ efforts to remove his clothing and put him on suicide watch. They responded by dousing him with pepper spray, jamming knees into his back and leaving him tied to a chair, according to a lawsuit brought by his family.
While the results of Campbell’s autopsy were pending, emails show, the head of the Lehigh County Corrections Department sent the coroner a video of the arrest of a Florida man whose death was attributed to “excited delirium” — a condition that pathologists say can suddenly kill drug users or the mentally ill, though they acknowledge it is poorly understood and unevenly applied.
“I found this video which appeared similar to our incident with David Campbell,” wrote the corrections chief, Edward Sweeney, “and I thought I’d share it with you as we await the toxicology report.”
The coroner’s ruling in the case stated “excited delirium complicating sickle cell trait, dehydration and abnormalities of the cardiac conduction system during restraint.” Manner of death: “undetermined.”
The Times described its findings to Simon Dyson, a British researcher who studies sickle cell conditions and deaths in custody. He said the cases follow a well-established pattern in which the trait is listed alongside other conditions, like high blood pressure or drug use, to create doubt about the role of law enforcement.
“It’s all throwing a smoke screen up around the death that makes it more difficult to effect a prosecution,” he said.
Determining whether a death is a homicide is ultimately a judgment call, though most pathologists interviewed by the Times said they applied the label if the intentional actions of one person led to the death of another — even if those actions were taken by the police and the person who died had health problems.
But not all medical examiners agree on how much another person’s actions must contribute to the death to call it homicide. Dr. Lisa Scheinin, a former deputy medical examiner in Los Angeles who wrote a journal article in 2009 about sickle cell trait, said she had been “very hesitant” to rule in-custody deaths homicides unless the police had played an important role.
“If you call something homicide, there’s going to be all kinds of people waiting to sue you, to sue law enforcement,” Scheinin said in an interview. “We generally have to make decisions without thinking about other consequences, but sometimes you just can’t help think about that.”
A medical debate
Most people with sickle cell trait never suffer a symptom, though studies and experts have suggested that on rare occasions it can cause the fatal curving of blood cells in people who overexert themselves when other conditions are present — for example, hot weather, high altitude or drug use.
Dr. Bruce Mitchell, the former director of hospital medicine at Emory University Hospital Midtown in Atlanta, who has studied sudden death and sickle cell trait, said the condition had been cited in the deaths of some military recruits because they are often made to run long distances in the heat and with heavy equipment without enough training or conditioning.
Several doctors and researchers who spoke with the Times said they would be skeptical of in-custody deaths attributed to sickle cell trait, unless the situation also involved other risk factors.
“The analogy I would make would be to someone who has heart disease,” Mitchell said. “It might be true that they died because of heart disease, but, well, they probably would have lived if you hadn’t put them in a chokehold and stressed their heart.”
In at least three cases reviewed by the Times, the person was exerting himself and did not appear to interact significantly with law enforcement. In another, the environment was harsh: Darryl Daniels, 30, stopped breathing in Reno, Nevada, in 1998 after taking cocaine and running for several blocks in 97-degree weather. The pathologist acknowledged that sickle cell trait was “usually benign and asymptomatic except under circumstances of extreme stress” but wrote that the heat, activity and stimulant drugs provided that stress even before the man was arrested.
More often, the Times found, the police reported that the arrested people struggled, prompting the medical examiner to rule that their physical activity precipitated a so-called sickling crisis, when the blood cells bend into crescents and block blood vessels. In many instances, law enforcement also used control techniques that doctors said could limit oxygen enough to cause sickling and death. These included repeatedly using stun guns and pepper spray and holding people facedown with their arms behind them.
Sickle cell trait alone cannot cause death, said Dr. Swee Lay Thein, a hematologist at the National Institutes of Health who has studied the condition. “It has to be something else, and something quite extreme,” she said.
Medical experts also said it could be misleading to attribute death to the trait based on the presence of cells that have clumped or sickled — something that often happens when people with the condition stop breathing. Finding the crescent-shaped blood cells during an autopsy is to be expected, the experts said, and does not mean the cells were like that before death.
In the case of Floyd, the medical examiner in Minneapolis noted the curved cells and said he had had sickle cell trait. But the autopsy indicated that it had not contributed to his death, and there was no evidence the cells had sickled before he died. In their unsuccessful motion to dismiss the case, Chauvin’s lawyers nonetheless suggested that the trait could cause trouble breathing.
The argument echoed claims made in other cases as early as 1973, the Times found. That year, 28-year-old George Lucas died in the Cook County jail in Illinois, according to media reports at the time. Inmates testified that guards had beaten, strangled and suffocated him with a blanket, while jail officials said they had only strapped him to his bed.
But after sickled cells were found during the autopsy, the coroner said Lucas would not have died were it not for the trait, Dr. James Bowman, a pathologist who participated in the hearing, wrote in an academic article years later. The death was deemed natural, and the guards were not charged. “Thus,” Bowman wrote, “the dangerous precedent for legalized murder of persons with sickle cell trait could become established.”