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.
During the first year of the requirement, the Office of the Chief Medical Examiner completed autopsies about 44% of the time, according to data from OCME and information obtained through a records request from the Department of Criminal Justice Services. The following year, preliminary information shows the number rose to 57%.
D. Pulane Lucas said those figures are troubling.
“It's important that we not forget that a variety of things lead people to being incarcerated. Too often people think, ‘Whatever they did, they deserve to be there. And whatever happens to them while they're there, they deserve it,’” said Lucas, who recently launched Uncounted in partnership with Virginia Commonwealth University’s Wilder School to more fully record in-custody deaths across the country. “My belief is that those who are in custody still deserve to be protected. They are not there — incarcerated — to be abused, neglected, forgotten, ignored.”
Lucas’ efforts stem from personal experience.
Stanley Wilson Jr. — her son and a former Detroit Lions cornerback — died in custody during 2023. Wilson was initially arrested and held at the Twin Towers Correctional Facility in Los Angeles, before being transferred to a mental health facility several months later, Lucas said.
The Los Angeles County medical examiner’s office notified her of Wilson’s demise, though it hadn’t been recorded as an in-custody death, because of an apparent disagreement between sheriff’s deputies and hospital staff. The county medical examiner later determined Wilson died from a blood clot after falling out of a chair during the transfer.
Lucas said a post-mortem exam showed that he had chronic traumatic encephalopathy — or CTE — a disease connected to repeated head injuries.
During the past decade, the commonwealth recorded 1,009 in-custody deaths at Virginia Department of Corrections facilities. A total of 556 autopsies were completed in that time, according to state agencies. The highest rate the procedures were conducted during that period was in 2022, when about 83% of in-custody deaths were followed by an autopsy.
In some cases, less extensive external exams have been completed, though state code doesn’t mention the exams while setting out OCME requirements in the 2024 law.
“Although dedicated funding was not included in the enacted budget, the OCME carefully evaluates the circumstances of each death and fully investigates each case,” a VDH spokesperson wrote in an email last year. “Based on the circumstances of death while in custody, the OCME will determine if an autopsy or external examination is needed.”
The year the law took effect, when there were 97 in-custody VADOC deaths reported, the medical examiner’s office completed 43 autopsies and 49 external exams, according to VDH data.
Andrea Armstrong is a Loyola University New Orleans professor whose work focuses on deaths in U.S. prisons and jails. In 2023, she received a MacArthur grant to support her work.
She said autopsies can be helpful to families, researchers and state agencies when there are “unclear circumstances” around a person’s death.
“Families might hear various versions of what happened during the last minutes of their loved one’s life. When a medical examiner provides the cause and manner of death, that can provide some certainty,” Armstrong said. “I think the intent behind requiring these is to also provide a sense of objectivity. Some families don't necessarily trust the preliminary conclusions of the prison or jail administration, in part, because they're not trained medical professionals.”
Armstrong added that medical examiners identify the cause and manner of death, not policies that might have affected the situation — or precluded someone’s demise.
But even DCJS is unsure of whether the in-custody deaths information it’s collected is complete. Documents released through a records request included a disclaimer: “The data in this table are separated according to the sources used for the figures. Years with different sources cannot be directly compared. (Calendar years) 2024 and 2025 are the only years in which DCJS exhaustively tracked down and verified each case and are believed to be more ‘complete’ for this reason.”
From 2016 through 2019, the department used data from the federal Bureau of Justice Statistics, Mapping Police Violence and The Washington Post’s “Police Shooting Database” to arrive at the numbers it reported. For data between 2020 and 2023, it used state medical examiner data in lieu of BJS information. And since then, the department began collecting the information itself.
VDH didn’t make Dr. William T. Gormley, the state’s chief medical examiner, available for an interview. Arkuie Williams, a state administrator in the office who reports to Gormley, didn’t respond to a request for comment.
In an emailed response to questions, a department spokesperson wrote: “This code section outlines what cases fall under the OCME's jurisdiction. Section 32.1-285 pertains to OCME performing autopsies on those individuals that are in custody of the Department of Corrections. This language was added during the 2023 General Assembly session and did not go into effect until January 1, 2024; therefore, this could explain your analysis for the past decade.”
In a later emailed statement, a spokesperson wrote that “OCME is striving to come into full compliance with this statutory requirement.” The email added that a fiscal impact statement estimated a need for up to $287,000 in additional funding to meet the requirements.
During calendar years 2024 and 2025, the email continued, 63% of in-custody deaths were followed by an autopsy — though the procedure wasn’t performed on people who died of a “natural disease” at a hospital or health care facility outside VADOC.
State code doesn’t make that distinction.
Armstrong said the language in Virginia’s law mandating autopsies “seems pretty clear” while noting an increase in the number of autopsies from 2024 to 2025.
“In terms of public health, people are dying and we don't look at each additional death as an increase in workload and an unfunded mandate,” she said. “Instead, the point of collecting this information is to identify which deaths would have been preventable. And to do that, you have to look not just at the cause and manner of death, but also the policies and practices that were in place at the facility where the person died.”
In 2024, Del. Cia Price, a Newport News Democrat, sponsored state legislation that required law enforcement agencies, local jails and the state prison system to report any in-custody death — despite a 2014 federal law that mandated the reporting already being on the books. Twice between 2020 and 2023, Virginia didn’t offer those numbers to the federal government; only the commonwealth, Puerto Rico and American Samoa neglected to report data during those years.
Part of Price’s legislation entailed creating a panel of former and current law enforcement, and prison personnel to examine the annual data and make recommendations to mitigate future in-custody deaths. The first assessment, released in July 2025, included suggestions for local jails, but the panel wrote that data on state custody wasn’t sufficient to make recommendations.
The report indicated 15% of 2024 deaths weren’t documented properly, in part, because of agencies struggling with what constituted an in-custody death. Since the report was released, 11 in-custody deaths were added to the tally, increasing the total from 194 to 205 for that year.
Price’s bill included a definition of an in-custody death being a person’s demise while they’re “detained, under arrest or in the process of being arrested, en route to be incarcerated, incarcerated, or otherwise in the custody of such law-enforcement agency or correctional facility.”
Price returned for the 2025 legislative session with a proposal to codify penalties for agencies that don’t fulfill in-custody deaths reporting requirements — despite federal law also spelling those out. Her bill was passed by the House, but didn’t make it out of a Senate finance committee.
Kelly Orians, a George Washington University law professor and director of the Prisoner & Reentry Clinic, suggested a variety of approaches to remedy the disconnect between in-custody deaths and the frequency of autopsies being performed: The governor’s office could step in; state lawmakers could add enforcement mechanisms to state code; or the Joint Legislative Audit and Review Commission could decide to conduct research on the issue and make recommendations to state agencies.
Until one of those avenues is pursued and fully realized, Lucas’ Uncounted project is working to fill in some of the gaps.
“Identifying the unjust is an act of justice. What we are doing with Uncounted, it is an act of justice,” said Lucas, whose organization hosts an online form to submit information on in-custody deaths. “Whether it is someone who is being erased from the database completely or whether someone's not having an autopsy done or whether aspects of the cause of death (are) being hidden, it is dehumanizing.”
On June 8, Gormley, the medical examiner, will attend a ribbon cutting ceremony in Hanover County marking the completion of the state’s new $189 million central laboratory — where his office will be located.
Read more at Red Onion Resources.
Disclosure: Independent reporter Dave Cantor is suing the Virginia Department of Corrections to gain access to documentation of the agency’s use of tasers at Red Onion State Prison.