For Helen Jones, the circumstances surrounding the death of her 22-year-old son John Horton III in 2009 were unsettling. Horton died while being held at Los Angeles Men’s Central Jail for a nonviolent offense in what authorities, Jones said, initially told her was a suicide.
That didn’t make sense to her, nor did the official autopsy’s listing of Horton’s cause of death as “undetermined.” She dove into legal dictionaries, anatomy books and forensic pathology texts to better comprehend the reports. She said she discovered discrepancies in her son’s jail records and saw photos that showed evidence of physical trauma on his body. She contends that Horton was beaten to death.
Despite never receiving clear answers, Jones was empowered through her research to demand accountability — the county paid $2 million to settle her wrongful death lawsuit in 2016 — and to advocate for others with similar stories.
Terence Keel and UCLA’s BioCritical Studies Lab
Her work inspired UCLA professor of human biology and society Terence Keel to get involved with the grassroots nonprofit Dignity and Power Now, of which Jones was a part, and other organizations fighting for those impacted by incarceration and working towards greater transparency in the criminal justice system.
Keel brings his expertise in the history of science, data science, critical forensic analysis, public health research and legal studies to bear in seeking accountability for in-custody deaths.
“It was Helen who taught me how to read an autopsy with the wisdom and experience of impacted communities,” said Keel, who is also a professor of African American studies. “From this, we launched the Coroner Report Project that standardized local wisdom and experience into research questions and protocol that allowed my lab to critically evaluate any death record.”
Under the umbrella of the UCLA BioCritical Studies Lab, Keel and his team of student researchers have done deep examinations of autopsy reports and related records for people who have died in custody, uncovering incomplete information, inconsistencies and contradictions.
‘The Coroner’s Silence’: How death investigations have evolved
The lab’s research, which is reframing the narratives around in-custody deaths, serves as the basis for Keel’s new book, “The Coroner’s Silence.” Funded in part by a grant from the National Institutes of Health, the book traces the evolution of the death investigation system in the United States from its roots in 12th-century England and examines its current relationship with the criminal justice system. Notably, Keel, a historian of science and medicine, points to the system’s shift from a more open process involving community members to today’s behind-closed-doors work of coroners, who are usually elected, and medical examiners, who are generally appointed by politicians and not directly accountable to the public.
Through an in-depth analysis of death records of almost a thousand people who died while in police custody in states such as California, Maryland and Pennsylvania, Keel discovered that the rising numbers of in-custody deaths affect all parts of the population.
“While Black men and Latino men disproportionately lead in terms of the number that die, every single demographic is found in our nation's death ledger,” he said. “This means middle-aged, white men, conservatives, Republicans, single mothers, Latinos, transgender people, non-binary people. Every segment of our society is dying in police custody.”
Over the course of the lab’s work, which also involved compiling and verifying a list of over 32,000 law enforcement-related deaths in the United States between 2000 and 2020, Keel’s team thought about what information was not included in official records and raised questions about coroner reports and death records that showed unexplained injuries, conflicting locations and unverified claims of mental illness or other health conditions.
‘It’s made me a better person’: Collaborating with the community
Zaia Hammond, a fourth-year student and a senior lead for the lab, helps her fellow researchers ask key questions. She initially joined the lab during her sophomore year after being part of the Program for Excellence in Education and Research in the Sciences, an intensive program that prepares and supports undergraduates interested in scientific research.
Hammond, who is pre-med and interested in addressing inequities in health care, said that working with Keel in the lab has expanded her mind.
“I've learned so much about not only what humanity means, but how we as society and the government can portray what it means to be human. For a lot of people who are incarcerated, that is stripped from them,” she said. “It's made me a better person, understanding how our law enforcement system works and how everyday people can actually make a change about what's going on that they don't even realize.”
Janet Asante, communications manager at Dignity & Power Now, who was a college student not too long ago, said there is an equivalent exchange that comes with students working side by side with families demanding change and accountability.
"When you care a lot about the social issues and care a lot about science, the day-to-day number crunching and empirical studies can feel disconnected from the ultimate impact that you want to see in the world,” Asante said.
"The work we do together makes a huge difference and really changes the narrative in public comment and other actions we take as an organization,” Asante added. “Students involved in our work bring us resources, access to data and proof of what we see every day. And by working with us, students get to see the impact of their work in more ways than they would otherwise.”
The lab also worked alongside the community organization Helping Ourselves to Transform on legislation in Maryland that sought the release of names and details of anyone who died inside a jail or detention center. The bill (SB 0036) proposed the formation of a civilian-led commission to review autopsies of people who died while in police custody.
Even though concessions were made before the bill was signed into law in 2024, it serves as an example of increasing transparency and accountability around death investigations in the United States.
‘A safer system for us all’: Reimagining death investigations
Keel and his researchers believe the narrow science-based approach used by medical examiners and coroners in the criminal justice system can only go so far in presenting the full truth about in-custody deaths. Meanwhile, public health and the social sciences have gone much further in explaining how people’s bodies and lives are impacted by complex interactions with society — research that greatly expands the potential factors involved in someone’s death, he said.
Inevitably, that knowledge can help death investigators move beyond simply blaming potential health conditions or using “undetermined” as a cause of death, allowing them to better understand and explain the conditions, attitudes and practices that contribute to in-custody deaths. And although the field has not yet evolved to embrace this research, Keel said he is “a perpetual optimist.”
“I believe that our democracy is strongest when we pay attention to people who are at the margins, who are telling us where our democracy is failing us. And if we can reform this system of death investigation, it makes a safer system for all of us,” he said.
