Jailhouse autopsy called out

Forensic pathologist says deputy coroner ignored the injury that killed Craig Burdine at the Sandusky County jail
Melissa Topey
Feb 8, 2014


Dr. Cynthia Beisser has ruled “excited delirium” as a cause of death as many as 10 times in her 22 years as a Lucas County deputy coroner, and every time she did, it involved a person who died in police custody.

Dr. Michael Baden, a forensic pathologist, says the last time Beisser used the ruling she was dead wrong: Craig Burdine was a victim of homicide inside the Sandusky County jail, not a sudden death brought on by drugs or alcohol as Beisser ruled.

The injuries Burdine suffered to his neck were as fatal as “a bullet wound to the head,” according to Baden.

Craig Burdine died Aug. 11, 2007. The last images of him alive were captured on surveillance video from a sheriff’s cruiser inside the sally port at the jail. A dash cam video, which is damaged and lacks audio in portions, shows a non-responsive Burdine being carried into the jail by Fremont police officers and jail guards.

The officers dragged him from the deputy’s cruiser by his arms and legs, with Burdine facing up and his back parallel to the ground as they quickly move past the frame.

Craig Burdine was dead just minutes later.

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Jail guards and police officers on duty wrote reports stating Burdine, who had already suffered severe injuries to his head, back, arms and legs from an earlier altercation at a party and later during his arrest by Fremont police, had become combative after he was moved to a shower room inside the jail, where there is no video surveillance.

At no point in the cruiser’s dash cam video, from inside the jail’s sally port, can Burdine be seen as combative with the officers.

Justice delayed

Ohio Attorney General Mike DeWine launched a criminal investigation in August after Jess Burdine, Craig’s father, pressed DeWine for help. DeWine’s office said there was never a criminal investigation prior to the AG’s involvement. Dan Tierney, an AG spokesman, said it was being treated “like a cold case.”

Click here to watch an interview with Jess Burdine

It hasn’t been determined whether a grand jury will be impaneled, or where that might happen. Tierney also said the AG’s office is conducting a “thorough” investigation.

Beisser gave a deposition in a wrongful death lawsuit brought by Burdine’s family. She testified she was not an expert on the topic of excited delirium, which is controversial and almost always associated with police custody or police contact deaths, according to a news article in the Miami Herald last year.

“The data supporting it is tenuous. I think excited delirium is often used as a catch-all to explain in-custody deaths,” Indiana University cardiologist Dr. Douglas Zipes told the newspaper.

Dr. Steven Karch, a cardiac pathologist in San Francisco, disagreed, according to the news article. Karch has extensively studied the syndrome and said most cases of excited delirium do not involve Taser stun guns, and usually involve police because of the violent outbursts by sufferers.

“It’s utterly real. It’s a not a made-up disease at all,” Karch said. “It is a first-class medical emergency.”

A Taser weapon was used on Burdine at least three times in the moments before he died.

Baden said Burdine likely was already in severe medical distress when he arrived at the jail, before being Tasered.

Burdine doesn’t make any sound while inside the cruiser for the five-minute transport, and there are no calls ahead to the jail suggesting he was being combative, or any kind of problem. He is also unresponsive as officers and jail guards attempt to coax him from the vehicle once at the jail, but that’s when the audio portion of video goes dead.

After several minutes, several officers can be seen briefly on the video carrying Burdine by his arms and legs.

Official version falls short

During Beisser’s six-hour deposition, taken Nov. 10, 2010, she stated nobody dies from excited delirium.

“They die of whatever is triggering the delirium. Well, I should clarify that. If drugs are involved then the drugs would be the cause of death. There are some cases as we talked about that are not drug induced. Some people have underlying natural disease. Some people just die a sudden cardiac death of all the stimulation,” Beisser said.

Beisser noted the massive injuries Burdine suffered in her autopsy report, including a gash in his head, burns on his back, bruises and lacerations all over and shattered cartilage in his neck. She discounted the injuries, however, and said they were not the cause of Burdine’s death, or even contributing factors.

Beisser testified she relied entirely on the official version provided by police officers and jail guards in reports and statements in ruling Burdine’s death caused by excited delirium. She also said she was not sure where in the jail Burdine died.

Baden, deposed for the lawsuit on May 11, 2011, said Beisser was clearly wrong in her ruling and wrong to overlook the injuries Burdine suffered. The injuries killed him, according to Baden, who said Burdine was a victim of a homicide.

Burdine became cyanotic — his skin color turned a bluish-purple — because he was unable to breathe, Baden testified, due to the broken cartilage in his neck blocking his airway.

“That correlated with the autopsy findings of neck injuries, of neck compression,” Baden said.

Among all the trauma Burdine suffered — being maced in the eyes during his arrest, being physically restrained, the open wounds and the Tasers — his neck injury proved fatal.

“He had suffered fatal neck compression, strangulation, before the EMTs got there,” Baden said.

The alcohol and drug levels found in Burdine’s system also were were too low to bring about the condition described as excited delirium, he said. It is being used too widely to explain sudden death, Baden said, and it almost always involves law enforcement.

Beisser in haze

In a 2004 death at the Lucas County jail, Beisser also found no wrongdoing but was later forced to correct her autopsy report.

Carlton Benton, a 25-year-old Toledo man, died at Mercy St. Vincent Medical Center in June after he was strangled by a deputy’s sleeper hold while at the Lucas County jail.

Beisser determined Benton died of a seizure disorder associated with the use of an antidepressant drug.

In a subsequent federal investigation, however, four witnesses came forward and testified they saw a jail guard put a choke hold on Benton and then saw Benton’s body go limp. Their statements weren’t included in the official reports provided by the sheriff’s office for Beisser back in 2004.

Beisser said her previous ruling was “nebulous” without that information.

That subsequent investigation determined the Lucas County sheriff and corrections officers gave false information about what happened to Benton.

In 2010 — six years after she ruled Benton died of natural causes — Beisser was forced to correct the death certificate to read “homicide.” 

Click here to read Beisser's deposition

Click here to read Baden's deposition



Corruption, corruption, corruption.


He said, she said. It is interesting that this guy is ALWAYS right. At least in his mind. She made her medical opinion.


She should have never done the autopsy since she works for the county where the death occurred.


She is LUCAS county...he was arrested in Fremont that is SANDUSKY COUNTY. Re-read the first couple of paragraphs.


You're right. I misread that!

Random Thoughts

In the interests of fairness and accuracy, Dr. Baden's opinion is not as clear cut as has been reported in this article and previous articles. The following is a direct quote from the U.S. District Court decision, which also contains a very detailed analysis of the evidence presented in the civil case (I strongly recommend that the Register post this decision which can be obtained from the District Court):
According to Senior U.S. District Judge James Carr, "Dr. Michael M. Baden, plaintiff’s expert, reviewed the medical evidence and first testified that Burdine died from compression around his neck; he later sought to revise that opinion to say that compression of either Burdine’s neck or back could have resulted in the fatal injury."

Random Thoughts

In addition to the District Court decision, I recommend that the Register post the U.S. 6th Circuit Court of Appeals decision which, in addition to providing another good summary of the evidence, specifically states, "Dr. Baden’s explanation for Burdine’s death fails to comport with the evidence in the record."

Seen it All

"Dr. Baden’s explanation for Burdine’s death fails to comport with the evidence in the record." Well OF COURSE IT DOES!! The "evidence in the record" was put there by the cops under question, and the so called Doctor who doesn't do her job thoroughly, but relies HEAVILY on the reports from said officers. Again, the ones being questioned in the death of this man.

Matt Westerhold

Thanks Random Thoughts and Seen it All. It does seem obvious Baden's information would "fail to comport," and the question of whether there ever was any criminal investigation or evidence generated from that prior to the AG's involvement remains unresolved.

The AG's office said there was no prior investigation; detective Sean O'Connell said there was a complete investigation by the Fremont Police Department; and the News Messenger reported the initial investigation was never completed. Since Fremont police officers were involved in the arrest and transport of Burdine into the jail, oftentimes an agency involved would ask for an investigation from an outside un-involved agency to avoid the appearance of a conflict in a criminal investigation.

It's a bit of a moving target to flesh out as coverage of DeWine's investigation contines. We have considered the same reasonings you both have expressed and will continue to review how we can broadly and fairly present this coverage and include the conflicting information and statements being made by public officials and in public documents.


Matt thanks for my laugh today! In your last paragraph you state "..how we can broadly and fairly..." Since when do you report fairly?

Matt Westerhold

Thanks Mikesee, you're a pretty consistent critic and it's good you got a chucke. Your question, however, is the same as if I were to ask you, "When did you stop beating your wife?"  It might be good if you could add a little more depth to your comments. 

Stop It



Really Matt? Beating my wife? This is what makes you a substandard editor. Since day one your articles regarding Limberos or any other article regarding SC law enforcement has been anything but fair reporting. Most news outlets offer objectionable reporting. The mantra for you seems to be your way and only your way.


Lets see if the moderators on here agree that your statement about me "beating my wife" is considered a personal attack or one that tries to pick a fight. Something that has NO foundation and is libel in itself as you imply that I beat my wife. Even I would not stoop to the level of accusing someone of beating their wife unless I had proof of it.

Matt Westerhold

Wow. You're really missing the point here, Mikesee. I did not ask you if you beat your wife, nor did I state that you beat your wife. I stated that your question, "Since when do you report fairly?" was the same as the cliche question "When did you stop beating your wife?" 


Moderators have removed this comment because it contained Off-topic comments.


You just want to argue mikey. Get a life!


If Dr. Beisser is simply going to go by what she is told by officials, then what is the point of an autopsy? There have been to many incidents in Sandusky county to just ignore them.


You scratch my hamhox and eyeole scratch your pork. Mutual protection. And that's the weigh it goze, lyke it or knot!

Julie R.

Wasn't Lucas County involved in choosing the Erie County prosecutor a few years ago as the "Prosecutor of the Year?"

If so, enough said.

Mr. D

Comes a bigger question; How many of Dr. Beisser's thousands of autopsies are tainted or botched?


I don't know that Dr. Beisser is necessarily corrupt, though a case for incompetent or lazy might be made!

It seems to me that autopsies are conducted to determine, or to confirm, a cause of death. To ensure the findings are entirely objective, the coroner's office shouldn't get the police reports or other investigatory notes until later in the process.

If the coroner's verdict meshes with a police report, then we'd know the truth had likely been found; if there are inconsistencies, then at least we'd know where to start looking for the problem(s)!


I agree with this...the coroner should be looking at the body that is in front of it and determining what the cause of death was from the MEDICAL evidence. You give her a report and now she is trying ton conform the medical evidence to align with the report. I would think this would be a basic thought line, but maybe not. I can't imagine in larger cities this is the way it goes, but never dealt with larger city medical examiners.


Your instincts are very good. It is inappropriate for a coroner, who is supposed to be a scientist, to accept police statements without question.

The problem in the Lucas County Coroner's office is one of lack of proper policies and procedure. It is very likely the elected Coroner James Patrick has not properly trained deputy coroners and does not have policies and procedures in place to prevent "police pre-determined autopsy results" from occurring.

There are several cases dating back to the mid 1990's where the Lucas County Coroner's office allowed outlaying county law enforcement officers with a stake in the outcome to direct the results. The elected county coroner system should be replaced with a state medical examiner system with regional crime labs.


Babo you are so correct on your statement.

Truth or Dare

Again, go to Ytube and punch in Frontline's documentary "Post Mortem". Don't want to watch the full 1 hr. doc., punch in the same and then Sneak Peek #1, then Sneak Peak # 2. It may just turn a light on regarding the problem of elected Coroners throughout our country.

Marcella Fierro, a forensic pathologist along with others and a medical study supports the need to set national standards, also suggesting the need to abolish elected Coroners. If you watch the documentary in it's entirety, you'll learn why things such as this happen on a daily basis all across America. People die questionable deaths everyday at the hands of those we should least expect, and then they're protected starting w/a Coroner's Report and then thru the Courts!

By the way, anyone ever charged, brought to trial for the "homicide" of Carlton Benton?

Simple Enough II

Neck & back injuries? Wonder if that could have been the result of him ramming head first into the brick wall of that home where he threw the guy in the fire when he showed up in the wee hours of the morning uninvited and not known by the people there. I think the stories focusing on only the coroner's report may be misleading people in coming to their conclusions.

my oh my

There's so.much more here the public doesn't know about and never ever will.....