An independent investigation commissioned by the City of Aurora found crucial missteps in the Aurora Police Department's encounter with Elijah McClain, including the initial pat-down and use of a carotid hold once police pushed him to the ground.
The 157-page report was released Monday morning. Aurora City Council will discuss the report during its meeting Monday evening.
McClain, whose deaths sparked protests last summer in the wake of George Floyd's death, died after police placed him in two carotid holds by police and EMS personnel injected him with ketamine to try to calm him. He was not suspected of committing any crimes when police approached him. He was 23.
The investigation sought to examine the actions of Aurora Police and Aurora Fire Rescue in August 2019 during and after they encountered McClain. It created a timeline of events and reviewed policies and procedures from the two responding agencies. The report provides the city with recommendations for overhauling certain policies. Investigators noted that the report does "not attempt to assign legal responsibility for Mr. McClain's death or determine his cause of death."
The report provides a nearly minute by minute look at the night McClain was approached by police.
It begins with police dispatchers getting a 911 call at 10:29 p.m. on August 24, 2019. The caller said they had seen a man in a black mask walking southbound on Billings Street. The caller said the man, McClain, "looked sketchy" and "he might be a good person or a bad person."
Nathan Woodyard was the first officer to respond to the call, at about 10:42 p.m. The report said Woodyard had his hands on McClain within ten seconds of him getting out of his patrol car. He and other officers who arrived on the scene decided McClain -- who had not committed a crime -- was acting suspicious by wearing a face mask and waving his arms while in an area with a "high crime rate."
The report noted that Woodyard's decision to turn the otherwise "casual encounter" with McClain into an investigatory stop was not supported by "reasonable suspicion that Mr. McClain was engaged in criminal activity." The officers and EMS involved in McClain's apprehension declined requests to be investigated for the report.
Woodyard was joined by Officers Jason Rosenblatt and Randy Roedema. Woodyard frisked McClain for weapons. According to the report, Woodyard explained he wanted to frisk McClain "based on him having a ski mask on, on Colfax in the middle of the night and it was causing people to call in."
But the report says Woodyard contradicts himself. He said he felt safe approaching McClain, adding that "he didn't have any weapons or anything I could see in his hand." Yet he said he didn't want to stop McClain by himself in that part of the city.
The panel couldn't find evidence that McClain was armed and dangerous enough to justify the pat-down he received by police.
The report also found that police weren't justified in their decision to physically restrain McClain by moving him by the arms to a grassy area and putting him in a second carotid hold.
Officers put McClain into the first carotid hold after Roedema said McClain was trying to grab his gun. Rosenblatt applied the first hold for about a second as McClain was taken to the ground. Woodyard applied the second hold, though it's unclear for how long. The report said the second hold caused McClain "to either partially or fully lose consciousness."
The second carotid hold was used after McClain was already on the ground, even though, the report notes, McClain's "ability to reach an officer's gun or other weapons was limited by the fact that Officer Woodyard was on the ground behind him, with his gun and pepper spray pinned beneath him."
The report raised issues with the department's handling of the case.
- The report's investigators said the major-crime/homicide unit's handling of McClain's death investigation raised serious concerns. The report found major-crime investigators failed to ask basic and critical questions about the use of force. Such questions would have helped prosecutors determine whether the use of force was legally justified.
- The incident was never referred to Internal Affairs investigators. Internal Affairs investigates whether an officer's conduct complies with policy.
- Aurora Fire personnel didn't examine or question McClain before giving him ketamine, a sedative, despite the fact that McClain was "moaning, gagging," and "exclaiming in pain" as officers restrained him. The report found that examining McClain, as well as measuring vital signs, would have helped in "clinical decision making" during these situations. It notes: "Aurora Fire appears to have decided to sedate Mr. McClain without conducting anything more than brief visual observation."
- The report notes Aurora Police and Aurora Fire did not have a clear "transition of care or command" plan in place. For example, EMS personnel were deferring decisions related to McClain's care to officers.
- Paramedic Jeremy Cooper recommended using ketamine on McClain because Cooper felt McClain's behavior was consistent with "excited delirium." Aurora Fire Lt. Peter Cichuniec advised using 500 milligrams, based on what the report said was an "inaccurate estimation that Mr. McClain weighed about 190 pounds." The report said Aurora Fire accepted McClain had excited delirium without "meaningful observation or diagnostic examination." However, the report notes "there was no evidence that had the weight estimation been accurate, that the outcome would have been any different." Investigators did not find "conclusive evidence that the ketamine administered to Mr. McClain was a direct cause of, or even contributed to, his death."
The report made several suggestions.
- Aurora police should review its training on stops, frisks and arrests. It suggests all such encounters should be thoroughly documented.
- Aurora police should review its use of force policy, provide enough guidance to police on how to avoid using force, and make it clear that de-escalation is required in every encounter when possible.
- The report suggests an overhaul of the "post-incident review process." It said the city should assess the training and supervision of major crimes detectives when it comes to potential criminal misconduct by police officers. It notes special training is needed for both detectives and supervisors to make sure any investigation is fair and complete.
- Have a simple model or template for agencies like Aurora Police and Aurora Fire to use when the departments transfer patients.
- A review of Aurora Fire's protocols, policies and trainings related to patient sedation.
The report released on Monday was approved in July 2020.
The investigation was led by Jonathan Smith, executive director of the Washington Lawyers' Committee for Civil Rights and Urban Affairs. Dr. Melissa Costello, an emergency-medicine doctor in southern Alabama, and Roberto Villaseñor, a former officer with the Tucson Police Department, helped in the investigation.
Aurora City Councilmember Allison Hiltz was a member of the public safety committee that recommended the independent investigation last year.
Hiltz called the investigation "damning," adding she was "horrified" by its findings.
"I hope that a majority of council sees this report and recognizes that we have a very serious problem," Hiltz said. "We can't just read this and do nothing."
McClain's mother, Sheneen McClain, issued a statement through her attorney praising the report. She noted it was released three days before what would have been McClain's 25th birthday.
"The independent investigation that was commissioned and paid for by Aurora makes clear what was already known: Elijah should never have been stopped by the police, never have been arrested, never have been subjected to extreme force by the police and should never have been forcibly injected with ketamine by Aurora Fire Rescue paramedics," the statement read. "Aurora is responsible for Elijah's tragic death by virtue of its employees' unlawful and unconscionable actions."
Aurora City Manager Jim Twombly said in a statement on Monday the city felt it was important to publicize the investigation as soon as the city received it. An Aurora police spokesperson said the agency wouldn't be providing additional statements to the press.
"We are currently reviewing their report and look forward to hearing additional context during their presentation before we comment further," Twombly said in a statement. "City management will work with the Mayor and City Council in coming days and weeks to assure the appropriate next steps are taken."
This investigation is one of several local, state and federal investigations examining McClain's death.
Aurora City Council is scheduled to a host a special meeting at 5 p.m. Monday to discuss the findings. Hiltz said it will involve a presentation on the report.
This story has been updated throughout.
Due to an editing error, this story initially misreported when the Aurora City Council meeting will be held.
