Elijan McClain surveillance

Elijah McClain in a ski mask pays for cans of tea before he left the convenience store and encountered Aurora police nearby on Aug. 24, 2019.

A report on an independent investigation of Elijah McClain’s death released Monday found the Aurora Police Department officers who stopped McClain did not have reasonable suspicion of criminal activity to do so and characterized McClain’s behavior in ways that conflicted with video and audio evidence of the encounter.

Paramedics from Aurora Fire Rescue also did not examine or question McClain before they injected him with ketamine. And there was not a clear transition of care or command authority from police to fire, the report found.

McClain, a 23-year-old Black man, died after being placed in a carotid hold by police and sedated with ketamine by paramedics on Aug. 24, 2019.

McClain was initially stopped by officer Nathan Woodyard, and immediately after joined by officers Jason Rosenblatt and Randy Roedema.

After McClain refused officers’ orders to stop — which the report said should have been a consensual encounter — they put McClain in a now-banned carotid hold and knelt on his body until he vomited and went unconscious.

When Aurora Fire Rescue personnel arrived, paramedics diagnosed McClain with excited delirium and gave him 500 milligrams of ketamine, a sedative, reports have found.

When he was put in the ambulance, he was not breathing and did not have a pulse. He did not regain consciousness.

McClain was pronounced brain dead on Aug. 27 and taken off life support on Aug. 30.

The Aurora City Council ordered an external investigation of McClain’s death in July.

The 17th Judicial District Attorney’s Office chose not to prosecute the officers. However, Aurora Police Chief Vanessa Wilson fired several officers, including Rosenblatt, who mocked McClain’s death in a selfie.

The independent investigation panel relied on body camera footage, video statements by the officers, their follow-up reports and handwritten notes from responders on the scene, audio of the 911 call, computer-aided dispatch records, police and fire department policies and training materials, patient care reports and the autopsy report for McClain.

The officers and Aurora Fire responders declined the panel’s interview requests, the report says.

An officer must have reasonable suspicion of criminal activity to justify an investigatory stop, and the stop has to use the least intrusive means reasonably available to verify or alleviate the officer’s suspicion.

The report found none of the reasons given by the officers or reported by the caller — McClain acting “suspicious,” wearing a mask and waving his arms, and being in an area with a high crime rate — met those standards.

“Upon review of the evidence available to the Panel, Officer Woodyard’s decision to turn what may have been a consensual encounter with Mr. McClain into an investigatory stop — in fewer than ten seconds — did not appear to be supported by any officer’s reasonable suspicion that Mr. McClain was engaged in criminal activity,” states the report. “This decision had ramifications for the rest of the encounter.”

The panel found the officers did not have sufficient evidence that McClain was armed and dangerous to justify frisking him.

Woodyard made conflicting statements about whether he believed McClain was armed, the investigation found, with the report including statements that he “felt safe making an approach, he didn’t have any weapons or anything I could see in his hand” and that he “didn’t want to stop this guy by myself, because pretty suspicious area tied with his actions and I didn’t want to contact somebody who I thought had weapons by myself.”

The Aurora Police Department’s Major Crime/Homicide Unit did not ask Woodyard to explain how the factors led to his conclusion that McClain might be armed or the contradiction in his statements.

The report reiterates that the 911 dispatcher communicated to the officers that the original caller reported they were not aware of McClain having any weapons.

After the officers subdued McClain, they described his behavior as “violent” and “fighting” and repeatedly referenced his “incredible strength.”

However, according to the report, audio of the incident — by this time the officers’ body cameras had stopped recording or fallen off their uniforms — records cries of pain, apologizing, vomiting, and sometimes incoherent sounds by McClain.

“His words were apologetic and confused, not angry or threatening. He became increasingly plaintive and desperate as he struggled to breathe,” says the report.

The investigation of McClain’s death by Major Crime “revealed significant weaknesses” in the police department's accountability systems, says the report, finding unit investigators did not ask basic questions about the justification for use of force against McClain “necessary” for any prosecutor to make a decision about whether the use of force was legal.

Questions often seemed designed to elicit answers containing specific, exonerating language found in court rulings, says the report. The incident was not referred to the department's Internal Affairs investigators.

“Major Crime’s report was presented to the District Attorney for Colorado’s 17th Judicial District and relied on by the Force Review Board, but it failed to present a neutral, objective version of the facts and seemingly ignored contrary evidence,” states the report.

The report found current police policies that require the chief of police to approve opening an inquiry and prevent Internal Affairs from initiating its own investigations put the chief in a difficult, potentially compromising position, and limits the independence of Internal Affairs.

The 500-milligram dose of ketamine given to McClain was based on the determination by paramedic Jeremy Cooper that McClain’s behavior had signs of “excited delirium,” a syndrome characterized by increasing excitement and wild, agitated, and violent behavior.

Paramedics accepted the officers’ belief that McClain had excited delirium without doing their own meaningful observations or examination of McClain, says the report.

By the time paramedics injected McClain with the dose of ketamine, he had not moved or made sounds for about a minute.

While Aurora Fire policies at the time allowed the use of ketamine on someone with excited delirium if there were concerns about the safety of the person or other people, “during the time that Aurora Fire was on the scene, Mr. McClain’s behavior in the presence of EMS should have raised questions for EMS personnel as to whether excited delirium was the appropriate diagnosis,” says the report.

The report also refers to the ketamine dosage as based on a “grossly inaccurate” overestimation of McClain’s size — estimated at about 190 pounds.

“Higher doses can carry a higher risk of sedation complications, for which this team was not clearly prepared,” says the report.

The Aurora City Council heard a presentation on the report’s findings before its regular weekly meeting Monday. A news conference is planned for Tuesday at 10:30 a.m.

In January, Attorney General Phil Weiser announced he would open a criminal investigation by a grand jury into McClain’s death.

McClain’s family has also sued Aurora for his death. A federal court has allowed that investigation to continue amid the grand jury investigation.

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