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Independent team says investigation into Elijah McClain's death was 'flawed'

McClain died in 2019 after being put in carotid hold, given ketamine dose
Elijah McClain
Posted at 9:20 AM, Feb 22, 2021

AURORA, Colo. — Independent investigators who were tasked with reviewing the death of Elijah McClain released the results of their review Monday morning, calling the investigation that followed the 23-year-old’s death “flawed.”

The investigators, who were commissioned by the Aurora City Council in July, will present their findings to Aurora City Council at 5 p.m. Monday, but city management decided to release the information in advance so the public can review it ahead of the meeting.

The investigators' report found that the events following McClain's death were "flawed" and "failed to meaningfully develop a fulsome record."

The report continues, saying the facts trouble the panel, but "it was not our charge to assess whether misconduct occurred; rather, our task was simply to report what we could learn from the record and make policy recommendations.”

The report said the events that led to McClain’s death happened quickly, but neither the person who called 911 nor the responding officers identified a crime occurring.

"Within seconds of exiting their cars, officers used force on Mr. McClain which they sustained over an extended time period, including two attempted carotid holds," the report reads. "EMS waited almost seven minutes after arriving to interact with Mr. McClain, and their first contact was to administer the sedative ketamine."

McClain, 23,died on Aug. 30, 2019, six days after hisoriginal encounter with police and paramedics. McClain had been walking home from a nearby convenience store when a passerby reported him to police as looking suspicious because he was wearing a face covering at the time.

After McClain was accosted by officers, he was accused of resisting arrest and put in a carotid hold, then eventually administered a heavy dose of the sedative ketamine by paramedics. He went on to suffer a heart attack and died six days later.

Anautopsy report from the Adams County coroner found McClain’s cause of death to be “undetermined.” Recordspreviously obtained by KMGH found that paramedics gave McClain 500 milligrams of ketamine – the maximum dose of the drug – which has led tomultiple reviews of the drug’s use by EMTs.

A review board determined that officers acted within department policy when they confronted McClain and used the force on him they did that day.

In addition to the findings, the independent panel also made several recommendations to the city, including:

  • Review policy, training and supervision regarding use of force and arrest practices
  • Improve accountability systems, including a more effective review by the Major Crime Unit and mandatory review by Internal Affairs
  • Clarify and strengthen the transition of an individual from suspect to patient when EMS is called

The panel also said the city should revisit its “policies, practices, training and culture regarding implicit bias” in order to reform its current crisis intervention system, maintain the independence of EMS and to consider options other than ketamine.

21CP Solutions, a global firm of experts in civil rights and public safety, has started a comprehensive review of the Aurora Police Department’s practices and will present its findings to the public and city council this spring. City Manager Jim Twombly and Chief of Police Vanessa Wilson requested this review.

The 17th Judicial District Attorney’s Office said in a letter in November 2019 that they were not going to pursue charges against the officers or EMS personnel involved in McClain’s death.

“Although extensive, the scope and character of the intrusion by law enforcement officers in effecting Mr. McClain’s detention was not itself a criminal act,” the letter reads. “There is no evidence that any of the officers sought to cause injury or death to Mr. McClain. Rather, evidence suggests that they exercised a degree of force they believed necessary to detain him and investigate into his possible criminal activity.”

Nick Metz, who was the chief of Aurora police at the time of the McClain incident, retired at the end of 2019 and was replaced on an interim, then permanent, basis by Vanessa Wilson, whopledged transparency and to hold officers accountable in the wake of the McClain incident and others for which the department was put under intense public scrutiny.

Earlier this month, the Aurora Civil Service Commission upheld the firings of three officers, including one who was involved in the initial encounter with McClain, who were involved ina scandal surrounding a photo they took and texted around to one another of officers mocking the carotid hold at the scene of McClain’s death. Another officer in the photo scandalresigned before he could be fired.

There are multiple other investigations underway at the state, local and federal levels, including a top-down review of the Aurora Police Department by the state attorney general, an independent investigation by Chicago-based 21CP Solutions to conduct a comprehensive review of the police department, and a review in the Colorado U.S. Attorney’s Office alongside the Department of Justice’s Civil Rights Division.

The city council asked for an independent investigation after expressing concern that a previous investigator who was hired by the city did not meet their "standards of neutrality." The new team, which was led Jonathan Smith, executive director of the Washington Lawyers’ Committee for Civil Rights and Urban Affairs, was asked to do the following:

  • Investigate the actions of APD in response to the 911 call, on scene, and during the subsequent criminal investigation and internal force review
  • Investigate the actions of Aurora Fire Rescue on scene and its administration of ketamine
  • Create a timeline of the events
  • Review all facts from the beginning to the end of APD’s and AFR’s contact with McClain
  • Review all relevant policies, procedures, and practices related to calls for service, police contact with individuals, use of force, calls for medical assistance, ketamine use, and administrative incident reviews
  • Create a written report that includes recommendations for the city to address the situation that occurred, and recommendations based on best practices that should guide the city in the future

Aurora City Manager Twombly said he felt it was important for the public to see the findings of the investigation at the same time the city did.

“We welcomed how comprehensive and thorough the investigators were over the last six months,” he said. “We are currently reviewing their report and look forward to hearing additional context during their presentation before we comment further. City management will work with the Mayor and City Council in coming days and weeks to assure the appropriate next steps are taken.”

A virtual news conference is planned for 10:30 to 11 a.m. Tuesday with City Manager Twombly, Aurora Police Department Chief Wilson, and Aurora Fire Rescue Chief Fernando Gray.

This story was originally published by Stephanie Butzer and Blair Miller at KMGH.