An independent panel investigating the death of a 23-year-old Black man who was detained in 2019 by the police in Aurora, Colo., issued a highly critical report on Monday faulting officers for stopping the man without justification and for escalating their use of force, including two applications of a neck hold intended to render him unconscious.
The report’s authors criticized Fire Department paramedics as slow to help the man, Elijah McClain, before injecting him with an improper dose of ketamine, a tranquilizer. Mr. McClain went into cardiac arrest on the way to a hospital. He died a few days later.
The panel also said that an investigation by local police detectives “raised serious concerns” for failing both to rigorously question the officers involved and to examine the circumstances of Mr. McClain’s death. In November 2019, three months after Mr. McClain’s death, the Adams County district attorney announced that criminal charges would not be filed, saying there was not enough evidence that the officers had broken the law when they used force on Mr. McClain.
Aurora officials said that the purpose of the report, commissioned in July by the City Council, was to create a timeline of events, and to recommend policy changes in order to avoid further tragedies. It was written by Jonathan M. Smith, a civil rights lawyer in Washington, D.C.; Roberto A Villaseñor, a retired police chief from Tucson, Ariz.; and Dr. Melissa W. Costello, an emergency medicine expert in Pascagoula, Miss.
Mr. McClain’s death attracted widespread attention as outrage grew after the death of George Floyd in the custody of the Minneapolis police in May. It is now the subject of several inquiries, including a criminal investigation by Colorado’s attorney general and a civil rights investigation by the Justice Department. The state’s health department is also conducting “a licensure investigation into the use of ketamine.”
The investigation by the Aurora Police Department’s major crime and homicide unit “raised serious concerns for the panel and revealed significant weaknesses in the department’s accountability systems,” the report said. That investigation “failed to ask basic, critical questions,” and its “questions frequently appeared designed to elicit specific exonerating ‘magic language’ found in court rulings.”
The panel recommended major policy and training changes for the city’s police officers and emergency medical workers. De-escalation training needs to be enhanced and more police stops should be documented, the report recommended.
The city also needs to examine the “personnel attitudes and perceptions” of its emergency medical workers, “surrounding all aspects of patient safety during a call for service,” the report said.
LaWayne Mosley, the father of Mr. McClain, said the report showed that Aurora “needs to be overhauled all the way, from top to bottom.” Mari Newman, a lawyer representing Mr. Mosley in a lawsuit against the city, said, “I’m not holding my breath” for those changes to be enacted.
Officers and paramedics acted unjustifiably throughout the encounter on Aug. 24, 2019, according to the report, which relied on police body camera video and audio, as well as interviews conducted earlier by the major crime unit.
Mr. McClain’s fateful encounter with the police began at about 10:40 p.m., after someone called 911 to report that a man who “looked sketchy” was wearing a ski mask and waving his arms. The man was Mr. McClain, a massage therapist, who was walking home from a convenience store with some iced tea.
The first officer on the scene was Nathan Woodyard, who, without justification, immediately ordered Mr. McClain to stop, according to the report. “Within 10 seconds of exiting his patrol car, Officer Woodyard placed his hands on Mr. McClain,” it said.
To justify an investigatory stop, an officer must have “reasonable objective grounds” and an “articulable or reasonable suspicion of criminal activity,” the report said. The officer must also rely on “the least intrusive means” to verify or dispel those suspicions, the report said.
In later interviews with the major crime unit, neither Officer Woodyard nor two colleagues who later joined him “articulated a crime that they thought Mr. McClain had committed, was committing or was about to commit.”
After the arrival of the other two officers — Randy Roedema and Jason Rosenblatt — Officer Woodyard frisked Mr. McClain for weapons, the report said. The other officers held Mr. McClain’s arms. Based on what the officers later told police investigators, the report concluded, the officers “were not able to identify sufficient evidence that Mr. McClain was armed and dangerous in order to justify a pat-down search.” The officers’ decision to move Mr. McClain to a nearby grassy area was also not justified, the report said, because there still was not probable cause that Mr. McClain had or was about to commit a crime.
At one point, Officer Roedema can be heard on police body camera video saying, “He grabbed your gun, dude.” That escalated the confrontation. Officer Woodyard, who was holding Mr. McClain’s left arm, later told investigators that after that comment, his goal was to “take him down to the ground as hard” as he could.
Ms. Newman, the lawyer for Mr. McClain’s father, disputes this detail, saying it was “clearly fabricated” by the officers in order to justify their behavior. She also said that the officers’ guns were in “security holsters” and couldn’t easily be removed.
Officer Rosenblatt said he applied a carotid hold to Mr. McClain’s neck for about one second as the officers were wrestling the 5-foot-7 Mr. McClain to the ground, according to the report. A carotid hold, according to the report, is the application of pressure “to the left and right sides of a subject’s neck to deprive the brain of oxygen and induce unconsciousness.”
While Mr. McClain was on the ground, Officer Woodyard applied another carotid hold to him.
The officers “applied pain compliance techniques and restraints to Mr. McClain continuously from the first moments of the encounter until he was taken away on a gurney,” the report said.
As the officers did this, the report said, Mr. McClain can be heard on police body video saying: “You all are phenomenal, you are beautiful. Forgive me.”
“Ow, that really hurt,” he said. “You guys are too strong.”
According to the report, Mr. McClain said as his voice trailed off, “It’s just that I can’t breathe correctly because …”
When emergency medical workers arrived, they appeared “to have accepted the officers’ impression that Mr. McClain had excited delirium without corroborating that impression through meaningful observation or diagnostic examination of Mr. McClain,” the report said.
Based on that impression, the paramedics decided to give Mr. McClain ketamine. But a fire lieutenant who was at the scene incorrectly estimated the weight of the 140-pound Mr. McClain, giving him enough ketamine for a person weighing 190 pounds, according to the report.
Jim Twombly, the Aurora city manager, said that city leaders were reviewing the report. “City management will work with the mayor and City Council in coming days and weeks to assure the appropriate next steps are taken,” he said in a statement.
A spokesman for the Police Department referred to Mr. Twombly’s statement and declined to comment further.
An email message to the Aurora Police Association was not returned on Monday night.
Howard Paul, a spokesman for the Emergency Medical Services Association of Colorado, said he was awaiting the report from state health officials before commenting.
Officer Rosenblatt was fired in July 2020 for writing “ha ha” in a text message to fellow officers who had sent him a photograph mocking the death of Mr. McClain. The two other officers involved in the encounter are still employed by the Police Department, a spokesman said.
Iris Halpern, a lawyer representing Sheneen McClain, Mr. McClain’s mother, said, “I think the report substantiated what we knew and what the city of Aurora was trying to cover up.”
Mr. McClain, she added, “had no part in his own death.”
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