McClain Investigation Report Recommends Changes to Prevent a Repeat; Bans Use of Ketamine

By Alex Morgan and Carlin Ross

AURORA, CO – Aurora Police officers on Aug. 24, 2019 targeted and surrounded Elijah McClain in response to a call for suspicious behavior, and although the caller reported no weapons on the individual and no signs of threat or harm to another person, when the police officers arrived, they performed a frisk/Terry Stop.

McClain was subject to the use of force which included two carotid holds and the administration of a sedative (ketamine), by members of the Aurora Fire Department.

A few minutes later he was dead.

Nearly a year after McClain’s death, on July 20, 2020, the Aurora City Council passed a resolution that authorizes an independent review of the actions performed by the police and fire departments.

Just this past week, about seven months after the review was initiated, the results were released.

The review looked at what happened in 2019.

Before officers grabbed McClain, a caller said a man “put his arms up” when the caller passed him, and that the man “look[ed] sketchy” and that “[h]e might be a good person or a bad person.” The caller described that he thought the individual was a “Black male” dressed in a black ski mask, brown long-sleeved shirt, and black sweatpants.

At around 10:42 p.m., Aurora Police Officer Nathan Woodyard was the first to arrive and make contact with McClain. McClain could be seen with a phone in one hand, a bag in the other, and earbuds in his ears. Officer Woodyard stepped out of his vehicle, approached McClain and ordered him to “stop.” Within 10 seconds of exiting his patrol car, Officer Woodyard placed his hands on McClain.

McClain had no observable weapon and had not displayed violent or threatening behavior. The officers later stated that they stopped McClain because he was overdressed, wearing a mask, and in an area common to “high crime.”

The officers decided to physically move McClain to a grassy area in order to “lay him down.” Although McClain did not show any signs of resistance, a carotid hold and “bar hammer lock” was performed on McClain until he began showing signs of struggling to breathe.

McClain apologized to the officers, told them he had his ID, told them his name and that he was “just going home…I’m an introvert and I’m different. Going home…I’m just different. I’m just different. That’s all. That’s all I was doing. I’m so sorry.”

Officers described him by radio to a dispatcher as “still fighting.” McClain continued, “Forgive me,” and said “you all are phenomenal, you are beautiful. Forgive me.”

As the officers waited for paramedics to arrive, McClain vomited and complained about pain and difficulty breathing, “Ow. I’m so sorry. I’m so sorry,” “Ow, that really hurt. You guys are too strong,” and, “It’s just that I can’t breathe correctly because …” as his voice trailed off.

McClain suffered a cardiac arrest shortly after and, after being taken to the hospital, was declared brain dead several days later.

The independent review panel included Jonathan Smith, leader of the Panel and Executive Director of the Washington Lawyers’ Committee for Civil Rights and Urban Affairs, Roberto Villaseñor, a law enforcement expert, and Dr. Melissa Costello, a practicing emergency medicine physician and EMS medical doctor.

The resolution mandated an examination of the facts surrounding the police and fire departments interactions with McClain, all relevant Aurora police and fire department policies, procedures, and practices, and a final report of the findings and recommendations of best practices for the City.

Importantly, the report and resolution outline the police’s decision to stop, frisk, arrest, and sedate McClain. As the report elucidates, Officer Woodyard did not have reasonable suspicion of criminal activity to make a Terry stop as McClain walked home masked and waving his arms.

One officer on the scene claimed he appeared to be walking in the demeanor of someone who had just committed a crime. McClain’s clean record, however, proves otherwise.

Once the Terry stop had ensued, Woodyard, joined by Officers Jason Rosenblatt and Randy Roedema, decided to frisk McClain under the unreasonable suspicion he was armed and dangerous. Officer Woodyard specifically stated he began the pat-down “based on him having a ski mask on, on Colfax in the middle of the night and it was causing people to call in.” McClain, on the other hand, reiterated copious times to the officers that he was listening to music and just wanted to continue his walk home.

The Panel ruled the officers did not meet the constitutional requirements to engage in a Terry stop or frisk.

Only a minute after the officers made the stop, they applied forceful techniques to make the arrest. Once taking him to the ground, the three officers applied a carotid control hold to McClain that ultimately led to his loss of consciousness. The officers continued to apply restraints after they were audibly and physically out of danger, with McClain pinned to the ground.

According to the Panel, none of the facts leading up to the crime were sufficient enough to make the arrest, as the use of force requires an officer to be in perceived danger.

While the EMS on the scene determined it was appropriate to administer ketamine to McClain after he had been unconscious for a minute, based on his “excited delirium,” they administered a wildly inaccurate dosage, considering McClain’s bodily measurements. Additionally, there was no clear transition of care from the Aurora Police to the Aurora Fire Department, even after the ketamine was administered.

After coming to these conclusions, the Panel offered recommendations in moving forward with a more just criminal justice system.

To begin, the Panel recommends that the Aurora Police Department reviews the training and supervision of its officers. It additionally recommends they review the use of force and de-escalation policy.

In regard to the Aurora Fire Department, the Panel recommends the Aurora Police implement a simple model for transition of care, while also reviewing the Aurora Fire to ensure they’re prioritizing safety and the EMS are capable of performing sedation assessments.

After analyzing the investigation with rigor, the Panel was left with four major concerns: implicit bias, crisis intervention, independence and separate authority of medical personnel, and the administration of ketamine.

While the Panel had insufficient evidence to deduce if bias was at play in McClain’s case, they did note that factors such as “increased perception of threat, perception of extraordinary strength, perception of higher pain tolerance, and misperception of age and size” could be indicators of bias.

The Panel additionally lacked evidence to identify whether or not McClain was experiencing a mental health crisis; however, they were able to identify flaws in the city’s capability to respond to calls of that kind.

Given this, the Panel suggested the city reconsiders its method of crisis intervention within the persons experiencing disabilities community.

Unable to identify the nature of the relationship between the Aurora Police and Fire, the Panel suggested the EMS acted as an “arm” of the police, rather than an independent unit. The Panel advises a review of communication between the two departments to ensure justice.

Lastly, the city of Aurora placed a moratorium on the use of ketamine by emergency medical staff. The Panel now urges the city not to replace ketamine with any other medication, as it would pose just as big of a risk to the patients and medical staff.

Carlin Ross is a senior at Santa Clara University who double majors in English and Philosophy. She’s originally from Bozeman, Montana.

Alex Morgan is a 3rd year Political Science Major at Westmont College. She is originally from Santa Barbara, California


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