Independent investigation into Elijah McClain’s death highlights widespread police accountability gaps

From the moment Elijah McClain was stopped while walking home on Aug. 24, 2019, up until he was loaded into an ambulance 18 minutes later, Aurora police officers applied some form of physical force against the unarmed 23-year-old, who was suspected of no crime, according to a new report. 

After being violently detained by officers, McClain was given a large dose of ketamine without being evaluated by paramedics. Soon after, he suffered cardiac arrest and was taken off life support days later.

The city of Aurora released a 157-page independent report on Monday detailing how Aurora police officers and paramedics mishandled the encounter that led to McClain’s death at every critical point — including detaining him in the first place. The independent investigators found that the initial investigation conducted by the police department was inadequate and upheld a false narrative from law enforcement, and the review highlighted far-reaching accountability issues within the Aurora Police Department. 

“The officers’ statements on the scene and in subsequent recorded interviews suggest a violent and relentless struggle,” the independent investigators wrote in the report. “The limited video, and the audio from the body worn cameras, reveal Mr. McClain surrounded by officers, all larger than he, crying out in pain, apologizing, explaining himself, and pleading with the officers.”

The independent investigation — which was commissioned by the city of Aurora during the summer protests last year against police brutality — confirmed what Sheneen McClain, Elijah’s mother, and many other community members already knew. 

“This report — with its stark and unequivocal indictment of Aurora officials conduct — is not based on new, revelatory evidence,” wrote Sheneen McClain in a written statement. “It is based on evidence that Aurora has had in its possession all along. Yet, at every stage, Aurora has defended its officials for their blatantly unlawful actions and refused to discipline anyone involved in Elijah’s death.”

Aurora Police officers had no legal justification for detaining McClain

One of the clearest takeaways from the independent investigation is that the officers who detained McClain — Nathan Woodyard, Randy Roedema and Jason Rosenblatt — had no legal justification in doing so. 

“An investigative stop, often called a Terry stop after the landmark case of Terry vs. Ohio, is considered a significant intrusion on individual liberty and is protected by the Fourth Amendment,” explained Jonathan Smith, the civil rights lawyer who led the independent investigation. Smith, along with his co-authors, presented the report to Aurora City Council members on Feb. 22.

Less than a minute after Woodyard exited his car and commanded McClain to stop walking down the street, officers physically moved him to a grassy area and quickly put him in two carotid holds on the ground. The independent investigation concluded that the officers were not justified in the level of force used against McClain throughout the encounter because there was no evidence that he posed a safety risk. Officers were responding to a 911 call after someone reported a “sketchy” looking person.

At one point during the encounter, one officer can be heard saying, “We’re just going to go forward with him, okay?” A different officer then replied, “okay,” as either Roedema or Woodyard grabbed McClain’s wrist or hand, according to the report.  One second later, an officer can be heard saying, “go” at the same time that Rosenblatt’s body-worn camera dropped to the ground. All three officers’ body-worn cameras were dislodged during the encounter.

During interviews conducted after the event, the officers justified their use of force by saying that McClain had resisted officers’ commands, showed “extraordinary strength” and at one point reached for an officer’s gun. But the audio capture by the officers’ body-worn cameras shows a drastically different story — one where McClain is pleading, apologizing, vomiting and crying out in pain as officers violently restrain him, independent investigators wrote in their report.

“The speed at which these officers acted to take Mr. McClain into custody, their apparent failure to assess whether there was reasonable suspicion that a crime had been committed, and the unity with which the three officers acted suggest several potential training or supervision weaknesses,” investigators wrote. 

Review of death highlights absent accountability systems, corroboration between officers

After McClain’s death, three reviews of the case were conducted by the police department’s Major Crime/Homicide Unit, its Force Review Board and the Aurora Fire Department.

Much of the information came from brief interviews with the officers involved by the lead investigator for the Major Crime/Homicide Unit, Detective Matthew Ingui. The independent investigators raised “serious concerns” about the police-led investigation, which they said exposed “significant weaknesses” in the department’s accountability systems.

The lead police investigator failed to ask “basic, critical questions about the justification for the use of force necessary for any prosecutor to make a determination about whether the use of force was legally justified,” the independent report stated. “Instead, the questions frequently appeared designed to elicit specific exonerating ‘magic language’ found in court rulings.” 

The officers were not asked if McClain had committed a crime or if they considered non-force options before resorting to violence, according to the independent report. Independent investigators said the police-compiled report “failed to present a neutral, objective version of the facts and seemingly ignored contrary evidence.”

The findings from the police-led review were put into a report that was presented to the Force Review Board and then-District Attorney Dave Young. Both entities used the information provided to clear all officers involved of wrongdoing. 

“The report from Major Crime, upon which the District Attorney relied, did not state the factors Officer Woodyard considered or whether they were articulable, specific, and objectively reasonable because he was never asked to, in fact, articulate them,” stated the report. 

“The District Attorney’s review failed to assess the conduct of the officers against well-established legal standards and did not reflect the rigor of a police investigation that one would expect of any other inquiry into whether a crime had been committed,” the independent investigation said.

The case was never referred to Internal Affairs because current policies prevent the process from self-starting without approval from the chief of police, according to the independent report.

The independent investigators sought to conduct their own interviews with the seven people who were originally interviewed during the police investigation into the case, as well as other Aurora officers, EMS personnel and Ingui. All interview requests were declined, because the individuals are currently being investigated by a grand jury, which was convened by the Attorney General Phil Weiser in January. The independent investigators were also unable to interview then-Division Chief Marcus Dudley, who oversaw the Major Crimes investigation, because he left the department before they could do so. Dudley is now the chief of police in Abilene, Texas.

“Because this Panel was not able to interview any individuals involved in the events leading to Mr. McClain’s death, the statements made by those individuals to Major Crime investigators were, in some cases, the Panel’s only source of information regarding certain events,” the investigators wrote.

Independent investigators point to the role of racial bias 

Although the independent report didn’t explicitly say that racial bias played a direct role in McClain’s death, the authors presented evidence to support it and encouraged the city to take a deeper look into their implicit bias practices, training and supervision.

“Research indicates that factors such as increased perception of threat, perception of extraordinary strength, perception of higher pain tolerance, and misperception of age and size can be indicators of bias,” the authors wrote in the report.

Officers said after the event that they stopped McClain because he was overdressed and wearing a mask in an area one officer referred to as “high crime.” In clearing the officers of wrongdoing, Young, the district attorney, used the same reasoning to justify the officers’ actions. 

A map provided to the panel during the investigation shows the area as having low to medium crime activity.

The officers that detained McClain said in their after-incident interviews that McClain displayed unusual strength and continuously resisted them, which was not shown to be true based on the available audio and video footage.

Melissa Costello, a medical and EMS expert who helped conduct the independent investigation, pointed to examples of potential racial bias when evaluating the actions of EMS personnel on the night that McClain was violently detained. After McClain was handcuffed, he could be heard “moaning, gagging, responding to the officers’ statements, exclaiming in pain, and struggling to breathe,” according to the report. The video footage does not show any attempt by paramedics to evaluate or question McClain before he was sedated with 500 mg of ketamine — a dose too large for his body size. 

Aurora Fire personnel repeatedly misjudged McClain’s age, height and weight, according to the report. A paramedic on the scene told the Major Crime investigators that McClain was 30 to 40 years old and approximately 6 feet tall. In reality, McClain was 23 years old, 5-foot-6 and weighed 140 pounds. 

“There’s good evidence that the weight of young Black men is consistently overestimated in medicine and in healthcare,” said Costello.

Costello told Aurora lawmakers on Monday that there is no definitive evidence that an accurate dosing of ketamine would have changed the outcome of the event. “(The) decline that he was having was going on before the ketamine was administered,” she said.

The decision to administer ketamine was made by Aurora Fire paramedic Jeremy Cooper, who had determined through a brief visual evaluation that McClain’s behavior was consistent with “excited delirium,” a syndrome characterized by agitation, aggression and distress.

“It is a concern of mine and of the panel that they did not press forward and initiate some contact with him,” Costello said. “EMS clearly had the opportunity to step in and do some evaluations that I think was necessary.”