AURORA | A report from the city’s contracted public safety monitor is calling for improvements to mental health services to prevent deadly confrontations between police and people in crisis.
Within the past year, Aurora police have had three officer-involved shootings while responding to mental health crises, including an April 9 incident that ended with an officer fatally shooting a man as he stabbed the officer. In a special report released Wednesday evaluating the incidents, the city’s monitor, Jeffrey Schlanger of IntegrAssure, says improvements are needed to the mental healthcare system to help prevent these situations.
The report says that the main lesson of recent events is that “even a city that has made real progress must continue strengthening the behavioral health treatment and crisis-response continuum so that fewer people reach the point at which a police-centered response becomes the last available option.”
According to the report, Aurora police and fire departments have made progress in reforming their response to mental health crises, but improvements are needed on the healthcare side as well.
“When a city is serious about reducing harm to its minimum, improving outcomes, and strengthening public trust, then continuous improvement must extend across the broader system in which paramedics, EMTs, clinicians, hospitals, dispatchers, behavioral health providers, police officers, and families operate,” the report says.
It urges the city to assess its mental health services, identify operational gaps and improve coordination between providers and public safety responders, as well as invest in “prevention, repeat-crisis intervention, family navigation, data-driven accountability and continuity of care.”
The report doesn’t evaluate the public safety response in the three incidents, but focuses on the possible prevention of similar situations through investment in mental healthcare. It questions whether “the public system surrounding behavioral health intervention is sufficiently robust to reduce the likelihood that such crises culminate in sudden close-range violence.”
State and local mental health system officials were unavailable to immediately comment, but a report from the National Alliance on Mental Illness found that people in mental health crises are more likely to experience use-of-force in interactions with law enforcement.
Between 2015-2020, a quarter of all fatal police shootings involved someone with a mental illness, according to NAMI. On top of crisis intervention training, the organization says police departments should embrace a culture shift.
“Creating a culture that focuses on reducing use of force, whether established by leadership or through official agency policy, can have a significant impact on day-to-day operations of law enforcement,” reads NAMI’s website.
In the April 9 shooting, 23-year-old Amare Garlington was killed after he stabbed Officer Mark Moore and a canine officer. Police and mental health clinicians had responded to Garlington’s apartment and tried to communicate with him for around 20 minutes before he exited his apartment with a knife. Police also used less-lethal force, including a 40mm launcher, to attempt to stop Garlington.
Investigations into the shooting are ongoing, and the Critical Incident Response Team, led by the 18th Judicial District, will determine whether Moore violated any law during the encounter and the shooting.
After the shooting, Garlington’s family told 9News that he had been turned away from a mental health facility just a week before the incident. Michelle Garcia, Garlington’s mother, said he struggled to get the help he needed and was turned away too many times.
“People lose their lives, officers are injured. You know, the poor canine, it’s just, it’s not fair for anybody. There’s so many victims just because our system will not help people. It needs to change,” Garcia told 9News. “Something has got to change.”
The report also describes two 2025 fatal shootings.
In one case, Aurora officers responded Sept. 18, 2025, to a Conoco gas station on South Havana Street after 17-year-old Blaze Balle-Mason called 911 and reportedly threatened to open fire inside the business and shoot responding officers. Officers used cover and deployed a 40mm less-lethal launcher before fatally shooting Balle-Mason, according to police video and reporting at the time.
Investigators later determined Balle-Mason was unarmed. Police experts outside Aurora described the encounter as what they said is a known phenomenon called “suicide by cop.”
Some of those experts questioned whether Aurora police handled the call correctly from the time dispatchers were called.
The third case involved 32-year-old Rashaud Johnson, who was shot and killed May 12, 2025, near Denver International Airport after officers responded to reports of a barefoot man behaving erratically for hours at the airport-parking facility and at one point began touching parked vehicles.
According to police reports, Officer Brandon Mills initially tried to determine what was wrong before a struggle broke out. After separating and waiting for backup, Mills fatally shot Johnson when he advanced again, police said.
Johnson was unarmed, barefoot and appeared to be in mental distress, the report states.
Rather than focusing on officers’ decisions or police strategy, the report argues that Aurora should examine what happened long before police were called to the scenes.
Schlanger recommends analyzing whether the individuals involved had previous contacts with hospitals, mental health providers, clinicians, emergency responders or family members seeking help. He also urges officials to determine whether intervention opportunities were missed because of fragmented systems, unclear legal standards, lack of follow-up care or barriers to treatment.
“One of the lessons of modern police reform is that not every public safety problem can be solved within the Police Department itself,” Schlanger said in the report.
Aurora has spent years attempting to improve responses to behavioral health crises, particularly after the 2019 death of Elijah McClain drew national scrutiny to the city’s police and fire departments.
McClain died, unarmed, at the hands of police and firefighters after being contacted while walking home at night from a convenience store after buying soft drinks. That death and others led to a state-led investigation into the department. Attorney General Phil Weiser concluded that Aurora police had long exhibited “patterns and practices” of using excessive force on members of the public, especially people of color.
The new report credits Aurora for building programs that addressed and identified staffing, training and procedural shortfalls.
Among them are the Aurora Mobile Response Team, which pairs clinicians with paramedics or emergency medical technicians for lower-risk behavioral health calls, and Crisis Response Teams, which pair specially trained officers with clinicians for higher-risk incidents.
The city also works with Aurora Mental Health and Recovery, which operates a 24-hour crisis walk-in clinic and stabilization unit.
Still, the report argues that existing services may not be sufficient or sufficiently coordinated.
A major concern identified in the document is the lack of a single systemwide authority overseeing Aurora’s behavioral health response network. The report says agencies may function effectively on their own while failing to operate cohesively across repeated crises and multiple points of contact.
“Without structured coordination and system-level review, opportunities for earlier intervention, risk identification, and continuity of care may be missed,” the report states.
While Aurora uniquely has a singular agency addressing mental health issues, a large collection of mostly independent mental health clinics and programs are spread across the state.
Recommendations in the report include creating Behavioral Health Incident Reviews modeled after police-force review boards but focused on system-wide analyses rather than determining whether force was justified.
Under the proposal, multidisciplinary teams would examine incidents involving serious injury, death or escalating behavioral health crises to identify gaps in communication, dispatch decisions, intervention efforts and follow-up care.
The report also calls for local and state audits of emergency mental health hold procedures, clearer police dispatch protocols and expanded data collection tracking crisis-related calls, subsequent referrals and outcomes.
The report repeatedly frames behavioral health services as being linked to public safety.
“When the larger behavioral health system is too fragmented, too episodic, or too difficult to navigate under stress, police officers are increasingly called upon to manage crises that have already advanced to a point of acute danger,” the report states.
Schlanger insists that city lawmakers now act quickly.
“Three young individuals are dead. A police officer was gravely injured. A police canine was seriously hurt,” the report states. “Aurora cannot change what happened on each of those fateful days. But it can potentially learn from them.”