AURORA | Elijah McClain died from complications from an injection of ketamine by paramedics after he was confronted and forcibly restrained by Aurora police in 2019, according to the 23-year-old’s amended autopsy report released by the coroner for Adams and Broomfield counties on Friday.
Forensic pathology consultant Stephen Cina wrote in the amended autopsy report dated July 1, 2021, that McClain’s death was caused by “complications of ketamine administration following forcible restraint.” The previous report, signed in November 2019, listed both the cause and manner of McClain’s death as “undetermined.” The manner of death was still deemed “undetermined” in the new report.
Coroners may be tasked with establishing the cause of a person’s death, which may be an injury or a disease, as well as the manner of death, which is a description of the circumstances of the event, like “accident” or “homicide.”
Cina wrote that the materials which led to the new determination had been requested before the original report was signed in November 2019, but either weren’t received or weren’t received in their entirety at that time.
Adams County Coroner Monica Broncucia-Jordan released the report Friday after a lawsuit was filed by Colorado Public Radio and other media outlets. While she initially refused to release the document since it included information reviewed by a grand jury which had not been made public, two judges weighed in and ultimately ruled that it could be released.
“Openness and transparency are at the heart of good government,” Broncucia-Jordan said in a press release Thursday. “I believe in the public’s right to information and want to be transparent about the work done in my office.”
While the concentration of ketamine in McClain’s blood was within the accepted therapeutic range, Cina said McClain nonetheless received an intramuscular injection that was higher than the amount recommended for someone of his weight constituting an overdose.
He noted that McClain appeared “extremely sedated” after he was injected with ketamine, and when placed on the stretcher was displaying agonal breathing — a pattern of gasping, labored breathing that is a sign of imminent respiratory failure.
“I believe that Mr. McClain would most likely be alive but for the administration of ketamine,” Cina wrote.
McClain was placed in a carotid hold by police shortly before he was injected with ketamine, but Cina said he could not “determine whether this carotid control hold contributed to death via stimulation of the carotid sinus, though the literature suggests that this was unlikely.”
“There were no findings in the neck indicative of traumatic asphyxiation,” Cina said. “During restraint the body weight of officers was used to subdue the decedent. However after this weight was removed, the decedent was still alive and able to speak. I have seen no evidence that injuries inflicted by police contributed to death.”
Cina said elevated levels of lactic acid, adrenaline and electrolytes in McClain’s blood following his struggle with police may have contributed to his death, but that he could not conclusively say what impact that may have had. He noted that McClain was a distance runner and had no heart problems prior to his death.
Ultimately, Cina blamed the 500 milligram injection of ketamine for McClain’s death, which according to the grand jury indictments of Aurora Fire Rescue paramedics Peter Cichuniec and Jeremy Cooper was more than 175 milligrams above what McClain should have received, given his weight.
Cina said deaths due to ketamine toxicity are usually classified as accidental, and that he did not have evidence that injuries or harm done while McClain was being restrained by police contributed to his death.
“I still contend that the appropriate manner of death in this case is UNDETERMINED,” he wrote. “I acknowledge that other reasonable forensic pathologists who have trained in other places may have developed their own philosophy regarding deaths in custody and that they may consider the manner of death in this type of case to be either HOMICIDE or ACCIDENT.”
Dr. Carl Wigren, a forensic pathologist in Washington state, questioned the report’s focus on ketamine, saying all the available evidence — including a highly critical independent review of McClain’s death commissioned by Aurora last year — point to McClain dying as a result of compressional asphyxia, a type of suffocation, from officers putting pressure on his body while restraining him. He was struck by one passage in the city’s review citing the ambulance company’s report that its crew found McClain lying on the ground on his stomach, his arms handcuffed behind his back, his torso and legs held down, with at least three officers on top of him.
That scene was not captured on body camera footage, the report said, but much of what happened between police was not because the officers’ cameras came off soon after McClain was approached. The cameras did continue to record where they fell and captured people talking.
Just because McClain, who said he couldn’t breathe, could be heard making some statements on the footage, does not mean he was able to fully breathe, Wigren said. Ketamine, which slows breathing, could have just exacerbated McClain’s condition, but Wigren does not think it caused his death.
However, another pathologist, Dr. Deborah G. Johnson of Colorado, said McClain’s quick reaction to ketamine suggests that it was a cause of McClain’s death, but she said its use cannot be separated from the impact that the police restraint may have had. McClain may have had trouble breathing because of the restraint and having less oxygen in your system would make the sedative take effect more quickly, she said.
Both thought the death could have been labeled as a homicide — a death caused by the actions of other people — which they pointed out is a separate judgment from deciding whether someone should be prosecuted with a crime for causing it.
McClain got an overdose of ketamine, Johnson said, noting that the paramedics were working at night when it is hard to judge someone’s weight.
“Was that a mistake to send someone to prison for? I don’t think so,” she said.
The City of Aurora in 2021 agreed to pay a $15 million settlement after McClain’s parents sued police for their son’s death. Elijah’s mother, Sheneen McClain, and her attorney, Qusair Mohamedbhai, declined a request for comment.
Ketamine has since been removed from the roster of drugs administered by AFR paramedics. Today, Versed, also known as midazolam, is the only sedative used by the agency.
Midazolam does have the potential to cause breathing problems, however, and the risk is compounded when used on people who are drunk or high on drugs that also impact breathing. For that reason, Aurora Fire Rescue planned to supply paramedics with another sedative, droperidol, which is safer to use on those patients.
But Aurora Fire Fighters Local 1290 and some City Council members pushed back on the plan during the council’s Sept. 19 meeting, saying the charging of medics Cichuniec and Cooper with manslaughter and criminally-negligent homicide had shaken Aurora firefighters and stoked liability fears.
“I feel like the timing of this is wrong,” Councilmember Curtis Gardner said. “I do not agree that we should be introducing a new sedative while we have firefighters on trial.”
Aurora Fire Rescue’s medical director, Eric Hill, also said at the time that he believed the two medics did not deserve to face charges for what the union described as a good-faith effort to provide care.
Cichuniec and Cooper injected McClain with ketamine without attempting to get his consent, after diagnosing him with excited delirium based on the testimony of police officers at the scene.
One of the reforms included in an agreement between Aurora’s public safety agencies and the Colorado Attorney General’s Office specifies that police no longer recommend or encourage the use of sedatives in the field.
The Associated Press contributed to this story.