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Autopsy: EMTs used too much ketamine in 2019 death of Elijah McClain, officers still facing charges


Julia Cardi

The Gazette (Colorado Springs, Colo.)

An amended autopsy report released Friday for Elijah McClain, a 23-year-old Black man who died in 2019 after an encounter with Aurora police, confirms a forensic pathologist’s opinion that McClain died from “complications of ketamine administration following forcible restraint.”

But the new report did not change his original determination that the manner of death — such as homicide, suicide, natural causes or accidental — was undetermined.

“Simply put, this dosage of ketamine was too much for this individual and it resulted in an overdose,” wrote Dr. Stephen Cina, the forensic pathologist contracted to perform the autopsy, in the amended report.

McClain died in August 2019, several days after a violent arrest by Aurora police while he walked home from a convenience store. The officers restrained him and put him in a carotid hold, a type of neck hold meant to gain someone’s compliance that can induce temporary unconsciousness, and a paramedic injected him with 500 milligrams of the sedative ketamine.

The officers had responded to a call of a person acting suspiciously, wearing a ski mask and waving his hands. But McClain was not accused of any crime.

McClain went into cardiac arrest and never regained consciousness. He was taken off life support and died in the hospital several days later.

The statewide grand jury released indictments in September 2021. Former officers Jason Rosenblatt, Nathan Woodyard and Randy Roedema, and paramedics Peter Cichuniec and Jeremy Cooper face 32 counts total including manslaughter, criminally negligent homicide and assault.

The original 2019 autopsy report ruled the cause and manner of McClain’s death “undetermined.”

But according to a probable cause review motion by Woodyard’s attorneys previously obtained by The Gazette, Cina changed his determination on July 1, 2021 — two months before the release of the indictments against the officers and paramedics. He opined McClain died of complications of ketamine administration following forcible restraint, noting ” Mr. McClain would most likely be alive but for the administration of ketamine.”

Cina’s amended report adds he saw “no evidence that injuries inflicted by police contributed to death” because McClain was conscious, able to speak and responsive following the neck hold and removal of the officers’ body weight from him.

He wrote he did not find evidence of “traumatic asphyxiation” and carotid holds are often used in martial arts without lasting negative consequences.

Cina maintained McClain’s manner of death as undetermined, writing he could not tell if physical symptoms from McClain’s struggle during restraint contributed to his death. He acknowledged that deaths from ketamine toxicity are typically classified as accidental, and added other “reasonable” forensic pathologists may also classify the manner of a death in similar circumstances as homicide.

The criminal indictment cites the opinion of an unidentified forensic pathologist who opined the manner of McClain’s death was homicide, and said complications from acute ketamine administration during “violent subdual and restraint” killed him. The language in the indictment is similar to testimony from Dr. Roger Mitchell, another expert who spoke to the grand jury.

According to the probable-cause review motion by Woodyard’s lawyers, Mitchell said “decreased oxygen to [McClain’s] brain during the chokehold and his ‘restrained subdual'” contributed to his death. He provided an opinion similar to Cina’s that ketamine was the complicating factor in the altercation that led to McClain’s death.

Cina’s report clarifies that manner of death is a determination based on the circumstances surrounding a fatality, not a medical diagnosis, and a homicide classification does not necessarily imply the death resulted from a criminal action.

The Adams County Coroner’s Office confirmed late Thursday it would release the amended report in full after an order by Denver District Court’s chief judge this week that an unredacted copy must be made public. The order came in a lawsuit by a coalition of news organizations, led by Colorado Public Radio, filed to compel the document’s release.

Adams County Coroner Monica Broncucia-Jordan also filed an emergency motion, according to a news release.

“Openness and transparency are at the heart of good government,” Broncucia-Jordan said in the release. “I believe in the public’s right to information and want to be transparent about the work done in my office. I also respect the rule of law and want to ensure nothing is released that will violate any court order or potentially jeopardize the prosecutions in this case. That is why it was imperative to have the Denver District Court weigh in.”

Colorado’s Open Records Act classifies autopsy reports as public records, but Broncucia-Jordan declined to release the amended report when Colorado Public Radio requested it because of another judge’s order sealing grand jury evidence from the criminal investigations into the three police officers and two paramedics present when McClain died.

In an order last week directing the report’s release within seven days, Adams County District Court Judge Kyle Seedorf ruled the report could be redacted to exclude new information from the grand jury investigation.

The report is published on the Adams County coroner’s website officeofthecoroner.com.


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