The autopsy report for Elijah McClain, an unarmed Black man who died while in police custody in Colorado three years ago, has been changed to update the cause of death from “undetermined” to “complications of ketamine administration following forcible restraint,” Adams County Chief Coroner Monica Broncucia-Jordan said Friday.
In August 2019, McClain, a 23-year-old massage therapist, was walking home from a store when he was apprehended by Aurora police officers responding to a “suspicious person” call. Police said McClain had resisted and he was placed into a carotid hold.
See the police encounter that led to Elijah McClain’s death
Paramedics diagnosed McClain with “excited delirium” and administered the powerful sedative ketamine. He suffered a heart attack on the way to the hospital. Three days later, he was declared brain dead.
The original autopsy report listed the cause of McClain’s death as “undetermined.”
The coroner’s office received body camera footage, witness statements and additional records that were part of a grand jury investigation and not available before the autopsy was performed, pathologist Dr. Stephen Cina wrote in the amended autopsy report.
“Simply put, this dosage of ketamine was too much for this individual and it resulted in an overdose, even though the blood ketamine level was consistent with a ‘therapeutic’ concentration,” CIna wrote. “I believe that Mr. McClain would most likely be alive but for the administration of ketamine.”
Cina, who was assisted at the autopsy by Broncucia-Jordan, wrote that based on his training and experience, he still believes the manner of death is “Undetermined.”
“I acknowledge that other reasonable forensic pathologists who have trained in other places may have their 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,” the pathologist added.
CIna could not determine whether the carotid hold contributed to McClain’s death, he added.
But “I have seen no evidence that injuries inflicted by the police contributed to death,” he wrote.
The amended autopsy report was signed in July 2021. It was released Friday after a Denver District Court judge approved the coroner’s emergency motion.
McClain’s death days after his interactions with police brought renewed scrutiny of the use of carotid holds and ketamine during law enforcement stops. His case gained renewed attention during Black Lives Matter protests in the wake of the police killings of George Floyd and Breonna Taylor.
Last year a grand jury indicted three police officers and two paramedics involved in the McClain case. They face charges of manslaughter, criminally negligent homicide and other charges.
In 2021, the city settled a civil rights lawsuit with the McClain family for $15 million, and the Aurora police and fire departments agreed to a consent decree to address a pattern of racial bias found by a state investigation.