Though it still lists the manner of death as “undetermined” — as opposed to a homicide or an accident — the report could bolster the prosecution of the police and first responders charged in McClain’s death and reignite calls for greater accountability from the city.
McClain, a massage therapist and self-taught musician, was walking home in August 2019 when he was detained by police responding to a 911 call that someone was acting “sketchy.” Officers tackled him and put him in a carotid chokehold, which restricts blood flow to the brain. Paramedics injected him with ketamine, a powerful sedative. He went into cardiac arrest on the way to the hospital and died several days later.
In the amended autopsy report, forensic pathologist Stephen Cina said the ketamine injection was excessive for McClain, who stood about 5-f00t-7 and weighed 140 pounds.
A review of body-camera footage that police did not provide during the initial autopsy showed that McClain was “extremely sedated” within minutes, according to Cina. He said he thought McClain was struggling to breathe as he lay on a stretcher and that respiratory arrest was “imminent.”
“Simply put, this dosage of ketamine was too much for this individual and it resulted in an overdose, even though his blood ketamine level was consistent with a ‘therapeutic’ blood concentration,” Cina wrote. “I believe that Mr. McClain would most likely be alive but for the administration of ketamine.”
It was not clear whether the carotid hold contributed to his death, Cina said, noting that medical literature suggested it would not have. He said that he saw nothing on McClain’s neck that showed he died of asphyxiation and that McClain could speak after the officers let him up.
Cina also noted that McClain was “alive and responsive to painful stimuli” up to the point that he received the ketamine shot.
“It is my opinion that he likely would have recovered if he did not receive this injection,” he said.
Deaths related to ketamine toxicity are usually classified as accidents, according to the report, but Cina said the manner would remain “undetermined” because other factors could have played a role.
He added: “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.”
In an emailed statement to The Washington Post, an Aurora police spokesman said the department “fully cooperated with the investigation.” A representative for Aurora emergency services did not immediately respond to a message seeking comment Saturday morning.
Prosecutors initially declined to charge anyone in McClain’s death, citing the lack of evidence in the original autopsy.
Some officials, medical experts and criminal justice advocates criticized prosecutors for not seeking a second medical opinion to avoid an “undetermined” manner of death.
Colorado Gov. Jared Polis (D) appointed a special prosecutor to reopen the case, and a grand jury was empaneled to consider criminal charges.
During the proceedings, the investigation of McClain’s death came under greater scrutiny when Colorado Public Radio reported that the county coroner had met with police before the autopsy was released and that police investigators were present during the examination.
In September 2021, charges were announced against three Aurora police officers and two paramedics. The defendants are expected to enter pleas in November.
Evidence that emerged during the grand jury proceedings prompted the coroner to alter the original autopsy report, but the changes remained secret for more than a year.
The amended version released Friday was made public under a court order after Colorado Public Radio and several other media outlets sued to get access to it.
McClain’s case drew little interest outside Colorado until the May 2020 murder of George Floyd by then-Minneapolis police officer Derek Chauvin. McClain’s death became a rallying cry in the months of protests that followed. Friends and family remembered him as a gentle person who would use his lunch break to play violin for animals at a local shelter.
Aurora last year agreed to pay $15 million to settle a lawsuit by McClain’s family. The city also banned the chokehold used in his arrest and is considering a ban on ketamine.