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Amended autopsy report for Elijah McClain cites 'complications of ketamine' as cause of death

Pathologist: “I believe that Mr. McClain would most likely be alive but for the administration of ketamine.”
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Posted at 2:58 PM, Sep 23, 2022

DENVER, Colo (KMGH) — The Adams County Coroner amended Elijah McClain’s autopsy report to show his cause of death was “complications of ketamine administration following forcible restraint” but left his manner of death undetermined.

In the amended report, written by Forensic Pathology Consultant Stephen J. Cina and dated July 1, 2021, Cina writes: “I believe that Mr. McClain would most likely be alive but for the administration of ketamine.”

He also says he has seen “no evidence that injuries inflicted by the police contributed to death.” The original report was also amended to say McClain went unresponsive “immediately following a police involved interaction.” The original report said he went unresponsive “during a police involved interaction.”

Cina writes in the amended opinion that McClain likely would have recovered from being in a carotid hold had he not been injected with ketamine.

“I believe this tragic fatality is most likely the result of ketamine toxicity,” Cina wrote in the amended report. “…Based on my training and experience, I still contend that the appropriate manner of death in this case is UNDETERMINED. 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.”

Cina also explains at the end of the report that “the manner of death is not a medical diagnosis and it is not determined by the autopsy.”

“In some cases, the manner of death may be deemed HOMICIDE but criminal prosecution may not follow (e.g. self-defense). Conversely, certain cases with a manner of death of UNDETERMINED may warrant prosecution if the entire facts of the case indicate that this is appropriate.”

The amended opinion says the original report signed Nov. 7, 2019, ended with McClain’s cause and manner of death as “undetermined” because it was done only based on the information available at the time. The amended report says the coroner’s office, since then, received “extensive body camera footage, witness statements, and additional records” that gave them more detail about what happened to McClain.

Cina, in the report, says all of those materials had been requested before the release of the initial report, “But the material was either not provided to us or not provided to us in their entirety.”

“Having insufficient information as of November 7, 2019 was one of the reasons the cause and manner of death in this case were deemed UNDETERMINED,” Cina wrote in the amended report. “Additional material of relevance has also been generated through the grand jury investigation.”

On Thursday, a Denver District Court judge ordered that McClain’s amended autopsy report must be released to the public without redactions. This came in the wake of multiple news organizations, including Scripps station Denver7, arguing it should be released.

Adams County Coroner Monica Broncucia-Jordan said she had filed a motion to get the court to release the amended report as well.

"I believe in the public's right to information and want to be transparent about the work done in my office," she said in a statement. "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."

CPR News filed a lawsuit on Sept. 1 arguing the amended autopsy report should be released. Denver7 and four other Colorado news organizations joined the lawsuit after open records requests to obtain the amended autopsy report were denied.

The original November 2019 autopsy report from the contracted pathologist found McClain’s cause and manner of death were “undetermined.” Former Adams County District Attorney Dave Young cleared the three officers involved in McClain’s violent arrest of any criminal charges and Nick Metz, Aurora’s chief of police at the time, said the officers did not violate any of the department’s policies.

Allison Sherry of CPR News reported on Sept. 2 that McClain’s autopsy had been amended based on confidential grand jury information that led to the indictment last year of three officers and two paramedics who face a 32-count indictment, which includes manslaughter and criminal negligent homicide, among other charges. Their arraignments have been pushed back multiple times, most recently on Aug. 12, when they were rescheduled for Nov. 4.

A team of independent investigators commissioned by the Aurora City Council issued a report in February 2021 that found the investigation that followed the 23-year-old McClain’s death was flawed. Former Denver District Attorney Mitch Morrissey explained in an interview with Denver7 that this was extremely rare.

McClain, who was 23 when he died, was stopped by officers with the Aurora Police Department on Aug. 24, 2019 after purchasing tea at a local convenience store in Aurora. Around the same time, investigators had received a call about a suspicious man wearing a ski mask and waving his arms in the area.

Aurora officers stopped him on Billings Street, just north of E. Colfax Avenue.

Police said McClain resisted when they tried to detain him and officers put him in a carotid hold and requested Aurora Fire Rescue paramedics to administer ketamine to get him under control. Later, it was determined that McClain was given 500 milligrams of ketamine— far above what was recommended for someone of McClain’s weight.

As he was transported to a hospital, McClain had a heart attack. He died on Aug. 30, 2019.

This story was originally reported by Blair Miller and Stephanie Butzer on