The Adams County coroner has changed the cause of death of 23-year-old Elijah McClain to ketamine administration following forcible restraint but maintains that the manner of death is “undetermined” — contradicting the state’s case against the police officers and paramedics who are charged in connection to his death.

It’s unclear exactly why the elected Adams County Coroner Monica Broncucia-Jordan and her contracted forensic pathologist changed their minds last year amid a statewide grand jury investigation.

In the amended autopsy report made public on Friday, Dr. Stephen Cina, who performs autopsies for Adams County, wrote that he received new information in the grand jury probe, including extensive body camera footage, witness statements and additional records. He said he requested those back when he performed the original autopsy in 2019, but didn’t get everything.

Cina noted that the large dose of ketamine McClain received by paramedics was the biggest culprit in his death.

“Simply put, this dosage of ketamine was too much for this individual and it resulted in an overdose … I believe that Mr. McClain would most likely be alive but for the administration of ketamine.”

Cina also goes on to mostly take the blame off of law enforcement officers for McClain’s death and noted that the carotid control chokehold McClain received by police likely would not have left any lasting damage to McClain’s health.

“This type of hold is often used in the martial arts with no lasting adverse consequences,” he wrote. “There were no findings in the neck indicative of traumatic asphyxiation … I have seen no evidence that injuries inflicted by the police contributed to death.”

Cina noted that his opinion is that McClain “likely would have recovered if he did not receive this injection.”

The initial autopsy, released a few months after McClain’s 2019 deadly encounter with police, had an “undetermined” cause and manner of death and was signed by Broncucia-Jordan, with Cina performing the autopsy.

But during the 2021 closed-door investigation by the statewide grand jury, new evidence was presented and the change was made official on July 1, 2021. It was released to the public on Friday.

McClain’s “undetermined” cause of death on the autopsy has been a thorn in the side of prosecutors and advocates seeking justice for McClain since 2019.

Shortly after McClain was forcibly detained by police and administered ketamine by paramedics on Aug. 24, 2019, he fell into a coma at a hospital and he never recovered. He died on Aug. 27, 2019.

Afterward, the then-local district attorney, Dave Young, declined to file charges against anyone in connection to McClain’s death, mostly citing the lack of a “homicide” ruling on McClain’s death certificate as the reason.

“Elijah McClain’s death was both tragic and unnecessary,” Young wrote in a 2020 press statement, amid roaring protests in Aurora and Denver around police brutality and McClain’s death.

“The forensic evidence revealed that the cause of death was undetermined. Specifically, the pathologist who conducted the autopsy stated that he was unable to conclude that the actions of any law enforcement officer caused Mr. McClain’s death. In order to prove any form of Homicide in the state of Colorado it is mandatory that the prosecution prove that the accused caused the death of the victim.”

Even with this new cause of death being ketamine, it is unclear how prosecutors move forward with holding those who touched McClain that evening accountable for his death without a homicide declaration on the death certificate.

This is particularly true for the case against the law enforcement officers, who didn’t handle the ketamine that night.

The new autopsy contradicts the findings in the state grand jury's indictment

Amid the protests in the summer of 2020, Gov. Jared Polis appointed Attorney General Phil Weiser as a special prosecutor to determine whether there should be criminal charges filed in McClain’s case. Weiser empaneled a statewide grand jury to investigate in January 2021.

In August of that year, behind closed doors, the grand jury completed their investigation.

Felony charges were filed against three police officers and two paramedics for McClain’s death, including criminally negligent homicide and manslaughter. In the 24-page indictment, prosecutors noted that, “Mr. McClain was a normal healthy 23-year-old man prior to encountering law enforcement and medical response personnel.”

It continued: “A forensic pathologist opined that the cause of death for Mr. McClain was complications following acute ketamine administration during violent subdual and restraint by law enforcement and emergency response personnel, and the manner of death was homicide.”

It is unclear who the forensic pathologist is who gave this opinion to prosecutors and the grand jury.

Ketamine was mentioned in the original autopsy, but not as the cause of death

In the summer of 2019, police stopped McClain, who was walking home from a convenience store, because they thought he seemed suspicious. McClain, who is Black, wasn’t suspected of any crime when they aggressively arrested him, took him to the ground and administered two carotid choke holds.

After McClain was handcuffed, paramedics arrived on the scene and chatted with the officers, who told them that McClain seemed to have “superhuman” strength. After approximately two minutes on scene, the paramedics concluded he was suffering from “excited delirium.” They came to this conclusion after talking to officers and observing McClain for one minute, according to the indictment.

Neither paramedic talked to McClain, physically touched him or took his vital signs.

McClain was administered 500 mgs of ketamine, which was administered after paramedic Jeremy Cooper determined McClain’s weight to be roughly 200 pounds. McClain actually weighed 143 pounds and his proper dosage should have been closer to 325 mgs of ketamine, according to the indictment.

Cooper told police, “we’ll just leave him there until the ambulance gets here and we’ll just put him down on the gurney,” the indictment said.

After McClain’s death, Dr. Stephen Cina, a contractor forensic pathologist for Adams County, completed the autopsy on Sept. 3, 2019. There were two Aurora police officers and two representatives from the Adams County District Attorney’s office in attendance.

“The 23-year-old, African-American male, Elijah McClain died of undetermined causes,” the original autopsy said. “Intense physical exertion and a narrow left coronary artery contributed to his death.”

Ketamine was mentioned at length in the original autopsy but Cina deduced that it wasn’t necessarily a factor in McClain’s death. The toxicology results noted in that original report was a ketamine level of 1400 ng/ML.

“The blood ketamine concentration was at a therapeutic level, but an idiosyncratic drug reaction … cannot be excluded,” Cina wrote. “According to Baselt’s Disposition of Toxic Drugs and Chemicals in Man, 8th edition, therapeutic ketamine levels in the serum and plasma range from 1.0-6.3 mg/L following a single intravenous administration … In terms of a fatality, the dosage administered or ingested is not as important as the resultant concentration of the drug in the blood.”

In that original autopsy, Cina also suggested that the fact McClain fought the officers during the original autopsy contributed to his death.

“The decedent was violently struggling with officers who were attempting to restrain him. Most likely the decedent’s physical exertion contributed to death,” he wrote. “It is unclear if the officers’ actions contributed as well.”

Coroner met with police before ruling the cause of death as ‘undetermined’

CPR News reported in 2020 that Broncucia-Jordan met with Aurora police officers investigating McClain’s death before she made her initial determination. And Cina told the elected coroner at the time that the manner of death “may be undetermined” before he had reviewed complete police reports, witness statements or video capturing a violent confrontation between police officers and McClain.

CPR sued the Adams County coroner under the Colorado Open Records Act to get the updated autopsy report. The Associated Press, KCNC-TV, KDVR-TV, KMGH-TV and KUSA-TV subsequently joined that lawsuit.

Broncucia-Jordan, arguing through Adams County Attorney Heidi Miller, said she wasn’t allowed to release the report because the Attorney General’s office, which is leading the prosecution of the three officers and two paramedics, told her it was part of the secret grand jury testimony and evidence.

CPR asked for a redacted version of the updated autopsy and that, too, was denied.

Denver District Judge Christopher Baumann on Thursday ordered the autopsy released, without redactions.

Lawyers representing the police officers and paramedics all declined to comment on the new autopsy report, as did a lawyer representing McClain’s mother, Sheneen. There was also no comment from the attorney general’s office.

The officers and paramedics have an arraignment scheduled on Nov. 4.