everything and just have a good time here night it's really not simple it's really that simple just a good ni just [Music] I [Music] [Music] I e e e e e e study session of February 22nd um 2021 uh is now call the order with the clerk please call the RO mayor Coffman here mayor proen Bergen here council member bersin here council member kums present council member Gardner here council member guber here council member hilts here council member Lawson here council member Johnston here council member Marano present and council member Mario presid okay there's the Quorum uh the only issue on on tonight's uh agenda uh for this study session are uh is the um results of the six-month independent study uh independent investigation on on the um circumstances surrounding uh the Elijah mlan incident of of August 2019 um the presentation will now proceed and we will take questions at the end of the presentation uh I want to uh inform council members at this time that we will have to conclude at 6:20 that staff needs 10 minutes uh to set up for our meeting at our regular meeting at 6:30 uh please proceed with the presentation uh the presenter's microphone is mute prepar for the presentation please proceed Katie he's is there a way to unmute him we're working on that right now hold on one sec I'm not sure what's going on [Music] you are now on muted good evening no sound press the star six what do I need to do maybe the star Sixx to unmute I can't can hear we can hear you now we can hear you now can you hear me now yes thank you I'm sorry about that um I hope that was not a problem on my end um so Mr Mayor members of the city council good evening I'm Jonathan Smith I'm the chair of the panel engaged to review incident on August 24 2019 between Elijah mlan and the Aur Aurora Police Department and emergency and Medical Response teams on behalf of my fellow panel members we thank the Aurora city council and Aurora government leadership for this opportunity we commend the city for taking this this step to provide transparency which is critical to building trust with the various communities that make up the city of Aurora Colorado on August 24 19 Elijah mlan was walking on billing Street in Aurora Colorado at approximately 10:40 in the evening he was approached by police over the next 18 minutes Mr mlan was taken into custody restrained subject to an attempted crowed hold and then a second successful cred hold injected with the sedative ketamine and suffered a Health crisis from which he did not recover he died a few days later the incident was investigated by the a police department and reviewed by the Adams County district attorney one officer was found to be in violation of policy for threatening Mr mlan with a dog bite all other uses of force were deemed lawful and within policy by the department and the County district attorney Community concerns about this incident and other allegations of police misconduct led the city council to in July of 2020 commissioned this team to review the incident we were charged with first in examination of the facts surrounding the Aurora Police Department and Aurora fire rescues contact with Mr mlan second an examination of all relevant and related Aurora police and fire department policies procedures and practices to include those related to calls for service police contact with individuals use of force calls for medical assistance ketamine use and administrative incident reviews and third the final report setting forth the investigation's findings and recommendations for best practices for the city of Aurora's consideration as it moves forward we delivered that report to the city this morning this investigation is one of several proceedings looking at this incident in addition to our work there's a state criminal investigation a state pattern and practice investigation a federal criminal investigation the city's receiving technical assistance from the firm 21cp and civil rights and tort litigation due to these investigations and other proceedings the panel did not reach any conclusions about whether any of the individuals involved violated policy the law or should be subject to civil liability we leave those determinations to the other proceedings underway our work is completely independent of each of these proceedings no one from the city or any other entity reviewed or otherwise influenced our conclusions or findings the conclusions are those entirely of the panel and the panels alone the panel consisted of Chief Roberto V Senor Chief V Senor served in law enforcement for 35 years he retired as the chief of the Tucson Police Department in 2015 among his many achievements he was appointed by President Obama to serve on the president's task force in 21st century policing and he's currently Consulting on police reform with agencies across the country Dr Melissa Costello Dr Costello is an emergency medical physician in Mobile Alabama she has written and taught extensively on emergency medicine and serves on a trauma Critical Care team for the United States Department of Health and Human Services she is a fellow of the American College of Emergency Physicians and a fellow of the National Association of EMS Physicians I am Jonathan Smith I am the executive director of the Washington lawyers committee for civil rights and urban Affairs I formerly led the special litigation section of the Civil Rights division of the United States Department of J Justice I've been practicing civil rights and anti-poverty law for more than 35 years the panel was represented pro bono by the law firm of leam and Watkins the panel is extremely grateful for the tremendous contribution The Firm made to this investigation and the preparation of the report the panel reviewed all the available information including body warn camera videos major crime unit um uh investigation interviews the reports of the major crime unit um the Force review board reports of the State Attorney the officer reports the autopsy report the MS reports the directives training materials standard operating procedures to the department and we had interviews with departmental leadership we were not able to interview any of the officers or medical personnel involved which is understandable given the other proceedings underway and we were not able to review the Hospital medical records because of privacy concerns tonight the panel will provide you with a summary of our conclusions and recommendations we are also prepared to answer any questions you have recognizing that the report is lengthy and detailed we' be willing to be available to answer additional questions of the city or the council at any future at a future appropriate time I will first take you through our conclusions regarding the facts and place them in the context of the Department's policies and the legal framework Dr Costello will then discuss the response of the Emergency Medical Teams their assessment and the administration of K Chief phis Senor will will present regarding our review of the post incident investigation and recommendations for policy training supervision and accountability changes I will then return to discuss areas of concern that we identifi during our investigation but are not part of our findings we will be then available to respond to questions our report in our presentation tonight is organized around key decision points these include the 911 call on the decision dispatch officers the decision to stop Mr mlan the decision to Frisk Mr mlan the decision to arrest Mr mlan by physically restraining him and moving him the decision to apply force in response to the threat or perceived threat that Mr mlan reached for an officer's gun the decision to app apply a second kateed hold when Mr mlan was on the ground The Continuous use of pain compliance um techniques and the contrast between the officer assertions and Mr McLean's audible statements the transfer of Mr mlan from police to EMS the assessment of Mr mlan by emergency personnel and the decision to render to administer ketamine at 10:29 p.m. on August 24 2019 A call came to the 911 District dispatch a young man told the operator that there was a man in a mask walking Southbound on billing Street the caller said that the man put his hands up and did all these kinds of signs when the caller passed him the caller said that he quote look sketchy end quote and that he might be a good person or a bad person the caller told dispatch that neither he nor anyone else was in danger and that as far as he knew the man was not armed the dispatch reped this as a suspicious person call and sent three police officers dispatch told the officers to quote cover a suspicious party at Evergreen Avenue and Billings it's a black male wearing a black ski mask and brown longsleeve shirt black sweatpants was waving his arms when 911 caller passed him think that's strange no known weapons are involved the officers responding were officer Woodyard officer officer Roda and officer Rosen black Mr mlan was 310 of a mile from his home at the time officer Woodyard was the first to arrive on the scene he parked his car briefly across the street and waited for officer um rhima and officer Rosen black to arrive Mr mlan was walking down the street with a bag in one hand and a phone in the other once the other officers arrived officer Woodard pulled across the street from Mr mlan got out of his car and told Mr mlan to stop I'm going to show you um now two videos of what happened next first the body War camera video of Officer Ward favor stop right there hey stop right there stop stop stop I have a right to stop you because you're being suspicious okay turn around turn around turn around right there following is body warn camera video of Officer Rosen blad at the same time perod approaching Mr mlan from behind because of the buffering um the video and I apologize for the volume of the video the sound on this video will not come through this is the only portion of the body warn camera video that we'll be showing this evening the video of what happened next is hard to watch out of respect for Mr mlan his family and those who knew him we will describe the events as shown on the video rather than play the video the videos are publicly available for those who wish to review them using a factual portion of her report as your guide as you can see from the video clips that I just showed you within fewer than 10 seconds from getting out of his car officer Woodyard physically grabbed Mr McLean's arm very shortly thereafter officer rosenblat grabbed his other arm during this time Mr mlan told the officers to quot stop end quote to let me go and quot you guys started to address me I was stopping my music to listen now let go of me rather than let Mr mlan go the officers continued to restrain him it is important to note that neither the caller nor any of the officers identified a crime that they thought Mr mlan had committed was committing or was about to commit a police officer May initiate a voluntary encounter at any time and it does not implicate the Constitution if any reasonable person would understand that they are free to go an investigative stop often called a Terry stop after the lmar case of terver Ohio is considered significant intrusion on individual liberty and is protected by the Fourth Amendment for an officer to compel a person to stop for the purpos of conducting a Terry or investigative stop the officer must under the Federal Constitution and Colorado law have reasonable suspicion that the person had committed a crime is committing a crime or is about to commit a crime moreover she or he must be able to articulate or state the basis relied upon to make the stop as will be discussed later in Greater depth in this presentation the major crimes investigators failed to ask the officers involved what basis they decided to convert the encounter from a voluntary one to an investigative stop through the use of physical Force there's much discussion in the report of the major crimes investigation that the officer stopped Mr mlan because he was suspicious that he was wearing a ski mask and heavy clothing was in a high crime area and that Mr mlan did not stop when asked by the officers under the case law which we discussed in the report none of these factors alone or together amount to Reasonable Suspicion in this regard it is worth pointing out a few things first Mr mlan was free to continue on his way unless the officers had Reasonable Suspicion to stop him the notion that his failure to stop when asked creates Reasonable Suspicion renders the notion of a voluntary encounter a nullity it cannot be that you are free to leave until you choose to exercise that right and that your decision to leave provides the basis to compel you to stay second the area which the the area was not in fact a high crime areaa as the this map shows the area in which Mr mlan was stopped by the police ranges from low to medium activity for Crime third that evening the temperature was in the 60s and Mr mlan was wearing a light jacket we don't know why he was wearing a ski mask but as the video shows most of his face is visible and the wearing of a mask without some evidence of criminal conduct is not enough to establish Reasonable Suspicion fourth when Sergeant Leonard arrived on the scene he repeatedly asked asked why Mr mlan was being restrained and whether there was any allegation of criminal conduct he even sent officer Ward to call 911 the 911 caller to determine if he saw anything criminal upon learning that there was no assertion that Mr mlan committed a crime he did nothing to change the conduct of the officers the officers told the major crimes investigators that they grabbed Mr mlan because they wanted to conduct a Frisk officer Woodyard stated that he decided to conduct a Frisk even before he got out of his car and that he waited for the other officers because he did not want to conduct the Frisk alone the authority to conduct the Frisk is a separate legal analysis from the authority to conduct a stop if an officer has Reasonable Suspicion to conduct a Terry stop she or he may conduct a Frisk only if the officer has reasonable and articulable suspicion that the person is armed and dangerous during his interview with the major crimes investigator officer Woodyard provided the following justification for his decision to to Frisk at this time officers Rosen blat and rhima they are to the south of him and they're walking up so I felt safe making an approach he didn't have any weapons or anything I could see in his hand and then when I went up to try to grab him my position of Advantage was his wrist and elbow he tightened his arms up and put them to his chest so I held my hand to his chest while trying to talk to him officer Ros and black grabbed his right arm and I had his left I'm trying to tell him to calm down and wanted to Pat him down for weapons based on him having a ski mask on on kofax in the middle of the night and it was causing people to call in I thought that he might have weapons on it the major crimes investigator and as far as we can tell no one else ever asked officer Woodyard why he thought Mr mlan may have weapons on him in our report we focused significant attention on the decision to stop and the decision to Frisk these decisions and the attendant uses of force set in motion the events that followed and led to the increasing and persistent use of force events unfolded very quickly at some point the Terry stop of Mr mlan was converted to an arrest the officers told the major climbs investigator that they decided to move him off a rocky area and onto the grass because they thought they needed to quote take him down end quote officer rosenblat told Mr mlan quote let's get over to the grass going to lay you down end quote officers need only reasonable suspicion to conduct a terrist stop while conducting a ter stop or a Frisk an officer is authorized to use a limited amount of force to effectuate that stop so long as such such NE steps are reasonably necessary to protect their personal safety and to main this maintain the status quo during the course of the stop however if officers use more Force than is necessary to protect officer safety and maintain the status quo the Terry stop is converted to an arrest once a Terry stop transforms into an arrest the officers must have probable cause that the individual committed a crime in order to continue the detention probable cause is a higher standard than Reasonable Suspicion necessary for a ter stop the use of forceful forceful techniques which include taking an individual to the ground generally turn a Terry stop into an arrest unless the officer can justify the force based on articulable grounds that the person is armed imposes a danger to the officer or others none of the officers articulated the grounds for which they had probable cause To arest None were ever asked by the major crimes investigator or others at this point less than a minute after the officers first approach Mr mlan Force has been used against him to conduct a Terry stop to attempt a Frisk and to effectuate an arrest I've spoken a bit about the Constitutional framework to consider these actions it's important to note as well that the Aurora Police Department speaks to this question at the time director 5.3 required quote when practicable officers will attempt to deescalate their force and or the situation so that lesser force or possibly no forces required end quote no effort to deescalate appears from the records available to us nor were the officers ever asked about their efforts to deescalate we note that the department has changed its policy since Mr McLean's death with regard to suspicious person calls to require that officers stop and observe before initiating an encounter to be certain that there is in fact a lawful Public Safety basis to stopping an individual that new policy will be discussed later in this presentation in Greater depth after the officers began moving Mr mlan from the sidewalk officer Rima told the officers quote he grabbed your gun dude end quote officer Rima told the major crimes investigators that he saw Mr mlan reach for the off reach for officer Rosen blad's gun the off officers then struggled to restrain Mr mlan Officer rosenblat attempted a cored hold when he released the hold after concluding that he could not accomplish it because he was in quote a bad position end quote officer Woodyard wrestled Mr mlan to the ground it is important to note that this happened within a matter of seconds case law has held that a suspect grabbing or attempting to grab an officer's gun authorizes officers to use Force up to an including lethal Force because a suspect who was able to gain control of an officer's weapon poses a grave risk to officers and others the body warn camera video at this point is scanted because officer Woodards and officer Rosen blad's cameras have been knocked to the ground the audio and the subsequent interviews indicate that any threat or P perceived threat was dissipated quickly when Mr mlan was taken to the ground by Officer Woodyard once Mr mlim was wrestled to the ground he was lying on his side officer Woodyard was lying next to him as officer Woodyard described chest to back officer woodyard's gun was underneath him while lying in this position officer Woodyard made a second attempt at a coted hold there's conflicting information on the audio of the body warn camera video and in the interviews about whether Mr mlan was rendered un unconscious one of the officers stated that Mr mlan made snoring sounds the panel notes that significantly at the time of this incident a kateed hold was considered less lethal Force Under Aurora Police Department policy section 5.8.3 permitted officers to apply a crowed hold when quote met with violent resistance and when lesser means have been tried unsuccessfully or other means are not feasible end quote GED holds have since been banned by the city of Aurora as a matter of policy during his interview with Major Crimes officer Woodyard Justified the use of the second kateed by reference to the prior attempt or perceived attempt by Mr mlan to reach for officer's gun by his own statements however that threat had been dissipated they were both on the ground and officer Woodyard was lying on top of his weapon a determination of whether force is reasonable turns on whether the officers were in danger at the precise moment that the force was used police officers must calibrate the use of force to the actual resistance they are experiencing as the level of resistance increases or decreases the level of force authorizes increases and decreases accordingly it is unclear from the record what current threat officer Woodyard was intending to address when he applied the second kateed hold finally I would like to talk about the use of pain compliance sck needs from the moment that aora police officers first encountered Mr mlan up until the time excuse me up until the time Mr mlan was placed in the ambulance stretcher officers applied some form of physical Force against him even once it should have been obvious that Mr mlan was not able to resist or Escape given both that he was handcuffed and the presence of multiple officers the officers continued to use paying compliance techniques throughout there were times when officers could be seen on bodyw war camera footage adjusting and intensifying arm bars and wrist locks pressing down on Mr McLean's back or large muscle groups causing him to cry out and plant pain while they were on top of him these appeared to be in response to almost any movement on Mr McLean's part the officers Justified the continued use of force on the grounds that Mr mlan continued to resist the officer's commands and showed extraordinary strength the audio captured by Body bodyw warn camera video contains two sharply contrasting narratives this is some of the most difficult audio to listen to if you choose to listen I urge you to pay close attention to what Mr mlan is saying saying and what the officers are saying and doing on the one hand Mr mlan is pleading and apologizing and expressing pain he complained several times that he could not breathe and at one point an officer was instructed to get off his chest Mr mlan can be heard saying I have no gun I don't do that stuff I don't do any F I do not I don't do any fighting why are you attacking me I don't believe in guns I don't even kill flies I don't don't eat meat I'm not a vegetarian I don't judge people for anything I respect all life forgive me all I was trying to do is to become better I'll do it I'll do it I'll do better to help all life I will do anything I have to sacrifice my identity I'll do it I'll do it you are all phenomenal you are all beautiful forgive me on the other hand the officers continue to perceive resistance telling Mr mlan to stop moving Moving And discussing various uses of force to restrain Mr mlan it is unclear whether Mr mcan's movements interpreted by the officers is resisting were attempts to escape or simply efforts voluntary or involuntary to avoid the painful Force being applied on him or to improve his breathing or to accommodate his need to vomit the officers used the force did not appear to relent even after Mr mlan was in handcuffs became progressively more ill and less responsive and surrounded by a large group of officers none of the officers who continued to apply Force after Mr mlan was restrained was asked to explain their continued use of force the case law makes clear that force is authorized to meet the resistance at the time that it was applied the evidence available does not provide a justification for those for the near constant use of very painful Force techniques I will now turn it over to Dr Castel thank you John um I hope everyone can hear me okay so when we look at the point from which EMS arrives uh in this case um there's really two separate things going on Jonathan has covered uh the police aspects of this very well I will dig more into the uh EMS aspects of this and as we looked at those there were several um categories of findings in which we identified issues in areas where we feel that Aurora fire rescue or both Aurora Police Department and Aurora fire rescue together can effectuate improvements in the interactions with future patients in this system uh one of the things that we identified that's been brought up in other places as well is that there was a delay in the transfer of control of this patient from the police to the EMS system uh another is the lack of clear communication and the possible loss of information between the police officer ERS and and Aurora fire rescue as they took over care uh the delayed and incomplete assessment of Mr mlan which we'll discuss uh the failure to obtain appropriate equipment and have that at Mr McLean's side an inaccurate estimation of Mr McLean's weight and then ultimately uh I'll discuss a little bit about some of the cognitive errors that I saw evidence of here and how those uh play a role in medical decision making you can go ahead so in discussing the issue of transfer of patient control there's always in these cases a transition between when a patient who is either a subject or a suspect um in Mr McLean's case he he was a subject of a police investigation um ultimately has to become a patient and the point at which that occurs is not always black and white as far as the timing uh however in in this case there was some evidence that that that there was a delay in that transition uh the transfer of control really the transfer of authority over what's happening at that scene has to occur for for a person to be to change from a subject of the police investigation to a patient that is under the control and authority of EMS and who then falls under the authority of the medical director and the paramedics and EMTs working under that person's license in this case EMS arrived uh about six or seven minutes before they actually uh initiated some Hands-On contact with Mr mlan uh there's uh several images on the body camera footage of them standing back and observing and while there is a lot of information that can be gleaned from observation it is a concern of mine and of the panel that they did not press forward and and initiate some contact with him in in the form of transitioning him to becoming more of a patient uh there was certainly some difference to the officers um even as even after the sedation had occurred there was some um discussion back and forth and it's difficult to say whether that was deference to the police officers on the scene or whether that was efforts at collaboration um It's always important for these departments to work together um and it is it is invaluable when they can work together seamlessly however in in this case the transition was not seamless and it didn't occur in a way where I feel like EMS clearly had the opportunity to step in and do some evaluation that I think was necessary um in in some of our discussions we um came across this culture um Chief Gray's Chief gray was able to summarize it best but we came across this culture of the the concept that the patient isn't a patient until the police say they are and and that's something that came through both in our interview with the chief but also in the interviews with the paramedics who are on scene and in some discussions about the culture of that department you can go ahead so this is one of the photographs um that I captured off of the the body warn camera footage and what you're seeing is the the Mr mlan is on the ground below this um and then these are our four the four members of the fire crew who are standing back and observing um watching and like I said they have been they have been at this point in this position for several minutes and this is about the time that the uh EMS crew from Faulk arrives Faulk is uh Faulk ambulance is the transport crew um Aurora fire and rescue does not transport patients they do initial treatment and assessment and for the patients that need to be transported they're transported by faul so this was while they were waiting for Faulk EMS to arrive both to effectuate a transport of Mr mlan and to uh arrive with the medications that they were going to require to sedate him um they had already made a decision to sedate at this point and you can forward it they had already made a decision to sedate at this point and there was discussion ongoing about the timing and how long things were taking which I'll get into a little bit more later this is an additional photograph of um now the arrival of the Faulk paramedic so at this point there's there's five medical personnel standing around this um this young man with uh the the law enforcement officers having him in custody and no one has initiated Hands-On contact at this point yet and and so this is the the point at which um there should have been some initiation of contact and the transition of authority really needed to have occurred prior to this point so you go forward so in response to this we felt like the recommendations that came through clearly were a need to clarify the policies and do more teaching and education on the transfer of authority from one agency to the other um inter agency relations are very important but ultimately um all of those things have to be superseded by the the importance of keeping patients safe um the culture within the Departments needs to be one of patient advocacy and patient safety as the primary driver of of all things that happen within these departments and we really want to see um uh Aurora fire rescue build a culture of patient advocacy uh there is um a duty to act um policy and language within Aurora fire rescue and that is uh an a a policy that allow that allows them and compels them to step in if they're seeing things um that are endangering patient safety on a scene and with the initiation and with the passage of the um duty to intervene uh legislation in Colorado that it refers to the public safety officers I felt it was important for them to review their duty to act policy within a RI rescue and make sure that that language uh was in line with the stronger um directives and the duty to intervene policy that governs law enforcement so you can go forward so there were several Communications failures uh in this um handoff uh when the handoff ultimately did occur and one of the important pieces of research that is out there is about the difficulty in keeping all of the information that's relevant to a case cohesive and communicating all of that information in a way that both the sender and the receiver of that information hear and and retain the same things um every transition of patient care uh does involve a potential for loss of information and there was some of that at play here um I'm going to play a video on the next slide of really what constitutes the entirety of the report that was from the police to the EMS agency and the information that they were working with at the scene you can go ahead Jonathan we should have audio so this is the approach of the paramedic or of the basic EMT from that crew there is about a 10-second interaction which we're not hearing the audio on so I apologize for that but essentially they said that he' had a kateed hold that they had um he had some vomiting and that he was the quote was he was quote definitely on something unquote and that was it that was the entirety of the discussion um between now the person who is the lead police officer on that scene and and communicated unfortunately to the junior most EMT on that crew uh whether any of that information ultimately made it to the paramedic were not is not clear uh but what is clear through the interviews is that the both paramedics did not recall having been told that one that there was a successful corate hold with loss of consciousness or that Mr mlan had been unconscious at any point during this interaction and so what we recommended and you can go ahead to the next slide what we recommended to address these things are to really research and develop within the um departments together uh a handoff tool whether that is a mental tool whether it's a written tool whether it's an electronic tool um some device or method by which um all of the agencies who handle patient information from Aurora Police to Aurora fire potentially to um to Faulk and then from Faulk to the emergency departments um that all of those transitions of care are done in a uniform way so that all of that information is conveyed clearly and in the expected format and in the expected order that way the people know if there's anything that's been missed um and then the other thing that came through in that video is the fact that um there was a discussion that was happening on the side there was this Interruption of a patient care report that was offered and then immediately uh another interruption in that discussion along with everybody moving around um that level of distraction and that level of multitasking um is one of the things that's been identified as a major issue in information loss when when it comes to transitioning patients and so the recommendation is that there be developed a formal process in addition to the tool that there is even just 15 or 30 seconds where the the the the receiver And the reporter on patient care information are are giving each other undivided attention so information is communicated clearly um you can advance so when it comes to the delayed the delayed assess assment and the incomplete assessment of Mr mlan by way of background uh assessment is is generally broken into both a primary assessment and a secondary assessment the primary assessment is essentially a walkup quick impression of what's going on um an assessment of a brief level of Consciousness is a patient responding or not um an assessment of essentially the basic ABCs just like we all learned in CPR class um and is you know is there Airway intact are they breathing do they have a pulse and then identifying major life threats in this case if they had life-threatening bleeding or if they had things that were that needed to be intervened on immediately and then generally includes an assessment of vital signs and the primary assessment is the one that lays the foundation for the clinical decision- making um secondary assessment sometimes happens later sometimes doesn't happen at all depending on the circumstances sometimes is very limited just to a specific complaint um if you have a broken leg it's a very easy assessment if you have a complex medical condition it can be very complicated uh however what we really know is and what we acknowledge in this report is that limits of the ability for paramedics to do this and for EMTs to do this on scene is a is a everyday reality of working in the EMS environment and really we understand and I know I understand in my experience there are lots of patients who can't get a complete assessment and and that is a daily reality both in EMS and in emergency medicine some patients are unconscious and some patients are are not cooperative and some patients are are don't have the information that we need and so the the limitations in our ability to assess are definitely a reality in this environment when you're transitioning a patient from law enforcement control to medical control um it can be especially challenging because there is a need for support from both sides to to do a medical assessment without compromising law enforcement's ability to maintain control and prevent injury both of the patient and of all of the surrounding personnel and so there is a reality that there are limitations however it was the feeling of the panel in this case that there was there was not enough limitation in their ability to access and assess Mr mlan to justify the lack of assessment that was done and so we offered several recommendations about that and and in addition talked a little bit about um that some of that difference and how that played into um the delay in their assessment and then the time pressures that uh they were feeling whether it was because of the diagnosis itself um once the head settled on a diagnosis of exited delirium that that diagnosis with carries some time pressure inherent in it uh in addition there's probably some self-imposed uh time pressures and then also some pressures from the surrounding officers and and firefighters asking what was taking so long and and you know where was the ambulance and and you know put your head in and check and see what's going on so all of those things led to the conclusions and the recommendations that we offer on the next slide essentially it sounds very basic but there's a lot here um it's the look at policies procedures and Trin training surrounding patient assessment um with a differentiation specifically between basic assessment and between a an assessment that should be um a minimum standard for assessment of patients who are being sedated in this case there's certainly a reason that the assessment was limited initially however it was the feeling of the panel that we felt once a decision was made to effectuate sedation chemical sedation that that should have carried with it a much higher threshold for trying to get in and do further assessment before sedation was administered um the the onus is on the paramedic to to do that assessment and to almost push in and and be able to get that done for the safety of the patients and the the flip side of that or the same side of that is that because there is such an imperative that this assessment be done at least in portions prior to sedation um particularly because the sedation itself will interfere with the paramedics ability to continue to get some of the assessment that helps them make a diagnosis that the training it to law enforcement should emphasize the fact that it is important for them to have adequate time and access to patients to assess them particularly when those subjects that are with law enforcement are going to become patients of EMS you go for it so the equipment issue that we brought up was the failure to obtain the appropriate equipment uh there were several places in the body warn camera footage where I was looking for the appearance of equipment the appearance of a monitor the appearance of oxygen and uh that's I did not see that um throughout this encounter um there were some equipment pieces that arrived sporadically throughout but not what I would traditionally have expected the crews that I supervise or other Crews to bring to the side of a patient who is in this um scenario uh there is policy that clarifies um what transport EMS crews are to bring when they respond secondarily to aora fire rescue but um we were not able to put hands- on policy that identify what the Aurora fire rescue crews are to bring to the side of a patient when they are first on scene um my my contention and the contention of the panel is that that the presence of equipment could potentially have prompted further assessment it's hard to stand over a bunch of equipment and not feel com some compunction to to begin to use some of that um additionally there was not a pre-sedation check off to verify that all of their equipment that they require for Sedation under their protocol was present and at Mr McLean's side and ultimately what we found from the reports and information in the interviews is that one of those pieces of equipment the capnography monitor was actually not where it was supposed to be it was ultimately in the in the ambulance but it was not in the location that anybody expected and was a delay in application of that device which could have provided some useful information over the course of his care um ultimately the cardiac monitors and other um tools to assess vital signs were not applied until Mr mlan was in the ambulance several minutes after his sedation and unfortunately at the point at which these were apped he was already in cardiac arrest and so we lost the opportunity potentially to intervene if there had been um something indicated on the cardiac monitor that he was clinically declining and so you can advance and this resulted in several recommendations um the first being another obviously review of policy protocols and trainings to make sure that there's a complete predation assessment um as far as can be done um whenever feasible um including predation assessments of cardiac and capnography monitoring with obviously the caveat that there are limitations to this and we understand those um exist in in all of these environments uh that said uh the protocol gives a list of things that need to be completed in a post sedation environment particularly in excited delirium patients and we felt that that list should be prioritized with particular attention to completion of all of the aspects of a primary survey that are not able to be completed in patients that require sedation early on in the process um particularly monitor application because that provides so much valuable and useful information in patients that are clinically declining uh the recommendation that surrounds that really is a strong recommendation for implementation of a manual checklist process uh ation chemical sedation of patients uh in this scenario and with the diagnosis of excited delirium is is one of the events we refer to as as a high-risk lowf frequency event in medicine um it's a terminology that has come out of several Industries um but all of those industries that deal with high-risk lowf frequency events um have implemented to varying degrees checklist processes um anyone who has gone back and watched uh the the solenberg um interviews and or read uh his book about the landing of the of the airline around the Hudson can understand the importance of checklists and how they contribute to safety uh even in scenarios where you're moving very quickly and especially in scenarios where you're moving very quickly you can go on to the next slide so the inarch estimation of the weight um Mr McLean's weight was uh was overestimated um by a large degree um depending on on who was asked what his weight was uh the weight estimates varied from a low of about 160 pounds to a high of 100 kilograms which is 220 pounds um by all the various sources uh at the time of his death he was 140 pounds um the only consistent thing we found from all of the places that his weight was reported is is that it was consistently overestimated um what we've looked at was the fact that number one I think a better assess would have potentially helped in improving the estimate I'm I'm trying to like I'm trying to speak over the the conversation going on in the background everybody mute their um um microphones thank you sorry about that speaking of distractions um so I think a better assessment would have have improved their their weight estimate um one of the primary pieces of a primary survey when we talk about Airway breathing circulation is that is the ABCDE the D is the assessment of of disability or their mental status and the E is expose it's get a look at the patient either remove clothing or get a better sense of what's going on with the patient by exposing their skin or any of those things and that was a step that was not done here prior to that sedation um and may have contributed to a better estimate on his weight um we then got into this um cognitive shortcut of rounding and um shortcutting the actual math that occurs in in the dosing of ketamine um the the small medium and large dosing which you here referred to and we discussed in in the report really leaves us in a place where we had an error in estimation which was then compounded by a rounding issue um that may be a perfectly valid tool but doesn't comply with the way the protocol is written um and so those two things together combined to result in a dose of ketamine that was was much higher than the an actual weight and an actual mathematical calculation would have resulted in that said there is no definitive evidence that we found uh in this that ketamine had a role in Mr McLean's death um his clinical status was declining prior to the administration of sedation um if anything the ketamine may have cont have contributed to some difficulties on the part of the paramedics after his sedation in assessing the fact that he was continuing to decline but that decline that he was having was going was was occurring before the ketamine was administered um secondly there and more importantly I think is that there was not evidence from the coroner or any of the records that accurate dosing would have changed his outcome um unfortunately um it is not a situation in which we can fortunately or unfortunately it's not a situation in which we can take this specific extra 140ish milligrams of ketamine and and place the BL blame there it's just that's not how this case went had transpired um the important takeaway though is the implication that this has for future patients and for many many of the medications that are used in the EMS environment that are all based on weight because there is not the opportunity to weigh these patients um in the field particularly when they can't tell you how much they weigh and there's a lot of medications that are weight-based and so looking at this go ahead you can move forward we made a couple of recommendations based on the issues here uh one was to explore Education and Training on accurate weight estimation um the piece of this that that came through in some of the reports is that there's good evidence that the weight of of young black men is consistently overestimated in medicine and in health care and even just having that piece of information in the back of their mind will allow paramedics and EMTs to make a mental adjustment of an estimate that they're making uh to prevent that inherent overestimation that that can occur in this population of patients and adjust for that and being educated on that is enough to help put offset that one place where this um role of implicit bias um rears its head in in in the medical environment um the other option is to give them other tools to to verify an accurate weight um driver licenses and state IDs all have weight listed the patients that can communicate can be asked and then we wanted to ensure that there was consistency in the protocols across the whole department we want to make sure that if they start teaching it one way that it stays that way throughout um and if there are cognitive shortcuts they need to be put in and Implement imple implemented in um protocol so that they are permissible under the rules you can give me the next slide lastly um there were some cognitive errors that played a role here and without getting into the Gory details of decision- making in medicine um essentially once someone has decided that a diagnosis is happening um there is a lot of um mental energy that goes into looking for information that helps prove that diagnosis and is and it is very very difficult even in very experienced clinicians to separate themselves from that diagnosis and look at either information that doesn't fit or information that contradicts what they have already found and the particular one that I was going to bring up and I bring up in the in the uh report as well is this concept of ascertainment bias um ascertainment bias is when you go into a situation expecting something and then you look for information that continues to prove your expectations and the example that I give is the idea of a patient who's collapsed um if you were to close your eyes and picture for a minute that you're an EMT and I want you to I'm going to send you out on a collapsed patient and I tell you that piece of information I give you next is that patient collapsed in a football stadium or alternatively I tell you okay that patient collapsed in an elementary school or that that patient collapsed in a nursing home and if you're picturing in your head what that patient looks like each time I Chang the setting or the scenario if they collapsed in a bar if I sent you because they collapsed at the jail if your patient in your head does not look exactly the same in every one of those scenarios then this is a little bit of those that cognitive decision-making that I'm talking about here and this Al this can allow an introduction of bias into clinical decision- making and it's important for Medics to understand how that plays a role and the role that protocols have and the adherence to protocols have in diminishing the bias that can affect um these decisions you can go ahead so our recommendations here uh are basically just to educate on cognitive errors and clinical decision- making understanding the process of how this happens uh that we want to continue to provide education on excited delirium I in the description we get further into the idea of how these errors can lead to somebody giving a diagnosis like exceded delirium and then only searching for information that validates that diagnosis and missing signs that there potentially something else going on um the focused excited delirium education is important because it is um such a unique entity within altered mental status or within behavioral problems or or those issues that rolling it into other protocols or rolling it into other disease entities is is potentially fraught with danger because you then roll that set of treatments into disease entities in which it's not appropriate so uh the recommendation was to maintain a standalone um excited delirium protocol um it is a it is a subsection of a protocol that's appropriate but it is a separate disease enti that that if it's maintained that way will allow us to manage that specific uh illness as a unique entity and not confound it with other issues that may cause altered mental status or psychiatric or behavioral problems um there are some things ongoing um there's there's a ton of discussion around ketamine and EMS right now and I think that over the next um probably six to 12 months there'll be some things coming um from the state there'll be some things coming from the federal government and that Aurora will be well served to to incorporate all of that into their findings um and into changes in their protocol next slide we did make some specific protocol recommendations these are probably more interesting for um the fire and EMS people who get down in the Weeds on protocol um but there were some recommendations about cross linking um being improving the the connections between protocols for for situations when you move from one to another um the uh discussion of checklists for high frequenc high high high risk low frequency events and for specific complex tasks and then there were recommendations around specific additions to the excited delirium protocol in um Aurora that have been shown through the research to provide benefit to patients um some of them are already in protocol and we just refined them and some of them are would be new additions you can go ahead and then there were a couple places I wanted to just say some positive things about the department um as far as what I was able to witness and what we were able to see on the video and in our review um the sedation and the interaction itself was a low frequency event when Mr mlan unfortunately had a cardiac arrest event and his heart stopped it's clear from the video footage that dealing with a cardiac arrest scenario with a situation where a patient's heart is stopped and we have to take over CPR and all of those um all of that resuscitation process it's clear that this is a situation that the the the paramedics are very well trained for the the Snippets of video and the and the resuscitation descriptions um are a classic demonstration of pit crw CPR which is definitely a best practice and has been shown to improve neurologic outcomes in cardiac RS resuscitation uh that came through loud and clear that their training and education and experience with this is solid and is a best practice that's already ongoing uh the second piece um that we wanted to point out was their quality assurance and quality improvement process um it is the structure is based on just culture it's a multi-disciplinary multi- agency quality review uh it is something that occurs on a regular basis and is involved with with their EMS physicians at a high level and um it is important to have that structure in place in order to ensure that there's a full thorough look at Patients where situations where there's a bad outcome um and to identify ways that the system can improve um these reviews are uh peer review protected they do have um certain legal protections that allow the system to be able to improve without um without outside eyes uh in order to be able to um have full disclosure of events that go through that go through this process and so as it pertains to Mr McLean's case in particular this was not something that I was able to review as part of the panel or that the panel was able to review was the results of the quality assurance process and that is certainly a set of of protection legal protections that I'm highly respectful of as a practicing physician because um we want to have events that we can look at and make sure that patients are safer um without that um level of scrutiny and exposure so let me see I think that's my last slide yeah I'm gonna turn it over to uh the uh Roberto via Senor good evening what I'll be talking about is the the post incident investigation of the case by the or Police Department the major crime unit was assigned to the case and on the video you can see Sergeant Leonard advising officers that this was going to be a major crime unit case because Mr mlan had cour out referring to the stoage of his heart while he was in the ambulance at that time he involves advol excuse me advised the involved officers to separate and not talk to each other which is standard procedure when these type of events occur in order to try and preserve the Integrity of the interviews upon arrival at the scene the major crime unit was briefed on the incident by Sergeant nunus who was also another supervisor who was on scene the Aurora's major crime unit along with Denver PD's major crime unit both responded in fulfillment of a memorandum of understanding between the two agencies this is an area where a PD is Progressive and joining with surrounding agencies to review these type of incidents unfortunately however the assignment of a investigator from within the agency of the involved participants tends to water down that that effort to make sure that the investigation is not biased detective Inu from aoy is assigned as the Le investigator next slide pleas major crime unit initiates the investigation that involves the interview of the officers they interview the police officers either the night of the event or a couple days after specifically officer Woodyard and officer Rosen blat were interviewed on August 25th and officer Ral was interviews in August 28th the officers were not allowed to view their body warn camera prior to being interviewed no other police officers were interviewed at that time even though there are several other officers on scene while Mr plane was being held down on the ground who could have given their perspective as to the level of resistance and what they observed this was one of our first indicators of the concern that we developed as a panel of how the case was investigated and the absence of internal affairs as component of the post investigation the firefighters were not in viiew till sometime interviewed till sometime after the event specifically firefighter Bradley was interviewed on September 9th lieutenant chunc and paramedic coer were both interviewed on September 11th these interviews are two weeks after the event and then firefighter deu was not interviewed until September 23rd which is four weeks after the event we felt this could be problematic because at this time the event had already become controversial and there was a lot of publicity about the event having that much time passed since the event occurred takes away the spontaneity of the responses that you could get from the participants and really best practice would be that you would try and get those interviews done as quickly as possible they had at least four detectives and one inv investig respond to the scene that night and if needed between the two agencies they could have brought more Personnel out to conduct those interviews in a quicker time period we also in the review of this investigation developed some concerns about the questioning and the leading nature of the questioning by Major crime unit the officers involved were not asked key questions as we pointed out several times about their conduct the justification for their actions their thought process of why they did what they did also at times that questions appear to be trying to generate what is looked at in the report is Magic language which comes from case law exonerating use of force next slide please as an example of this I I took some excerpts of the interview of B Woodward by detective anyway and I'll read them here and these are the words taken directly off of the the recorded interview okay and then you heard officer rhma say he's going for your gun or going for a gun Officer Woodward says yes detective in says okay and how do that physically make you feel Ward replies to be honest kind of sick okay besides sick how would you were you what and officer Woodward then kind of Ms and detective Engle says emotionally how did you feel what ran my emotions up next slide please detective anyway continues okay were you nervous yeah were you scared a little bit yeah okay so was there fear within you yes there was detective inry says okay both for your own safety and and then that point officer would finish and say for my safety and the officers on scene the leading nature of these questions and quality posed it raises concerns about you know trying to get the individuals to that location where they say the words that have been shown by case law that it does justify the use of force actions next slide please in addition the report of the major crimes unit in the panel's opinion somewhat stretched the the uh record in a parent attempt to exonerate the actions of the officers rather than present virgin facts for example the report stated that the officers were there quote to check on his well-being and that they attempted to explain to mlan why they wanted to talk to him and determine if he needed medical assistance nothing that we could find in the record the video or the interview support these assertions the closest evidence in the record is that officer Woodard stated that he would have stopped Mr mlan even absent the call because he was acting strangely none of the officers ever Express the concern that he might need medical help in Emergency Medical Services appears to have been summoned in compliance with the Aurora policy that whenever a cored hold is applied EMS must be called to the SE to do an evaluation furthermore detective Inu wrote officers Roda Woodard and Rosen black continue to struggle with violently resisting the claim through their entire encounter even after he was placed at the handcuffs unquote and while it is true that at least one or two two officers were in contact with Mr mlan until he was placed on the gurnie the video and the audio did not support the claim that Mr mlan was violently resisting throughout the contact but could actually he be heard he could actually be heard crying cleaning vomiting at times and completely silent at others any movement on his part was met with swift countermeasure of control holds or body pressure of major muscle groups all of which appeared to cause further pain it's unknown if the caus further movement on Mr mim's part that this was a cycle that was generated but what was clear is that the movement did not appear to this panel to be violent in nature once he was on the ground in an whenever I'm sorry next slide please Whenever there was a significant police event including an in cussy death or officer ball shooting the potential for criminal impact to critical impact to the community exists the Department of Justice is so concerned about this event they provided guidance to the cop the cops office Community or police office this says a criminal investigation of an agency employee particularly one involving a felony or crime of moral tarud is so serious that an agency should consider Extraordinary Measures to ensure that the investigation is as thorough and independent of conflicts of interests as possible best practice usually accomplishes this by having internal affairs conduct an investigation looking at it from the perspective of policy and procedures while the appropriate criminal investigative unit will review the potentiality of any criminal misconduct that did not occur here the goal of the major crimes investigation of an in custody to death such as this one like any other investigation conducted by the unit focuses on the determination whether crime has been committed this is a significant scenario when the potential suspect is a criminal misconduct that is being investigated as a police officer in order to maintain any level of trust within the community the investigation has to be above reproach that it cannot be perceived that the officers being afforded any special consideration on the other hand the role of internal affairs is to protect the Integrity of the agency by ensuring compliance with policy its standard is a civil one not a criminal one and as such there are different rules that govern the investigation and the employees action in part again the doj provide guidance stating that Internal Affairs should conduct all serious administrative investigations included but not limited to officer invol shootings in custody deaths alleged constitutional violations allegations of racial profiling or discriminatory policing or racial Prejudice dishonesty drug use several other criminal violations and then ends with as well as cases referred directly by the agency head or Commander staff Internal Affairs should also conduct all administrative investigations of allegations of misconduct that are likely to result in litigation against the agency or its members next slide please we also looked at the Force review board's role in evaluating the investigation the Force review board started their review after the department received the declination letter from the Adams County district attorney on November 22nd 2020 their DEC excuse me I'm sorry 2019 their decision appeared to be based in large part on the summary provided by detective in which we already have mentioned above in response to our inquiry about any other items viewed by the Force review board the police department informed us that the only thing that they looked at was the police reports and the bodyw war camera videos provided with the summing report even so there should have been concern about the jus ation for the ter stop as we indicated earlier and the attempt to Frisk based upon information in the reports in the video the acceptance of the report and the lack of further inquiry or investigation is concerning especially considering the controversi scrutiny of the case was already receiving the board met on January 28th 2020 to discuss the case and declared that the officers were policy compliant on January 31st 2020 next slide please we felt that there were some recommendations that we could provide and started with trading on constitutional requirements the panel did not conduct a thorough review of all training and supervision of officers that process is part of other ongoing investigations in reviews however we do recommend that the city look at providing training in a couple of areas as you see highlighted above first Terry stops and the role of reasonable suspicion we have focused on this extensively in this report because the Terry stop the original stop and the lack of reasonable suspicion of any CRI activity started a Chade of events that everything else flowed from the speed at which the officers reacted had placed hands on Mr plan the apparent failure to assess whether there was reasonable suspicion that crime would been committed and the unity with which three officers acted suggest potential tradeing or supervision issues in ctional law surrounding terrorist stops without assessing other incidents of the training program the panel can't reach a definitive conclusion but best practices would have dictated that the officers would have spent more time observing rather than immediately placing hands on Mr mlan without a more particularized objective basis to suspect Mr was involved in criminal activity the panel also recommends that every car stop and every fris be thoroughly documented for each stop and separately for each fris the officer should be required to provide a description of the reasonable suspicion that justified the stop at the separate basis for the search each stop report must be reviewed for policy compliance appropriateness under the circumstances and individual or agency Improvement excuse me we also looked at the use of force training possibilities there we looked at the reassessing the necessity and amount of force and that how much force should be applied based upon the level and threat and resistance being reduced throughout the contact the unremitting use of force throughout this encounter and what appears to be aair to allow Mr claim to comply after he was taken into custody raises concern about whether officers have sufficient guidance on the need to reassess the necessity amount of force Ed once the level and threat of resistance is reduce often times best practice this is called the continual decision-making model where the officers are trained and taught about the need to constantly assess second by second what is going on in addition greater emphasis needs to be placed on the role of deescalation and all potential use of force incidents while the officers were repeatedly heard telling Mr mlan to stop up to relax to chill out prior to taking it to the ground the fact that they were making these statements after they had already grabbed and control him without any reasonable suspicion of criminal activity somewhat defeats the spirit of deescalation next Slide the post incident review of the death of Mr mlan is of serious concern to the panel and reviewed significant weaknesses in the Department's accountability systems the urges the city to consider overhaul of the postens review process to ensure that inadequacies are identified and addressed in policy training and supervision the panel strongly urges the city to assess the training and supervision of the major crimes detectives as it relates to the investigation of potential criminal misconduct by police officers remaining objective and independent while investigating fellow officer presents unique challenges both detectives and supervisors need special training to Ure that the investigations are both fair and complete the panel believes that this case should have been referred to Internal Affairs as been said repeatedly and strongly urges the city to consider the important role of internal affairs in reviewing an officer involved death while major crimes in homicide roles to determine whether a crime is committed the role of internal affairs is to protect the Integrity of the agency by ensuring compliance with policy the current policy of requiring that only the chief can open Internal Affairs investigations places the chief in a difficult position and limits the opportunity of review by the department for compliance with policy the panel urges the city to reform the three excuse me the forth review board to provide a more critical and objective analysis of these use of force the failure of the board to examine the incident in detail and to look at each use of force against Mr claim separately and with care is a lost opportunity the Force review board should be a critical part of continuous assessment and learning process and every incident should be interrogated for what it could teach the department to avoid negative outcomes in the future we do though applaud I'm sorry next slide we do applaud steps that aora PD has taken since this event in June of 2020 the aora police thoughtfully instituted the following policy changes which address several of the issues we brought forward first was being a ban on the use of the corate hold this guidance is included in the policy on less lethal use of force but we also recommend that it be repeated or at least cross reference in the directive 503 use of force and deadly force and directive 504 reporting and investigating use of force next is the policy dealing with relief of involved officers the department has made an important change to a policy required that officers involved in a significant physical altercation be relieved once the altercation has ended by the first available officer who did not go Hands-On this change of policy is a positive step to ensure that any subsequent use of force be based on the actual resistance at the time and not on the prior conduct by the person being taken into custody the implementation of the policy will reduce unnecessary uses of force and be safer for officers and members of the Comm we also applaud the implementation of a bystander intervention policy policy states that sworn member shall when in a position to do so given the totality of the circumstances safely and immediately intervene to prevent another swor member from using physical force that exceeds the degree of force permitted by law appropriate action may include but is not limited to verbal or physical intervention immediate notification to supervisor or a direct order by supervisor to Cease the use of unreasonable Force finally and we have talked about this earlier the change in the policy on dealing with suspicious person costs upon arrival and locating suspicious person the responding member should take some time to observe the person unless there is something going on that requires immediate contact members should not rely solely on the reporting parties descri to justify a contact and members should use their training and observation skills to determine if the person who is acting suspiciously and that the person was is or seems about to be involved in criminal conduct turn it back over to John for areas of concern of time I will um if I may just briefly not make specific findings on but we're of significant concern to the panel um we've provided the um the City in our report um with the discussion of the um the research on implicit bias in law enforcement and the delivery of Emergency Medical Services um well from a single incident it is extremely difficult um without the direct evidence of bias to be able to assess bias we did um uh see uh indicators that we uh in this incident um that would uh uh sort of advise the city to take a deeper look at um implicit bias it's implicit bias practices training and supervision um the perception of people of color is more threatening the perception of people of color having unusual strength indifference to the effect of use of force um indifference to pain um delay in the administration of care misperception of the dangerousness of neighborhood misp misperception of age size and size of people of color um this is an area where um further work needs to be done and we would recommend that the either the pattern of practice investigation of the work being done by 21 CP would um benefit from further exploration from looking at other incidents beyond the single incident uh we also while there's no nothing in the record to indicate that Mr mlan was in behavioral mental health crisis um the fact that the call that was made to 911 um suggested that um Mr mlan was acting borly strangely um the officers uh themselves um and particularly officer Woodyard indicated that he would have stopped to check on Mr McLean's welfare um did cause us to take a look at the crisis intervention system in Aurora um we did make some very specific recommendations Aurora has adopted the CIT International model um but does not um follow that model with Fidelity and we would strongly encourage a review of its policies procedures to provide more guidance and greater Fidelity to the CIT model there's very good specific material and CIT International materials we want to congratulate the city for its adoption of a pilot of a Cahoots Model A non law enforcement intervention model um and would hope that at the conclusion of that pilot that the city um strengthened support uh Cahoots approach um it's been successful in other jurisdictions and we believe that it can be a tremendous benefit to the city of Aurora and finally um uh Dr Cell mentioned this earlier uh as the city does its review of the use of ketamine um Dr Castell has provided some commentary on the dangers of the Alternatives um to the use of ketamine and uh in the course of that review we encourage uh the city to take a look at what its alternatives are um as it moves forward to determine whether camine should be returned to usage in Aurora or um there are alternative sentatives that would be used under any circumstances um with that that it concludes our formal presentation and we would be prepared to answer questions now if the council and the mayor um have them and there's time to do so you know uh this is Mayor Mike coffin I I'm would would ask the panel if we could do this um uh that staff advised me that um the time required uh by the panel was going to be much less than it than it was and we uh need to start our regular meeting at 6:30 and so would it be possible to have an additional meeting uh where the public would clearly uh have access to the meeting um whether it's a special study session or however it it is what it is structured uh but with with the panel uh be willing to do that this is very important to this city and I don't want to rush the ability for members to ask questions um I can speak for myself and I'll let Dr Dr the Chiefs speak for themselves would be pleased to um reconvene with the the city or city leadership or with the council okay to answer any further questions thank you very much what I will do then is I I'll look at the schedule uh and find time uh for another meeting uh and thank you very much for all your work uh for your presentation on an issue uh we cannot move forward as a city uh unless we understand the problems that we've had and so I want to thank you so much for your independent investigation into this what is a hor what was a horrific incident uh to our city and and remains a wound in our city and so uh with that uh I'm going to conclude uh this particular uh presentation and thank you very much and uh we will again I will work with you on another date uh for a time uh that uh the members can can be able to ask questions and not be rushed and I want to thank council member hiltz uh for for this recommendation uh that I've accepted so thank you panel for all your work and look forward to an additional meeting where we will have the ability to ask questions uh with that uh the study session is adjourned we will reconvene in in the regular meeting uh of the city council at 6:30 p.m. thank you everybody [Music] [Music] you me now