(CNN) The Colorado Attorney General's Office released the findings of its 14-month investigation into the Aurora police and fire departments Wednesday.
The 112-page report found that the police department has a pattern of practicing racially biased policing, excessive force, and has failed to record legally required information when interacting with the community, according to a news release from Attorney General Phil Weiser. The report also found APD used force against people of color almost 2.5 times more than against White people.
The report revealed the fire department had a pattern and practice of administering ketamine illegally, the release said. Ketamine is used by medical professionals as an anesthetic, according to the Alcohol and Drug Foundation, and it's also used illegally to get high.
"Our team conducted a thorough examination -- with the aid of the full cooperation of the city of Aurora -- and developed important findings on how Aurora can come into compliance with the law and elevate the effectiveness and trustworthiness of law enforcement," Weiser said.
The report comes out more than two years after Elijah McClain died in August 2019. McClain, 23, was stopped by police while walking home from a store, placed in a carotid hold and then injected with ketamine. While he died in 2019, his story gained renewed attention in June 2020 after the police killings of George Floyd and Breonna Taylor and the rise of the Black Lives Matter movement.
Spurred by protests in Aurora and a viral online petition, Gov. Jared Polis announced a re-examination of the case last year. Weiser was appointed as special prosecutor and opened a grand jury investigation into the case in January.
Earlier in September, a Colorado grand jury indicted three police officers and two fire department paramedics involved in McClain's death. Each was indicted on charges of manslaughter and criminally negligent homicide among other crimes as part of a 32-count indictment.
"We will not waver from our deep commitment to a 'New Way' of policing, ensuring public safety and serving our diverse, culturally rich community in Aurora," City Manager Jim Twombly said in a statement. "I am still digesting the details of the Attorney General's report, and it is painful to hear."
Investigators examined more than 3 million internal police records and went on 220 hours of in-person ride-alongs with on-duty officers and firefighters during the course of the investigation, the report said.
Investigators attended nine months of weekly Force Review Board meetings where they reviewed bodycam footage of officers using force, and reviewed how the department evaluates that type of conduct, the report said.
Dozens of interviews were conducted with police and fire employees and the team listened to community feedback on the issues, the report said.
Investigators also read 2,800 reports from the last five years about the use of force by Aurora police officers.
It was found that there was "a consistent pattern of illegal behavior" by police, Weiser's news release said.
"Nearly half of the individuals whom Aurora Police used force against were Black, even though Black residents make up about 15% of the population in Aurora," Weiser's release said, citing the APD's Force Review Board's annual use-of-force reports.
Black people were also more than twice as likely to get arrested than Whites, Weiser's release said.
"In short, Aurora Police has failed to create and oversee appropriate expectations for responsible behavior," the report said.
The investigation found officers "generically reciting 'stop resisting'" when trying to control subjects that appeared to not be resisting, the AG report said. The investigation team observed officers taking people to the ground with force without giving them adequate time to respond to an officer's command.
Even in circumstances where someone would be in obvious mental health distress, but not a threat to themselves, the investigation found officers immediately escalating the situation, the report said.
Officers used force on people who presented no danger and had not committed a crime, but simply refused to comply, the report found.
Aurora Police Chief Vanessa Wilson issued a statement saying the department would work with Weiser's office to determine how to implement changes.
"We acknowledge there are changes to be made. We will not broad brush this agency or discount the professionalism and integrity that individual officers bring to our community every day," Wilson said. "I have and continue to hold officers accountable as evidenced by my recent disciplinary actions, which are supported by many officers in the department who are proud to wear our badge."
The Aurora Fire Department suspended the use of ketamine on September 14, 2020, but ketamine administration records from January 2019 to June 2020 show that during that period, the department reported administering ketamine 22 times for excited delirium, a life-threatening medical emergency, according to Weiser's release.
"These records show that, in more than half the incidents, paramedics failed to follow ketamine monitoring protocols and administered ketamine at doses above the maximum allowable dose for the reported weight of the subject," the release said.
AFD paramedics diagnosed McClain, the 23-year-old Black man killed during a police stop in 2019, with "excited delirium." Neither paramedic checked his vital signs, talked to McClain or touched him before making the diagnosis, according to an indictment from earlier this month.
They then injected McClain with a dose of ketamine based on an estimate that he was 200 pounds, when he actually weighed 143 pounds, according to the indictment. He was declared brain-dead three days later.
AFD indicated it does not plan to reinstate the use of ketamine, but the report outlined requirements in the event it decides to do so. The requirements include reviewing dose recommendations, developing a "uniform method" to assess an individual's agitation so as to reduce unnecessary use of the drug, providing clear training and policy information for officers to give paramedics, and creating a tougher review process to ensure policy compliance, Weiser's release said.
Fire Chief Fernando Gray said in a statement, "we find value in the report."
"Before the investigation was completed, our department had already taken myriad steps to enhance our service delivery such as extending the quality improvement/review process, improving our patient care documentation capabilities, and modifying the medical protocols to provide additional clarity between police and fire on medical interventions, which ultimately addressed many of the concerns which were brought forward in the report," he said.
The investigation team is requiring "that Aurora pay for an independent monitor, chosen with input from Aurora Police, Fire, and City Council, who will report to a court and provide periodic public updates about Aurora's progress in implementing these changes."
"In addition, to ensure that these changes can be implemented to the greatest extent possible, we will require the Aurora Civil Service Commission to make its work publicly transparent and available for review to the fullest extent that current law permits for all work addressing Aurora Fire and Police," the report read.
The report said the city and attorney general are required to enter a negotiation period to "make these changes part of a voluntary consent decree." There will be 60 days for the city and the attorney general's office to come to an agreement and implement the changes.