Investigation of the
Aurora Police Department
and Aurora Fire Rescue
September 15, 2021

Table of Contents
1.

Executive Summary .................................................................................................................. 1

2.

Scope of Investigation and Methodology ............................................................................. 4

3.

2.1.

Basis for Investigative Authority and Reason for Investigation ......................... 4

2.2.

Scope of Investigative Mandate .............................................................................. 4

2.3.

Our Work in the Investigation ................................................................................. 4

Background ................................................................................................................................ 6
3.1.

Aurora Background ................................................................................................... 6

3.2.

Aurora Police .............................................................................................................. 6
3.2.1. Notable Recent Incidents............................................................................ 6
3.2.2. Morale and Retention Issues ...................................................................... 9
3.2.3. Chief of Police History............................................................................. 10
3.2.4. Structure of the Organization.................................................................. 10
3.2.5. Training—Changes at the Police Academy ............................................ 11
3.2.6. Training—Changes to In-Service Ttraining ........................................... 12
3.2.7. Accountability Mechanisms ...................................................................... 12

3.3.

Aurora Fire Rescue .................................................................................................. 15
3.3.1. Falck Rocky Mountain ............................................................................... 15
3.3.2. Ketamine Use by Aurora Fire .................................................................. 16

3.4.

Aurora City Council ................................................................................................. 16
3.4.1. Recent Changes .......................................................................................... 16
3.4.2. Report and Recommendations from 21CP Solutions .......................... 18

3.5.
4.

5.

Aurora Civil Service Commission ......................................................................... 19

Successes of Aurora Police and Fire .................................................................................... 21
4.1.

Early Adoption and Extensive Use of Body-Worn Cameras ........................... 21

4.2.

The Force Review Board to Review Use-of-Force Incidents ........................... 21

4.3.

The Creation of a Force Investigation Unit to Allow Affirmative
Investigations of Uses of Force ............................................................................ 22

4.4.

Change in Training Philosophy and Culture at Academy .................................. 22

4.5.

Expanded Community Involvement..................................................................... 23

4.6.

Recognition of Need for Improvement and Change by Senior
Management ............................................................................................................. 24

The Effect of This Investigation .......................................................................................... 25
5.1.

Increased Scrutiny of Police Does Not Increase Crime Rates ......................... 25

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6.

7.

5.2.

Policy Restrictions on Uses of Force Are Associated With Improved
Officer Safety............................................................................................................ 26

5.3.

Policy Restrictions on Uses of Force Are Associated With Increased
Safety for Justice-Involved Residents ................................................................... 27

5.4.

Policy Restrictions on Police Are Not Associated With Less Engaged
Policing ...................................................................................................................... 27

5.5.

Successful Reform Efforts Are Comprehensive ................................................. 28

Pattern and Practice Findings: Legal Background ............................................................. 30
6.1.

Limitations on Discriminatory Policing Practices .............................................. 30

6.2.

Legal Requirements for Stops ................................................................................ 31

6.3.

Legal Requirements for Use of Force and Arrests............................................. 32

6.4.

Legal Requirements for Use of Ketamine ........................................................... 34

6.5.

Recent Changes to Colorado Law ......................................................................... 34

Finding #1: Aurora Police Has a Pattern and Practice of Engaging in Racially
Biased Policing Against People of Color as a Whole and Black People in
Particular ................................................................................................................................... 37
7.1.

Background ............................................................................................................... 37

7.2.

The Team’s Investigation of Aurora Police’s Data ............................................. 39
7.2.1. Assembling the Data Analytics Team ..................................................... 39
7.2.2. Data Collection ........................................................................................... 40

7.3.

Data Analysis ............................................................................................................ 41
7.3.1. Interactions.................................................................................................. 41
7.3.2. Arrests .......................................................................................................... 45
7.3.3. Reported Uses of Force ............................................................................ 48

7.4.

Explanations for the Data ...................................................................................... 51
7.4.1. Geography, Gender, and Age and Use of Force................................... 51
7.4.2. Type of Offense or Level of Force Used .............................................. 52
7.4.3. Income ......................................................................................................... 52
7.4.4. Officer Discretion ...................................................................................... 54
7.4.5. Use of Population-Level Demographics ................................................ 55
7.4.6. Excluding Incidents Where Race Information is Unknown or
Unavailable .................................................................................................. 56

7.5.

The Data Combined With Other Evidence Shows a Pattern and
Practice of Race-Based Policing ............................................................................ 57

7.6.

Changes Needed ...................................................................................................... 57
7.6.1. Improved and More Detailed Policies and Guidance to
Prevent Racially Biased Policing .............................................................. 57

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7.6.2. More Specific Standards and Expectations on When Officers
Should Stop, Arrest, or Use Force........................................................... 58
7.6.3. Track Outcomes for Those Arrested for Misdemeanors .................... 61
7.6.4. Improved Academy and In-Service Training ......................................... 61
7.6.5. Better Timely Recordkeeping ................................................................... 62
7.6.6. Improved Hiring and Recruiting Procedures, Including Major
Changes to the Civil Service Commission Standards ........................... 63
8.

Finding #2: Aurora Police Has a Pattern and Practice of Using Force
Excessively ................................................................................................................................ 67
8.1.

Law and Aurora Policies ......................................................................................... 67

8.2.

Data and Information Reviewed ........................................................................... 69
8.2.1. Documents Relating to the Use of Force .............................................. 69
8.2.2. Force Review Board and Other Meetings .............................................. 69
8.2.3. Ride-Alongs ................................................................................................. 69
8.2.4. Community Concerns Based on Interviews .......................................... 70

8.3.

Findings ..................................................................................................................... 71
8.3.1. Force and Threatened Force Used Against Those in Mental
Health Crises ............................................................................................... 71
8.3.2. Using Force When the Only Criminal Violation is Failure to
Obey ............................................................................................................. 76

8.4.

Causes of Violations ............................................................................................... 80
8.4.1. A Culture at Aurora Police That Emphasizes Justification for
Force, Rather Than Whether Force Was Lawful and
Appropriate ................................................................................................. 80
8.4.2. Use-of-Force Policy and Implementation Focuses on
Maximum Force Permitted Under Law .................................................. 83
8.4.3. De-Escalation is Misunderstood and Not Consistently
Practiced ...................................................................................................... 83
8.4.4. Mental Health Issues Are Not Adequately Addressed ......................... 85
8.4.5. Force is Used Disproportionately Against the Black
Community ................................................................................................. 85
8.4.6. Aurora Police Inadequately Documents the Use of Force ................. 86
8.4.7. Aurora Fire and Aurora Police Do Not Adequately
Coordinate ................................................................................................... 86

8.5.

Changes Needed ...................................................................................................... 87
8.5.1. Improve Use-of-Force Policies to Give More Specific
Guidance to Support Officers ................................................................. 87
8.5.2. Enhance Training on New Policies ......................................................... 87

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8.5.3. Change the Focus and Purpose of the Force Review Board
and the Force Investigation Unit ............................................................. 88
8.5.4. Develop Measurable Goals to Improve How Officers Engage
With Those Experiencing Mental Health Crises................................... 88
8.5.5. Develop a Joint Policy for Aurora Police and Fire to
Coordinate on Scenes and Conduct Joint Trainings............................. 88
9.

Finding #3: Aurora Police Has a Pattern and Practice of Failing to Document
Stops as Required by Law ...................................................................................................... 89
9.1.

Legal Background .................................................................................................... 89

9.2.

Aurora Police Fails to Document All Stops as Required by Senate Bill
217 .............................................................................................................................. 89

9.3.

Aurora Police Reports Do Not Include Required Detail Describing
the Reasons Supporting the Contact or Stop ...................................................... 90

9.4.

Changes Needed ...................................................................................................... 91
9.4.1. Develop Policies and Create Systems to Comply With
Colorado Law on Documenting Stops ................................................... 91
9.4.2. Amend Aurora Police Policies to Include a Separate Directive
Addressing Stops That Complies With both Colorado and
Federal Law ................................................................................................. 91

10. Finding #4: Aurora Fire Rescue Has a Pattern and Practice of Administering
Ketamine Illegally .................................................................................................................... 92
10.1.

Ketamine and Its Use by Aurora Paramedics ...................................................... 92
10.1.1. Ketamine Use by Paramedics ................................................................... 92
10.1.2. Changes to Colorado Law on the Use of Ketamine ............................ 94
10.1.3. Aurora’s Suspension of Ketamine Use in 2020..................................... 95
10.1.4. Structure of Aurora Emergency Medical Services ............................... 95

10.2.

Findings on Aurora’s Practices of Ketamine Use............................................... 95
10.2.1. Records of Past Ketamine Use Show Disparate Dosing of
Ketamine Not Based on Weight and a Failure to Follow
Monitoring Protocols ................................................................................ 95
10.2.2. Officers Sometimes Requested Chemical Restraints and Failed
to Document That Paramedics Chemically Restrained the
Person .......................................................................................................... 99

10.3.

Findings on Aurora’s Ketamine Protocols ......................................................... 103
10.3.1. Protocols Did Not Emphasize the Need for Paramedics to
Conduct an Independent Examination of a Patient .......................... 103
10.3.2. National Ketamine Protocol Trends and Recommendations
From Medical Associations Conflict With the High Doses
Permitted by Aurora Fire’s Protocol ..................................................... 106

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10.4.

Required Changes .................................................................................................. 107
10.4.1. Review Ketamine Dose Recommendations ......................................... 107
10.4.2. Maintain a Uniform Method to Assess Patient Agitation.................. 107
10.4.3. More Stringent Review to Ensure Protocol Compliance .................. 108

11. Facilitating Meaningful Reform .......................................................................................... 110
12. Next Steps .............................................................................................................................. 111
13. Acknowledgments ................................................................................................................. 112

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1.

Executive Summary

We, an investigation team appointed by Colorado’s Attorney General, Phil Weiser, find that
the Aurora Police Department and Aurora Fire Rescue have a pattern and practice of
violating state and federal law. Specifically, we find that Aurora Police1 has a pattern and
practice of racially biased policing, using excessive force, and failing to record required
information when it interacts with the community. Aurora Fire has engaged in a pattern
and practice of administering ketamine in violation of the law.
Our 14-month investigation included extensive data analysis and direct observation of
Aurora Police during over 220 hours of in-person ride-alongs with officers on patrol and
firefighters on duty. We assembled and examined a dataset of over three million records
from Aurora Police’s internal systems. We attended nine months of weekly Force Review
Board meetings, where we reviewed body-worn camera footage of officers using force, and
observed how Aurora Police evaluates the conduct of its officers. We read 2,800 reports
and associated documents from the last five years about the use of force by Aurora Police
officers. We evaluated Aurora Police’s use of force and related policies put in place after
legislation changed in 2020,2 heard community feedback from scores of community
members, and conducted dozens of interviews with Aurora Police and Fire employees.
Over the course of our investigation, we saw consistent patterns of unlawful behavior by
Aurora Police and Aurora Fire.
Aurora Police has a pattern and practice of racially biased policing. With the help of
a team of professional statisticians and econometricians, we conducted a detailed analysis
of internal Aurora Police data reflecting police activity since 2018. We observed statistically
significant racial disparities—especially with respect to Black individuals—in nearly every
important type of police contact with the community, from interactions to arrests to uses
of force. These disparities persisted across income, gender, and geographic boundaries.
Together with the other information we reviewed, we find that Aurora Police engages in
racially biased policing, treating people of color (and Black people in particular) differently
from their white counterparts.
Aurora Police has a pattern and practice of using excessive force. We found that
Aurora Police has repeatedly engaged in unlawful and unconstitutional uses of force,
regularly applying greater force than reasonably warranted by the situation. For example,
we observed officers using force to take people to the ground without first giving them
adequate time to respond to officer commands, or generically reciting “stop resisting”
when trying to control subjects, even though it appeared from other available evidence that
the subject was not resisting. We observed officers immediately escalating in circumstances
where the subject was in obvious mental health distress but not presenting an imminent
risk of harm to themselves or others. We observed officers using force on individuals who
had not committed any crime and presented no danger but who simply refused to comply
For readability, we refer to the Aurora Police Department as Aurora Police and Aurora Fire Rescue as
Aurora Fire throughout this report.
2 We did not review Aurora’s historical policies, including those related to stops or use of force in place prior
to the major legislative change in 2020 in Senate Bill 217.
1

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with orders. In our review of Force Review Board meetings, we saw Aurora Police
continuing to analyze force only under pre-existing federal requirements rather than under
the more stringent requirements of Colorado law. In addition, our investigation found that
Aurora Police has a misplaced view of de-escalation, focusing on whether officers calm
down after using force rather than avoiding unnecessary escalation in the first place.
Aurora Police has a pattern and practice of failing to document stops as required
by law. Colorado’s landmark law enforcement reform law, Senate Bill 20-217, requires that
officers have a legal basis for making any contact with a member of the public, and also
imposes strict recordkeeping requirements whenever any such contact is made. We found
that under policies that have been in place since 2020 (after Senate Bill 217 was enacted),
members of Aurora Police conduct resident stops without documenting those stops as the
law requires. This leads to an entire category of police interactions (so-called investigative
or Terry stops) for which there is little to no documentation, and as a result, even less
scrutiny. Compounding this problem, Aurora Police policies in effect since 2020 do not
provide adequate guidance to officers on when a Terry stop is appropriate under the law.
While it administered ketamine, Aurora Fire had a pattern and practice of using
ketamine in violation of the law. Through a comprehensive review of Aurora Fire’s
ketamine and care reports, we saw a consistent pattern of illegal ketamine administrations.
Aurora Fire relied on a ketamine review process that did not adequately ensure that
paramedics followed the legal requirements for administering ketamine. Its review process
failed to identify problems when ketamine was inappropriately administered or was
administered at the request of police, and therefore did not improve its processes and
training to prevent future violations.
We then determined why Aurora Police and Fire violate the law. Most failures with Aurora
Police relate to systematic and severe culture problems, created by several factors.
First, Aurora Police’s culture leads to the frequent use of force, often in excess of what the
law permits. Training is ad hoc and does not address specific needs of the organization as
shown by officer behavior. Policies are short on detail or practical guidance, often doing
little more than reciting the legal requirements set forth in court cases and applicable
statutes or regulations. In short, Aurora Police has failed to create and oversee appropriate
expectations for responsible behavior.
Second, Aurora Police does not meaningfully review officers’ uses of force, relying on
formal and informal systems that favor findings that officers followed policy and that
hamper candid feedback on how to improve.
Third, the Aurora City Charter gives the Civil Service Commission total control over
entry-level hiring and the right to reverse all meaningful discipline that the Chief of Police
can impose. The Commission overturns discipline in high-profile cases in a way that
undermines the Chief of Police’s authority, such that as a result, Aurora Police officers
who violate law or policy often remain on the force. And because of the Commission’s
hiring practices, Aurora Police officers do not reflect the diversity of the city.

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To address these problems, the Attorney General will require Aurora to fix its
organizations in several ways; some of which directly relate to practices that violate the law,
others of which focus on culture, leadership, and structures that lead to or enable the illegal
conduct. Aurora must confront both the violations and their underlying causes to stop
these patterns and practices of violating the law.
We strongly encourage Aurora to enter a consent decree that will require specific changes
and ongoing independent oversight. Aurora has committed to continue to cooperate with
our office to try and develop a consent decree. If this effort is unsuccessful, we will seek a
court-imposed order correcting these problems. To enable Aurora Police and Fire to make
these necessary changes, we will—if they choose to cooperate with our team—work with
them to develop specific and tailored solutions with their input, guided by experts on our
team, and reflecting input from the community.
Our team approached this investigation with an open mind and did not pre-judge any
outcome as we carefully considered the evidence. We appreciate that the City of Aurora,
Aurora Police, and Aurora Fire cooperated fully with our investigation. The conclusions we
reach here are the result of a fair, independent, and objective investigation.
Our team brought diverse backgrounds and experience to this work. Several members of
our team worked as law enforcement officers for urban police and sheriff ’s departments,
totaling 74 collective years of service. One member of our team was a former patrol
officer, Chief of Police, and City Manager for Arlington, Texas. Other team members have
extensive prosecution or public defender experience, including one team member who was
the United States Attorney for Idaho and who worked for several years in the Civil Rights
Division at the Department of Justice and another who served as a Deputy Assistant
Attorney General for Civil Rights at the Department of Justice. Another team member is a
former public defender and served as Deputy Chief Counsel to the President’s
Commission on the BP Deepwater Horizon Oil Spill.
We appreciate that the risks that first responders take must stand equally alongside a deep
commitment to the rule of law. By working to elevate law enforcement, our community
can both be safe from danger and free from racial discrimination. Indeed, it is critical that
community members can trust that law enforcement operates fairly and is worthy of their
trust. In issuing this report, and working to implement a consent decree to address
Aurora’s documented failings, we will remain focused on how we can work together to
elevate and improve law enforcement in Aurora.

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2.

Scope of Investigation and Methodology
2.1.

Basis for Investigative Authority and Reason for Investigation

Senate Bill 217, a law enforcement accountability bill enacted in Colorado in 2020, provides
the basis for our investigative authority. The law authorizes Colorado’s Attorney General to
open a civil investigation of any governmental authority for engaging in a pattern or
practice of conduct that violates state or federal constitutions or laws.3 A pattern or
practice investigation looks at whether members of a government agency have a pattern of
misconduct related to the rights, privileges, or immunities of people that those members
interact with.
Shortly after the bill passed, Attorney General Phil Weiser began to investigate whether
Aurora Police and Aurora Fire have a pattern or practice of violating the United States or
Colorado constitutions or federal or state statutes. We find that both Aurora Police and
Aurora Fire have a pattern and practice of violating these constitutions and laws. We
discuss our findings in more detail below.
The death of Elijah McClain in August 2019 and subsequent protests focused attention on
Aurora Police and Aurora Fire. Our focus in this report is on the government agencies—
Aurora Police and Aurora Fire—and not on any particular incident. Because of ongoing
criminal proceedings, we do not address Mr. McClain’s death in this report.
2.2.

Scope of Investigative Mandate

Our investigation of Aurora Police focused on stops and arrests, uses of force, and
possible discrimination in enforcement activities to understand whether Aurora Police had
a pattern or practice of violating the law.
Once we determined they did, we then looked to understand the causes of those
violations, focusing on Aurora Police’s policies and procedures, hiring processes, training,
discipline, record-keeping, and culture.
As for Aurora Fire, our investigation focused on the use of ketamine. We reviewed the
records for each ketamine administration, the protocols and procedures for administering
ketamine, situations in which Aurora Fire administered ketamine to a subject after a use of
force by the police, and Aurora Fire’s process for reviewing ketamine administration. We
also looked at coordination between the police and fire departments when they jointly
respond to an emergency.
2.3.

Our Work in the Investigation

During our investigation, we spoke to current and former personnel at Aurora Police,
including command staff, union representatives, training academy personnel, and patrol
officers. We participated in over 190 hours of ride-alongs, where we rode with patrol
officers and sergeants on duty while they patrolled all three of Aurora’s policing districts,
focused on the swing shift, from afternoon to early morning. We visited police
3

§ 24-31-113, C.R.S.

4

headquarters and the training academy; observed most Force Review Board meetings from
December 2020 through September 2021; and attended several community-police
meetings, including Internal Review Board meetings and Citizens’ Police Advisory Team
meetings. Finally, we spoke to many interested community members and leaders, including
faith leaders, immigrant community leaders, members of various police advisory boards,
and many others who expressed interest in sharing their experiences. In each community
conversation, we asked community members to refer any others to us who may wish to
share their experiences. During the many months of our investigation, we also hosted an
intake form on our website for community members to report any concerns related to
Aurora Police or Fire to our office.
We spoke to leadership, training, union, and other firefighting personnel affiliated with
Aurora Fire. We participated in over 30 hours of ride-alongs, covering multiple fire
stations. We also observed Aurora Fire on our police ride-alongs.
We interviewed others working for the City of Aurora and the Civil Service Commission to
learn how those organizations functioned and interacted with Aurora Police and Aurora
Fire.
Our team reviewed documents and data from both the police and fire departments, and the
Colorado Department of Public Health and Environment. We collected and reviewed over
2,800 use-of-force reports from 2016 to 2020. We retained a group of statisticians and
economists to conduct a statistical analysis of Aurora Police data on police activity
including arrests, use-of-force incidents, and number of resident interactions. And we
reviewed Aurora Fire’s procedures for ketamine administration and past incidents where
Aurora Fire administered ketamine.

5

3.

Background
3.1.

Aurora Background

Aurora is Colorado’s third-largest city with a population in 2019 of 369,111.4 It is diverse—
the four largest ethnic groups in Aurora are white (non-Hispanic) (44.4%),
Hispanic/Latino (28.6%), Black (16.5%), and Asian (6.5%).5 About 20% of Aurora
residents are foreign-born, with the majority emigrating from Latin America (38,185), Asia
(18,857), and Africa (10,536).6 Aurora has grown rapidly, more than doubling in size since
the 1970s.7
Aurora Police classifies the city into three districts. District 1 includes most of western
Aurora and is subdivided into eleven patrol areas or “beats.”8 District 1 encompasses many
of the most diverse areas of Aurora and includes many residents who speak a language
other than English. District 2 covers most of northeast Aurora, with eight beats.9 District 3
includes most of southeast Aurora, also with eight beats.10 A Police Area Representative
(PAR) Team in each district has responsibility for establishing relationships with
community members and responding to resident concerns about their neighborhoods.11
3.2.

Aurora Police
3.2.1. Notable Recent Incidents

Recent incidents involving Aurora Police increased scrutiny of Aurora Police and
heightened community tensions.
Shortly after Mr. McClain’s death, three Aurora Police officers took photos of themselves
near the scene of the police encounter with a memorial for Mr. McClain in the
background. The officers texted the photos to other officers, including one of the officers
involved in Mr. McClain’s death.12 Among other things, the photos depicted the officers
reenacting a carotid hold and grinning. The Police Chief fired three of the officers, another
officer resigned, and the three fired officers appealed their terminations to the Civil Service
Commission. The Commission upheld the three terminations. Additionally, nearly a year
after Mr. McClain’s death, officers in riot gear broke up a violin vigil honoring Mr.
McClain’s life and love for the violin by deploying chemical agents including pepper spray
after reporting that some protestors were throwing rocks and the officers ordered the vigil

2019 American Community Survey 5-Year Data Profile, Demographic and Housing Estimates, U.S. Census
Bureau.
5 Id.
6 Id. Selected Social Characteristics.
7 City of Aurora, Aurora History.
8 City of Aurora, District 1.
9 City of Aurora, District 2.
10 City of Aurora, District 3.
11 City of Aurora, Police Area Representatives (PAR).
12 3 Officers Fired Over Photos Taken Near Elijah McClain Memorial, The New York Times, July 4, 2020.
4

6

to end.13 This conduct led to a class-action lawsuit against the City of Aurora and various
officers by the rally attendees.14
Recent incidents unrelated to Mr. McClain’s death raised further concerns about officer
accountability, training, and decision-making.
In December 2018, a man died after fighting with Aurora Police officers after they found
him choking another person.15 In the course of subduing the man, officers tased him
nearly a dozen times, punched and struck him with batons repeatedly, and ultimately
restrained him face-down using four sets of handcuffs linked together. He was declared
dead about an hour after he was taken into custody. Although the coroner’s office found
that the man died of “restraint asphyxia” and ruled the death a homicide, prosecutors did
not seek criminal charges against the involved officers. The man’s widow filed a wrongful
death lawsuit against Aurora alleging excessive force.
In March 2019, two residents found an on-duty Aurora Police officer unconscious,
unresponsive, and armed in the driver’s seat of his running police vehicle.16 Although an
Internal Affairs investigation found that the officer was alcohol-impaired and had violated
multiple policies, he remained employed by Aurora Police and never faced charges for
driving under the influence from the incident. An independent report by former United
States Attorney John Walsh found Aurora Police’s response deficient in many ways.17
Also that month, an officer shot and killed a man experiencing a mental health crisis in his
sister’s apartment, who was alone when officers responded.18 The man had called 911
claiming that he was holding hostages and that two people were dead. After his death, the
man’s family filed a lawsuit in which they asserted that the sister told officers that the man
was alone and unarmed. Aurora Police did not discipline the involved officers, who alleged
that the man had charged them with a machete, and were cleared of criminal wrongdoing.
In August 2019, an officer left a female prisoner upside down in the back of his patrol car
for more than twenty minutes after her arrest.19 The officer chose to restrain the woman by
tying her handcuffed hands to her feet behind her back and she slipped off the back seat as
the officer took her to jail. Aurora Police publicly released the officer’s body-worn camera
video, which shows the woman with her head on the floor of the car and her legs in the air
as she asks the officer for help, says that she cannot breathe, and calls the officer “master.”
The officer, who ignored the woman’s requests, was fired.

Thousands Call For Justice For Elijah McClain in a Day of Music and Marching, CPR News, June 27, 2020.
Inside Lawsuit Over Police Attack on Elijah McClain Violin Tribute, Westword, July 24, 2020.
15 Widow of Man Who Died After Fight With Aurora Police Files Wrongful Death Lawsuit, Sentinel, Dec. 11,
2020.
16 Aurora Cop Drives Drunk On Duty: Keeps Job, No Arrest, CBS Denver, Dec. 10, 2019.
17 City of Aurora, Report on Independent Review, Aurora Police Department’s Response to March 29, 2019
Incident Involving an Aurora Police Officer, March 2020.
18 Federal Judge Denies Immunity to Aurora Officers in Shooting Death Lawsuit, The Gazette, Sept. 8, 2021.
19 ‘Please Don’t Let Me Die Back Here’: Aurora Police Video Released of Woman Cuffed, Hobbled in Back
of Patrol Car, CBS Denver, Sept. 29, 2020.
13
14

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In March 2020, an officer held an Indian-American doctor at gunpoint as the doctor
parked in the parking structure of a refugee center that he owned and operated.20 After
pulling his car into the structure, the doctor honked at a police cruiser that was blocking his
car’s path. An officer got out, approached the doctor’s car, drew his gun, questioned the
doctor at gunpoint about what he was doing, and demanded proof that he owned the
building. The doctor recorded the incident on his cell phone. The Chief of Police
suspended the officer for 40 hours without pay and mandated that he attend de-escalation
training. After publicly criticizing this discipline as inadequate, the doctor filed a civil
lawsuit alleging excessive force.
In August 2020, officers held a Black family at gunpoint and ordered the family
members—including four children aged six, twelve, fourteen, and seventeen—out of their
SUV, made them lay face down on the hot summer pavement, and handcuffed them.21
Officers later said they confused the family’s car for a stolen vehicle—the vehicles had the
same license plate numbers but were from different states, and the stolen vehicle was
reportedly a motorcycle, not an SUV. The stop led to a lawsuit alleging inadequate training
and lack of probable cause in stopping the family.22
That same month, an officer responded to a man trespassing at a grocery store, who was
lying down on the ground with his arms underneath him as a different officer tried to
arrest him. The responding officer—who did not activate his body-worn camera—
punched the man multiple times in the ribs and then tased him five times in a two-minute
period. Aurora Police fired the officer for using excessive force in February 2021.23
And in July 2021, a police officer responding to a trespass call repeatedly struck an
unarmed man in the head with his gun, choked him for nearly a minute, and threatened to
shoot him.24 A second police officer stood by and did not intervene. Both officers were
arrested—the first for attempted first-degree assault, second-degree assault, felony
menacing, official oppression, and first-degree official misconduct; the second for
misdemeanor charges of failure to intervene and failure to report use of force by an
officer. The first officer resigned shortly after the incident, and the Chief of Police fired
the second officer for violating Aurora Police’s policy directives and failing to intervene,25
though appeals of that decision to the Civil Service Commission remain active. Reports

Colorado Officer Who Pointed Gun at Doctor’s Head on His Own Property Suspended 1 Week, NBC
News, Sept. 17, 2020.
21 Family Sues Aurora Police Over Botched Stolen-Car Response That Left Children Handcuffed, Held at
Gunpoint, The Denver Post, Jan. 26, 2021.
22 Gilliam v. City of Aurora, Complaint and Jury Demand, Jan. 25, 2021.
23 Aurora Police Officer Fired for Excessive Use of Force, 9 News Denver, Feb. 11, 2021.
24 Police Body Cam Video Shows Aurora Cop Strangling, Pistol-Whipping Trespassing Suspect, Netting
Criminal Charges For 2 Cops, Sentinel, July 27, 2021.
25 Aurora Police Officer Involved in Pistol-Whipping Arrest Fired by Police Chief for Failing to Intervene,
The Denver Channel, Aug. 12, 2021.
20

8

described the Civil Service Commission hiring the first officer despite a prior arrest for
pointing a gun at a roommate while drinking.26
This list of recent incidents is not comprehensive. Aurora Police has been in the news
recently for many more issues, including an officer who was recorded asking paramedics to
sedate a subject,27 and several officers arrested for DUI, some of whom were fired.28 Each
of these incidents renewed media attention and community scrutiny of Aurora Police, both
locally and nationwide.
3.2.2. Morale and Retention Issues
The recent incidents involving Aurora Police have impacted not only community trust, but
also officer retention and morale. Aurora Police saw 150 officers leave or be fired from
around January 2020 to July 2021, a turnover rate of nearly 20%.29 In contrast, Aurora
Police’s annual turnover rate from 2014 to 2019 averaged just 6.5%. Aurora faces more
challenging police retention issues than other police departments—departments in
comparable Colorado jurisdictions, including Denver and Colorado Springs, saw much
smaller changes in the number of departing officers.30
In interviews and ride-alongs, some officers shared that they felt unsupported by the
community, Aurora Police leadership, and local elected officials and leaders, particularly
after Mr. McClain’s death. Some expressed frustration at what they perceived to be a lack
of accountability, believing that, for example, Aurora Police handled the incident involving
the on-duty officer found drunk in his running vehicle poorly, which hurt morale. Others
cited more reasons for officers leaving Aurora Police—tensions with the community,
confusion over recent legislative police reforms in Colorado, lack of direction and support
from police leadership, conflicting orders from various levels of leadership, the multiple
ongoing investigations, and general concerns about the future of policing. Aurora Police
personnel also expressed concerns that it has not been losing bad officers, but some of its
most experienced officers and officers of color.
The retention issues have impacted staffing capabilities, the level of experience within
Aurora Police, and the composition of the executive leadership team. Although officer

Criminal History of Aurora Officer John Haubert Sounds Alarm on Hiring Process, CBS 4 Denver, July 28,
2021.
27 Aurora Body Camera Video Shows Police Asking Medics to Give Powerful Drugs to Suspect to Calm Him,
The Denver Channel, Dec. 3, 2020.
28 Aurora Police Sergeant Arrested for DUI in Denver, KDVR News, July 7, 2021; Aurora Police Officer Fired
Nearly a Month After Drunk Driving Crash in Colorado Springs, The Denver Channel, Apr. 6, 2020.
29 Aurora Tries to Fight Uptick in Violent Crime, While Losing Officers at Alarming Rate, The Denver Channel,
July 2, 2021; ‘Just Unprecedented’: Aurora Police Saw 60% Rise in Officers Leaving Department Last Year,
Sentinel, Feb. 19, 2021.
30 Did Colorado Law Enforcement Flee the Profession in 2020? Depends on the Department, Denver Post,
Mar. 8, 2021 (noting that the Denver Police Department saw 81 officers leave in 2020, down from 100 the
year before, while the Colorado Springs Police Department saw 73 officers leave in 2020, up from a four-year
average of 53 officers leaving annually).
26

9

recruitment has remained steady, Aurora Police personnel expressed concern that the
eventual effect of the high turnover rate will be a much less experienced department.
3.2.3. Chief of Police History
The challenges faced by Aurora Police came in the midst of a leadership transition. Chief
Nick Metz, who joined Aurora Police as its chief in 2015, retired at the end of 2019.31
Chief Vanessa Wilson then spent seven months as Interim Chief, and the City Manager
and the majority of City Council officially appointed her as Chief in August 2020.32 Chief
Wilson became the first female and openly LGBTQ+ individual to lead the police
department and remains its chief today.
3.2.4. Structure of the Organization
Aurora Police currently employs about 744 sworn police officers and 237 civilians.33 In
2020, out of 758 police officers and recruits, Aurora Police employed 600 white officers
(79.2%), 79 Hispanic officers (10.4%), 31 officers of two or more races (4.1%), 28 Black
officers (3.7%), 15 Asian officers (2.0%), and 1 Hawaiian/Pacific Islander officer (0.1%).34
Of those officers, 662 were male (87.3%), and 96 were female (12.7%).
The Chief of Police oversees an executive leadership team comprised of a deputy chief of
police; an executive officer; three division chiefs overseeing the Professional Accountability,
Operations, and Metro Divisions; and two managers overseeing the Community Relations
and Business Services Divisions.35 The Professional Accountability Division is responsible
for professional standards, training, and electronic support. The Operations Division
houses most police officers and oversees the three districts, patrol sections, and police area
representatives assigned to the three districts. The Metro Division covers the Investigations
Bureau and Special Operations Bureau, which include specialized units such as Major
Investigations, SWAT, K-9, the Crisis Response Team, and the Traffic Section. The
Community Relations section oversees recruiting, Aurora for Youth, and other communityoriented programs. Finally, the Business Services Division handles administrative services,
equipment and facilities, records and support, and property and technical services.36
The leadership team also includes six commanders who oversee the three districts, the
Internal Affairs Bureau, the Investigations Bureau, and the Special Operations Bureau. The
district and Special Operations commanders are supported by four captains, also called
deputy commanders. Under the captains are lieutenants and then sergeants, who directly
oversee patrol officers.

Aurora Police Chief Nick Metz Announces Retirement, to Leave Department at End of 2019, The Denver
Channel, Sept. 27, 2019.
32 Vanessa Wilson Appointed Chief to Lead Aurora’s Beleaguered Police Department, Sentinel, Aug. 4, 2020.
33 City of Aurora, Police.
34 Aurora Police Department, 2020 4th Quarter Affirmative Action Report, Jan. 11, 2021.
35 City of Aurora, Executive Leadership Team.
36 City of Aurora, Organizational Chart.
31

10

Two unions compete for membership of Aurora Police officers—the Aurora Police
Association and the Fraternal Order of Police, Lodge 49. In 2019, FOP Lodge 49 was
certified by majority vote to serve as the collective-bargaining unit for police officers
beginning in 2021, replacing the Aurora Police Association.37 The contract between Aurora
and the FOP Lodge 49 runs through the end of 2022.38
3.2.5. Training—Changes at the Police Academy
Aurora Police operates its own police academy that, as of 2021, trains about twenty cadets
in each of five sessions per year. All officers hired into Aurora Police—both entry-level
and lateral—must go through programs at the academy. Before 2021, the entry-level
academies occurred twice a year, lasted for 26 weeks, and trained about 40 recruits per
academy. The Training Section changed the frequency of the academies due to concern
about losing qualified applicants to other police agencies with more frequent academies
and more flexible hiring schedules. The entry-level academies train recruit officers on the
law, firearm usage, law enforcement driving, custodial arrest techniques, self-defense, and
other police tactics.39
Police leadership described major changes being made to the culture and curriculum of the
training academy as of mid-to-late 2020. Because our investigation began in late 2020, we
did not review training curriculums or content that the training academy used before 2020.
Leadership told us that it has tried to make the academy less militaristic than it has
historically been—by, for example, stopping the use of military terminology, no longer
assigning officers “battle buddies,” and ending the practice of yelling at recruits and using
public embarrassment as punishment for mistakes. Leadership also reported that the
academy is seeking to shift to a guardian mindset focused on officers’ roles as guardians of
the community.40 Leadership has prioritized improving the diversity of academy staff, so
the officers working there are more reflective of the demographics of the recruit class.
The Training Section has also changed the academy’s curriculum. The academy has
increased community involvement by, for example, bringing in Black members of the
community to speak to recruits about their experiences with police. Asian academy
instructors spoke to recruits about the increase in anti-Asian violence in the wake of
COVID-19. And the academy has incorporated critical incidents involving police in other
jurisdictions into its training—for example, training recruits on distinguishing between
drawing their Taser versus firearm after the police killing of Daunte Wright in
Minneapolis.41 Training personnel shared additional plans to reshape the academy—
continuing to incorporate more community groups into training, such as members of the
LGBTQ+ community; working with a local acting group for more realistic in-person
Aurora FOP Lodge 49, Who We Are.
Agreement Between the City of Aurora and Fraternal Order of Police, Lodge # 49, January 1, 2021
through December 31, 2022.
39 City of Aurora, Academy Life.
40 For a discussion of the different approaches to policing, see Sue Rahr & Stephen K. Rice, From Warriors to
Guardians: Recommitting American Police Culture to Democratic Ideals, New Perspectives in Policing, April 2015;
Samuel E. Walker & Carol A. Archbold, The New World of Police Accountability 17-19 (3d ed. 2020).
41 What to Know About the Death of Daunte Wright, The New York Times, Apr. 23, 2021.
37
38

11

scenario-based training; using a new simulator for scenario-based training that includes
situations in which de-escalation rather than using force is the right outcome; and
implementing joint scenario-based training with both the police and fire academies.
3.2.6. Training—Changes to In-Service Training
Aurora Police’s in-service training provides mandatory recurring training for patrol officers
and other police personnel after graduating from the academy. It “focuses on those skills
pertinent to the performance of functions crucial to the delivery of law enforcement
services to the community.”42 It includes training on uses of force, arrest control, firearms,
legal updates, anti-bias, and other topics. As with the academy, we did not review in-service
training used prior to 2020.
Although we heard from some officers that the quality of training offered by Aurora
surpasses that of training offered at other Colorado police departments, we also heard that
Aurora Police has historically neglected meaningful in-service training, with one sergeant
describing its treatment as a “check-the-box” exercise. On ride-alongs and during
interviews, officers expressed a desire for fewer online trainings and more scenario- and
skills-based trainings on community interactions, night-time decision-making, firearm
usage, and other tactics. Training personnel similarly described a desire for better in-person
scenario-based training and highlighted several new areas of focus for in-service training:
de-escalation, use-of-force report writing, and mental health issues in both civilians and
officers.
By the end of 2021, officers will have participated in three in-service training blocks.43 The
first is online-only and includes training on anti-bias, community policing, de-escalation,
mental illness, and excited delirium. The second training will be in-person, covering topics
including firearm usage, emergency vehicle operations, and arrest control tactics. The third
block of training is new for 2021 and will require patrol officers to train in-person on deescalation through verbal judo, use-of-force report writing, and high-risk stops, among
other topics.
We did not have an opportunity to observe the new block of training, which is scheduled
for the fall of 2021. The Training Section shared its plans to implement some of the same
changes planned for the academy in that block, including having community members
participate and using actors for more realistic scenario-based training. Training personnel
also plan to use incidents captured by body-worn cameras of Aurora Police officers during
in-service training.
3.2.7. Accountability Mechanisms
At least four potential accountability mechanisms govern police departments—internal
discipline (including termination), lawsuits, community feedback, and City Council
oversight of the City Manager and Chief of Police. Discipline and termination are
governed by the Internal Affairs Bureau with supervision by the Chief of Police and
42
43

Aurora Police Department Directive 07.02 (revised Aug. 20, 2020).
2021 APD In-Service Schedule.

12

review before the Aurora Civil Service Commission.44 Internal Affairs handles the process
for all allegations of misconduct, including community complaints, internal complaints,
and potential policy violations.
Resident complaints raised over 1,500 allegations against sworn officers from 2018 to 2020,
and 951 of those complaints were sustained, meaning Aurora Police found that officers
violated policies. Only 53 allegations were about excessive use of force. Aurora Police
representatives explained that a single complaint may include more than one allegation
against more than one officer. But Internal Affairs tracks the number of cases it
investigates (not allegations) and the number of officers with complaints sustained against
them or not. Because the number of allegations does not correspond to either the number
of cases referred for investigation or the number of officers investigated, it was impossible
for our team to determine how many officers were the subject of complaints. This
accounting disconnect obscures the complaint process and makes it difficult for the
community to know if complaints are a useful accountability tool.
However, when a preliminary investigation reveals a serious complaint that if sustained
could result in more than 40 hours suspension without pay, it should be referred for
further Internal Affairs investigation. Those cases generally resulted in sustained
complaints. In the 122 serious cases investigated by Internal Affairs between 2018 and
2020, it sustained allegations against 122 officers and did not sustain allegations against 35
officers. Supervisors in each district investigated another 112 less-serious cases. Our team
was not provided the outcomes for these district-level investigations.
After the Internal Affairs process, the Chief of Police may impose discipline, subject to
review by the Civil Service Commission.45 An officer may appeal any disciplinary order
other than an oral or written reprimand.46
Our team could not determine how many of the 122 officers received discipline as a result
of the sustained complaints, or how many of the 112 less-serious cases led to officer
discipline. While Internal Affairs posts generic descriptions of investigation outcomes on
bulletin boards in each police station, the overall lack of transparency makes it difficult to
know how Aurora Police uses resident complaints to spot recurring problem behaviors,
address policy gaps, or discipline officers for misconduct.
Lawsuits likewise have not created accountability for Aurora Police officers. Aurora has
recently settled lawsuits involving excessive use of force in response to a noise complaint47
and a K-9 officer ordering a police dog to bite a restrained woman.48 City representatives
reported that in recent years, settlements included requirements that Aurora Police make

Aurora Police Department Directive 10.02. (revised May 19, 2020).
Aurora Police Department Directive 10.02.15 (revised May 19, 2020).
46 Aurora Municipal Code, § 3-16(8).
47 Aurora Police to Pay Man $285,000 Settlement for Ordering Him out of Home, Slamming Him on
Ground, 9 News Denver, Dec. 10, 2020.
48 Aurora Pays $80,000 Settlement After Police Ordered Dog to Bite Woman Being Restrained by Officers,
The Denver Post, Feb. 24, 2021.
44
45

13

certain changes, such as adopting a new SWAT policy, adding trainings on vehicle stops,
and responding to persons with epilepsy.
However, we saw no evidence of a coordinated approach by the city to provide direct
feedback to officers and their supervisors whose conduct prompted lawsuits. Allegations
from the lawsuits do not launch a formal process to help Aurora Police identify patterns of
rights violations or other opportunities to improve. Complaints from the lawsuits are not
included in an early warning system database that could notify a supervisor and trigger
interventions. Instead, the City Attorney’s office states that they maintain a dialogue with
each city department to discuss allegations and their implications. Those informal
conversations, while necessary, do not systematically examine the costs imposed by officer
conduct and lead to a less comprehensive review of any patterns that a police department’s
early warning system is designed to catch.
Aurora reports paying over $7 million in settlements for claims of excessive force and
constitutional violations by Aurora Police over the ten-year period from 2008 to 2018. Of
course, police departments settle lawsuits for many reasons, and a settlement does not
necessarily mean that a legal violation occurred. But generally, significant settlements occur
in cases which pose risk that the city, or officers that it indemnifies, will be found to have
violated the law.
The payouts by Aurora to settle claims of excessive force and constitutional violations do
not directly impact Aurora Police’s budget or create other direct consequences for the
organization. Rather, the city handles all liability in an aggregate Risk Management Fund
that provides self-insurance for most claims and purchases excess insurance coverage for
large liabilities. This Fund is a separate line item in the city’s budget. It aggregates all
liabilities facing the city, whether they arise from police conduct, vehicle accidents, or other
municipal operations in various other city departments.49 Our discussions with Aurora
personnel reinforced the lack of a direct connection between payments made to resolve
cases against the police or fire department and any consequences to the police or fire
departments. Without such direct connection, lawsuits provide inadequate incentives to
change police behavior.50
Senate Bill 217 waives qualified immunity in some specific circumstances and adds a
provision which states that officers themselves may face personal liability up to $25,000 in
lawsuits for police misconduct when their employer finds that “the officer did not act upon
a good faith and reasonable belief that the action was lawful.”51 This provision has not
City of Aurora, 2021 Operating and Capital Improvement Budget.
Samuel E. Walker & Carol A. Archbold, The New World of Police Accountability 47-49 (3d ed. 2020) (“The
basic flaw in the strategy of seeking police reform through civil suits is the assumption that public officials
will react in a rational and coordinated manner. That is, they will see a problem (the costs of police
misconduct cases) and will take the necessary steps to reduce those costs. The evidence, however, indicates
that public officials respond indifferently and with no coordinated plan. In practice, one agency of local
government (the police) perpetuates the harm, another agency defends it in court (the law department), and a
third agency writes the check (the treasurer).”); Joanna C. Schwartz, Myths and Mechanics of Deterrence: The Role
of Lawsuits in Law Enforcement Decisionmaking, 57 UCLA L. REV. 1023, 1067 (2010) (finding “most law
enforcement officials know little about lawsuits alleging misconduct by their officers”).
51 § 13-21-131(1) & (4), C.R.S.
49
50

14

been in effect long enough for us to determine how it will play out in practice. As we
discuss below, many officers are concerned about the uncertainty created by this bill.
Community feedback provides another avenue to ensure police accountability. As discussed
in later sections, Aurora has several advisory teams comprised of community members
who give feedback on police policies, disciplinary decisions, and recent critical events.
These feedback mechanisms make community perspectives available to the police
department, but advisory teams do not have any decision-making or policy authority.
Finally, political accountability for appointment of the City Manager and the Chief of
Police creates some potential feedback for Aurora Police. But this feedback focuses on
consequences for past decisions, rather than specific input on forward-looking decisions.
We find that these accountability mechanisms do not work to provide sufficient feedback
for Aurora Police on the behavior of its officers. The feedback that does occur is too
cumbersome, ad hoc, and diffuse to provide meaningful input to the organization. To
follow the law, Aurora Police must improve its accountability mechanisms.
3.3.

Aurora Fire Rescue

Aurora Fire Rescue is led by Chief Fernando Gray, who joined Aurora Fire in June 2017.52
It employs about 440 full-time personnel and has seventeen fire stations located
throughout Aurora.53 Within four years of starting at Aurora Fire, all firefighters receive
training to become registered Emergency Medical Technician Paramedics.54
Interviews with fire personnel revealed that Aurora Fire has not seen the same turnover,
morale, and community relations issues as Aurora Police. But many raised similar concerns
over the effect of recent legislation, potential liability, and changes to Aurora Police policies
that impact their cooperation. Aurora Fire has also faced recent controversy, including the
termination of the second-in-command Deputy Chief following an investigation into his
misuse of time off, retaliation against a subordinate, and use of racially derogatory
language.55
3.3.1. Falck Rocky Mountain
Falck Rocky Mountain is the sole emergency ambulance provider for Aurora. Falck is a
Danish-owned private company, whose business unit Falck Rocky Mountain has contracted
with Aurora Fire since 2015.56 Through this partnership, Falck responds to over 30,000
medical services requests each year in Aurora. On most calls for medical service, at least
one Falck ambulance responds alongside Aurora Fire. Aurora Fire typically maintains

Aurora Names Dallas Firefighter Fernando Gray New City Fire Chief, Sentinel, Apr. 11, 2017.
City of Aurora, Fire Stations.
54 City of Aurora, Aurora Fire Rescue Recruiting FAQs.
55 Aurora Fires Deputy Fire Chief Stephen McInerny for Policy Violations, CBS Denver, Mar. 5, 2021.
56 Falck Rocky Mountain.
52
53

15

medical control over major calls and Aurora Fire personnel provide Advanced Life Support
services, often using Falck ambulances and medical supplies from Falck.
3.3.2. Ketamine Use by Aurora Fire
Starting in 2018, Aurora Fire requested and received a waiver from the Colorado
Department of Public Health and Environment to permit paramedics to administer
ketamine outside of a hospital setting. Without such a waiver, paramedics may not
administer ketamine in Colorado. The waiver required, among other things, ketaminespecific training, specific protocols for administering ketamine, and detailed reporting to
the state shortly after every use. For the entire time of this waiver, Aurora Fire paramedics
administered ketamine under the supervision of its medical director, Dr. Eric Hill. In 2020,
Aurora City Council suspended the use of ketamine by its paramedics and the waiver
expired in 2021.
3.4.

Aurora City Council

Aurora is a council-manager form of government, run by City Council and the City
Manager. City Council includes Aurora’s mayor, one member from each of the city’s six
wards, and four at-large members. City Council hires the City Manager, who oversees the
day-to-day operations of the city government, including Aurora Fire and Aurora Police.57
3.4.1. Recent Changes
Aurora City Council made several policy changes in response to Elijah McClain’s death and
the public reaction. First, City Council unanimously approved a moratorium on the use of
ketamine by Aurora Fire and Falck Rocky Mountain.58 The moratorium became effective
on September 15, 2020, and required Aurora Fire to remove ketamine from all service
units. It expired on March 24, 2021, but Aurora Fire has stated that it has no immediate
plans to resume ketamine’s usage.59
Second, City Council funded a pilot program that would permit mental health workers to
respond to some 911 calls instead of police officers.60 The program—modeled after the
Support Team Assisted Response, or STAR, program from Denver, and the Crisis
Assistance Helping Out On The Streets, or CAHOOTS, program from Eugene, Oregon—
will feature an EMT or paramedic and mental health clinician responding to mental healthrelated calls instead of police. The city started the program in September of 2021.61
Third, City Council launched an independent investigation of Mr. McClain’s death, led by
Jonathan Smith, executive director of the Washington Lawyers’ Committee for Civil Rights

City of Aurora, Your Aurora Government 2021.
City of Aurora, Ketamine Moratorium.
59 Aurora Has No Immediate Plans to Re-Implement Ketamine After Elijah McClain Review, KDVR News,
Mar. 19, 2021.
60 Aurora Funds New Program to Replace Cops With Clinicians to Some 911 Calls, Sentinel, Sept. 21, 2020.
61 Denver’s STAR Program Will Be Replicated in Aurora Starting This Week, Denverite, Sept. 6, 2021.
57
58

16

and Urban Affairs.62 City Council set the scope of the investigation, which focused on the
timeline of events leading to Mr. McClain’s death, the actions of Aurora Police and Fire
during the encounter, and the policies and procedures associated with use of force,
ketamine use, and administrative incident reviews, among other issues.63 The investigation
team released its findings on February 22, 2021.64
Fourth, City Council established a Community Police Task Force composed of twelve
community members and one ex officio police member.65 City Council asked the task force
to review Aurora Police policies and procedures and to provide recommendations on
improving police interactions with community members. The Community Police Task
Force presented its recommendations to City Council on April 5, 2021.66 Its primary
recommendations included:
•

The creation of an independent citizen’s oversight office with investigatory and
subpoena powers, responsible for:
o reviewing resident complaints, critical incidents, and Aurora Police policies
and practices,
o reviewing all Aurora Police disciplinary actions, with the power to overturn
or refer such cases,
o contemporaneously receiving all body-worn camera footage, and
o working with the Civil Service Commission on hiring and discipline;

•

An increase in funding for mental health services, including a co-responder
program pairing officers with mental health professionals, mandatory mental health
training, and mental health screening for officers;

•

The creation of various programs to protect the anonymity of officers who report
misconduct of other officers, provide for community member “safe to tell” tip
lines, diversify the police academy classes to reflect Aurora’s demographics, and
monitor the social media activity of police officers; and

•

An amendment to the Charter giving the independent citizen’s oversight office
authority that is parallel to that of the Civil Service Commission.

City Council has begun to implement some of these recommendations.

Aurora City Council Unanimously Approves Scope of Elijah McClain Investigation, Sentinel, July 21, 2020.
Independent Report Released in Elijah McClain Case, City of Aurora, Mar. 16, 2021.
64 City of Aurora, Investigation Report and Recommendations, Feb. 22, 2021.
65 City of Aurora, Community Police Task Force.
66 City of Aurora, Agenda and Meeting Minutes from April 5, 2021, 72-83.
62
63

17

3.4.2. Report and Recommendations from 21CP Solutions
Chief Wilson and City Manager Jim Twombly hired 21CP Solutions, a group of experts
focusing on the areas of civil rights and public safety, to review Aurora Police’s policies,
procedures, and operations.67 21CP Solutions presented its report and recommendations to
City Council on August 16, 2021.
The 21CP Solutions report considered how Aurora Police could improve their policies and
organization to align with recognized best practices in procedural justice and policing.68
The report identified six areas where Aurora Police could improve their operations:
policing practices, community engagement, organizational structure, officer development,
accountability, and data management.69
Most of the report focused on Aurora Police’s policies and practices, where 21CP
Solutions recommended:
•

Specific changes to Aurora Police’s use-of-force, arrest, crisis intervention, and
bias-free policing policies;

•

Commitment to a dedicated mental health crisis response model;

•

Guidance on how officers write use-of-force narratives and general offense reports
for all stops and standardized reporting of required data for all encounters;

•

Improved guidance on use-of-force investigation, review, and adjudication;

•

Periodic analysis of data demonstrating trends in arrests, stops, uses of force, and
biased-based policing; and

•

Improved transparency of resident complaints.

The report also suggested strategies to address staffing shortages and recommended
expanding the roles and collaboration between the Community Policing Task Force and
Police Area Representatives. Other suggestions included:
•

Improving communication between command staff and officers;

•

Recruiting and hiring more diverse officers to better reflect the Aurora community;

•

Using scenario-based training on stops, searches, arrests, de-escalation strategies,
critical decision-making, procedural justice, and bias-free policing;

•

Revising the Field Training Officer and Peer Support programs;

City Undertakes Comprehensive Review of Police, City of Aurora, Aug. 25, 2020.
21CP Solutions, Recommendations for the Aurora Police Department, August 2021.
69 We have summarized these areas of focus. The 21CP report titles each area: Critical Operations;
Community Engagement and Participation; Organization and Command Structure; Selection, Supervision,
and Support of Personnel; Accountability; and Equipment, Technology, and Data Systems.
67
68

18

•

Enhancing the Early Intervention System to improve officer development;

•

Overhauling the complaint, investigation, and disciplinary process for officers;

•

Reviewing the Civil Service Commission’s equity in hiring and discipline decisions;
and

•

Creating data analysis and management technology solutions.

21CP Solutions released its report in August 2021, and it covers many areas where Aurora
Police has already committed to making adjustments.
3.5.

Aurora Civil Service Commission

Aurora’s Charter creates a Civil Service Commission and gives it significant oversight of
police and fire operations. Five community members selected by City Council serve on the
Commission.70 The members serve three-year overlapping terms and are limited to three
consecutive terms.71
Aurora gives the Civil Service Commission extraordinary control over hiring and discipline
of police and fire employees. The Charter grants the Commission sole responsibility for the
examination and certification of all entry-level applicants to the police and fire
departments. As a result, Aurora Police and Fire cannot make the final decisions on entrylevel hiring.72 The Commission also sets the service requirements and examination
procedures for internal police and fire promotions.73 Finally, the Commission can review
discipline imposed by the police and fire chiefs. Any disciplinary order other than an oral or
written reprimand may be appealed to the Commission, and the Commission can affirm,
reverse, or modify the disciplinary order by majority vote.74 This oversight over disciplinary
decisions has been controversial—for example, the Commission overturned a decision by
former Chief of Police Nick Metz to terminate a lieutenant who referred to a group of
Black residents as “Alabama porch monkeys.”75
We heard concerns from community members and police officers about the scope of the
Commission’s power, particularly as it relates to hiring and discipline of police officers. A
recent analysis of the 2018 to 2020 police academies found that the Commission’s hiring
process leads to disparate outcomes for applicants of color—of 2,809 white applicants
who met minimum qualifications, the Commission hired 119, for a hiring rate of 4.24%.76
In contrast, the Commission approved the hiring of only 5 of 454 qualified Black

City of Aurora, Civil Service Commission.
Aurora Charter, § 3.17.
72 Aurora Charter, §§ 3.16(10), 3.17(3).
73 Aurora Charter, §§ 3.16(6), 3.17(3).
74 Aurora Charter, § 3.16(8)(e)-(h).
75 Aurora Officer Fired for Racial Slur Reinstated by Civil Service Commission, KDVR News, July 10, 2018.
76 City of Aurora, Aurora Civil Service Commission 2020 Overview and Recent Entry-Level Hiring
Summary, p. 57-60.
70
71

19

applicants (1.1%), 32 of 1,073 qualified Hispanic or Latino applicants (3%), and 5 of 139
qualified Asian applicants (3.6%).
We also heard concerns about the Commission’s minimal transparency—meeting
recordings or transcripts are unavailable online, and community members have little insight
into hiring and disciplinary decisions. As for disciplinary decisions, the Commission does
not publicly release any documents or information except for the formal appeal filed by the
member and the Commission’s ultimate disciplinary findings. And the Commission only
produces these documents in response to requests under the Colorado Open Records
Act—it does not make this information easily accessible online or otherwise.
The federal government investigated the entry-level hiring practices of the Civil Service
Commission in 2009. The government began the investigation because of information
suggesting that Aurora Police and Fire had far lower percentages of Black and Hispanic
personnel than would be expected based on comparable agencies. The investigation
covered all phases of the hiring process but at first focused on Aurora’s use of written
examinations to screen Police and Fire applicants. In 2012, the government expanded the
investigation to determine whether Aurora’s use of a physical abilities test during the entrylevel hiring process discriminated against female candidates for Aurora Police. This
investigation closed in 2013 and did not result in a formal consent decree. Instead, Aurora
voluntarily made changes to its hiring process in response to the government’s concerns,
including awarding “preference points” to an applicant’s overall ranking for hire if they
were proficient in a second language; replacing Police and Fire’s written examination and
interview process with a more objective video-based examination; moving the Police and
Fire physical abilities test from the beginning to the end of the testing process; and giving
the Civil Service Commission responsibility for conducting Police and Fire entry-level
background investigations.
City Council recently appointed several females and people of color to serve on the Civil
Service Commission. Community members expressed optimism about the Commission’s
efforts to diversify its membership, but shared concern that those efforts would be
insufficient to create actual change.

20

4.

Successes of Aurora Police and Fire

While we find that Aurora Police and Fire have a pattern and practice of violating the law,
as explained in further detail below, we did observe some aspects of Aurora Police and Fire
that embraced best practices for public safety agencies. Though some of these practices
must improve as a result of our findings, Aurora’s decision to adopt many of these
practices into their departments represents noteworthy progress towards improving their
agencies.
4.1.

Early Adoption and Extensive Use of Body-Worn Cameras

Aurora Police began deploying body-worn cameras in 2016.77 Senate Bill 217 requires all
law enforcement agencies throughout Colorado to use body-worn cameras by 2023.78
Aurora’s decision to do so several years earlier has enabled better outside review of their
officers’ conduct and more accurate review of use-of-force incidents. Aurora recently
provided officers with new camera systems that have better video quality. Although not all
features are operational on the new system, the cameras will activate automatically when an
officer leaves their vehicle or unholsters their weapon, and doing so will activate the
cameras of any nearby officers.
Of course, opportunities to improve how the body-worn camera program works remain,
including improved training to ensure compliance with policies. For example, Aurora
should ensure that officers understand the new camera system’s automation and manual
overrides and always mount the cameras on their outermost garment. As one example,
officers activated the old camera system by touching the front of it. This is now how
officers turn off the new cameras. This means that officers in the habit of touching their
camera to turn it on are now inadvertently turning off the automatic system. In addition, we
frequently saw cameras dislodged during uses of force, which officers have said is still a
problem with the new cameras.
4.2.

The Force Review Board to Review Use-of-Force Incidents

Aurora established a Force Review Board in 2016 to review significant uses of force by its
officers. This Board has a mix of department members, including representatives from the
Training Section, the Professional Standards Section, and a sergeant and officer.79 Many,
and sometimes all, of the members of the Force Review Board are outside the chain of
command of officers involved in a particular incident. The Board typically meets once a
week and reviews the reports and body-worn camera videos of significant uses of force.
We observed the Force Review Board meetings for over nine months during this
investigation.
Reviewing uses of force outside the chain of command can improve consistency in how
officers use force, allow for Aurora Police to learn how to reduce the need for using force
in the future, and ensure that Aurora Police’s training on interacting with the community
City of Aurora, Internal Audit Report—Aurora Police Department Body-Worn Camera Compliance, p 8.
§ 24-31-902, C.R.S.
79 Aurora Police Department Directive 05.04.7 (revised Aug. 12, 2021).
77
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21

and using force reflects what the Force Review Board learns about the actual experiences
of Aurora Police.80
Under Aurora Policy, the Force Review Board must review “Use of Force Reports for
compliance with Standard Operating Procedures, Department Directives and applicable
law.”81 Use-of-force reports are created by sergeants and others in the chain of command
above the officers who used force.
While we commend Aurora for the establishment of the Force Review Board, as we
discuss below, its operation falls far short of its potential, particularly in its focus simply on
what can be justified under the law, rather than what is legal and appropriate in the
circumstances.
4.3.

The Creation of a Force Investigation Unit to Allow Affirmative
Investigations of Uses of Force

Chief Wilson recently created the Force Investigation Unit to support the Force Review
Board. Until the creation of the Force Investigation Unit, the Force Review Board could
only review information from the body-worn cameras or the reports created by those in
the chain of command. This limitation prevented full internal investigations of uses of
force, as the Force Review Board was limited to only those reports created for it by those
supervising the officer.
We had the opportunity to review the operation of the Force Investigation Unit for several
months. Based on our limited review, the Force Investigation Unit brings some level of
objectivity to the review, but we still see similar patterns in the review of force—a focus on
justifying the force used rather than evaluating whether it was both legal and appropriate.
And the operation of the Force Investigation Unit does not yet meet its potential.
Members of the unit said that it was formed in part to help identify trends and patterns in
uses of force by officers, but no structured method of doing this exists. However, the
Force Investigation Unit has begun to standardize the presentation and review of uses of
force, lessening the prior inconsistency in use-of-force review that resulted from sergeants
and others in the chain of command evaluating lower-level uses of force.
4.4.

Change in Training Philosophy and Culture at Academy

In 2020, Chief Wilson appointed Lieutenant Brett Parvin to lead the Training Academy
with a mandate to change the philosophy and approach to training at the Academy. As
discussed above, these changes—particularly for the entry-level academy programs—
represent significant positive steps. The approach appears to be focused on creating a
guardian culture that emphasizes protecting the community Aurora Police serves.82 In
addition, the Training Academy plans to increase community involvement, including
participation by community members who have encountered police uses of force. Because
Samuel E. Walker & Carol A. Archbold, The New World of Police Accountability 298 (3d ed. 2020).
Aurora Police Department Directive 05.04.7 (revised Aug. 12, 2021).
82 Sue Rahr & Stephen K. Rice, From Warriors to Guardians: Recommitting American Police Culture to Democratic
Ideals, New Perspectives in Policing, April 2015.
80
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the changes are underway, we cannot determine whether they will create the desired effect.
We would expect to see meaningful changes in measures such as a decrease in excessive
uses of force, community complaints, referrals to Internal Affairs, and similar measures.
And Aurora Police must extend the changes from the Training Academy to In-Service
Training of current officers. While we understand Aurora Police plans to extend this
training, it has not fully done so.
4.5.

Expanded Community Involvement

Aurora Police has started several efforts to engage and receive feedback from the
community. These efforts reflect Aurora Police’s desire to seek community input into its
operations, needs, and discipline.
•

The Aurora Key Community Response Team was created in 1992. Community
stakeholders representing diverse groups meet regularly to facilitate
communications between the police and community.

•

Aurora Police created the Community Policing Advisory Team (“CPAT”) in 2017.
It is a smaller group of community leaders who meet monthly and consult
leadership on promotions at the commander level. CPAT members also help
connect police to community events and provide input on noteworthy events.

•

The Aurora Community Police Task Force is new as of 2020 and members are
appointed by Aurora City Council. This group makes recommendations to the
police and also reviews police policies and procedures.

•

The Chief ’s Review Board is a blended team of law enforcement and community
members that City Council appoints to review police disciplinary matters and make
recommendations to Chief Wilson. To increase community input, transparency,
and diversity, Chief Wilson added four community members to this Board.

•

The Independent Review Board is also a blended team of law enforcement and
community members who review disciplinary matters and make recommendations
to Chief Wilson.

•

The Community Relations Section was recently created by Chief Wilson and
includes Aurora for Youth, Recruiting, and Community Resources.

•

Police Area Representatives (“PAR”) work in the three Aurora police districts and
facilitate connectivity between the police and community members at major city
events, school activities, and food drives. PAR officers focus on building
community relationships.

None of these efforts to expand community involvement give any actual decision-making
authority to those outside of Aurora Police, nor do they empower community members to
obtain more information beyond that provided by Aurora Police. But these efforts do
create more transparency and provide more information to the community. As with other
positive steps, Aurora Police can and should build on these efforts.
23

4.6.

Recognition of Need for Improvement and Change by Senior
Management

In November 2020, Chief Wilson introduced A New Way, Aurora’s five-point plan to
restore trust.83 The plan focuses on five primary concepts: operating, leadership, service,
accountability, and engagement.
A few key changes respond directly to concerns expressed by community members.
Command staff understand the need to move from a “what can we do” perspective on
arrests and uses of force to a “what should we do” perspective. Aurora Police added
Accountability to its core values of Duty, Honor, and Integrity. This addition of
Accountability is a needed change.
Aurora Police leadership has prioritized improving diversity and gender equity at all levels
of the agency, starting with internal promotions. To implement this goal, officers now must
participate in diversity, equity, and anti-bias training, and must read the book Difference
Matters: Communicating Social Identity by Brenda Allen about race, age, and gender identity
before any promotion.
Increasing accountability and transparency are critical to improving community relations.
Chief Wilson created a Force Investigation Unit that will interview people who witnessed
use-of-force events, to bring more perspective to the review. As discussed, this new
investigation unit reports to the Force Review Board. Additionally, a Police Auditor will
review Standard Operating Procedures. Internal Affairs synopses will soon be publicly
available to educate the community about discipline and improve operations.
Aurora Police states that it intends to work with the Crime and Justice Institute, an
organization that specializes in developing effective policies for law enforcement
organizations, to perform a comprehensive redraft of Aurora Police’s policies relating to
the use of force.
As for community engagement, Chief Wilson and the command staff have committed to
continuing and improving the community task forces that are already operational. They
have also conveyed that they are focused on the Explorer Program and the Chief ’s Youth
Advisory Team to engage younger community members.

83

City of Aurora, A New Way: Our Plan to Restore Trust.

24

5.

The Effect of This Investigation

We are aware of several concerns surrounding the new legislation on police accountability
and this investigation. In other cities where similar investigations took place, officers
expressed concern that restrictions and lack of training on new use-of-force policies could
make them hesitate at a crucial moment, putting them, other officers, and the public at
risk.84 Police union representatives echoed those concerns.85 This year, two Colorado
officers were killed by armed assailants, highlighting the significant risks that always
accompany serving as a police officer.86
Public officials in Colorado have said they worry about how public scrutiny is affecting
officer morale and public safety.87 During ride-alongs, officers told us that they feared the
threat of lawsuits or losing their jobs if they made even the smallest mistakes under the
recent legislation, which provides for potential individual liability. That concern, coupled
with what officers describe as conflicting directions about how and whether to contact
community members, has some officers reluctant to take on roles where high levels of
community interaction occur. As a result, some special assignments that focus on high
levels of contact designed to deter crime are often understaffed.
The changes we require in this report are designed to improve public safety, officer safety,
and confidence in Aurora Police and Fire. When implemented properly, appropriate
accountability measures do not create higher crime rates or increase risks to officer safety.
Indeed, as the discussion below shows, some police departments that worked to support
officers with comprehensive training, clear guidance, fair discipline policies, and positive,
engaged supervision saw crime rates and resident complaints fall dramatically while officer
safety improved.
5.1.

Increased Scrutiny of Police Does Not Increase Crime Rates

Investigations of police departments and their resulting reforms are associated with
decreases in the overall violent crime rate.88 In several major cities, for example, crime rates
declined substantially following consent decrees.89 “Both property crimes (down 53%) and
violent crimes (down 48%) decreased in Los Angeles,” and this drop in crime was not
mirrored in several nearby communities that did not attempt reforms. Cincinnati’s violent
Stephen Rushin & Griffin Edwards, De-Policing, 102 CORNELL L. REV. 721, 725-26 (2017); see also Lawrence
Rosenthal, Good and Bad Ways to Address Police Violence, 48 URB. LAW. 675, 737 (2016).
85 The LAPD is Officially Suggesting a Few Things Officers Can Try to Do Before Pulling the Trigger, Los
Angeles Times, Mar. 15, 2016.
86 Colorado Officer Killed in Boulder Grocery Store Remembered as Hero Who Put Others First, NBC
News, Mar. 30, 2021; Police Chief Says Slain Colorado Officer Was ‘Targeted’ in Monday Shooting, CNN,
June 22, 2021.
87 ‘We Need to Take Our Community Back’: Aurora Police Chief Addresses Rising Gun Violence, KDVR
News, June 22, 2021; Aurora Overtakes Colorado Springs as 2nd Most Violent City in Colorado, KDVR News,
Mar. 17, 2021.
88 Kenny Lo & Sarah Figgatt, Violent Crime Rates Declined in 10 Jurisdictions Following Comprehensive
Police Reform, Center for American Progress, Nov. 16, 2020.
89 Paul Butler, The System Is Working the Way It Is Supposed to: The Limits of Criminal Justice Reform, 104 GEO. L.J.
1419, 1459 (2016).
84

25

crime rate also dropped 56%.90 Following Pittsburgh’s consent decree, crime rates,
including homicides, decreased consistent with the national trends.91 These cities show that
policing reforms are associated with improved community safety.
True, some cities experienced a small increase in property crimes and “street crimes like
burglary, motor vehicle theft, and robbery—i.e., criminal activity that is likely sensitive to
situational deterrents like aggressive street policing.”92 But in those cities, the “apparent
uptick in crime was concentrated in the years immediately after the initiation of external
regulation and diminished into statistical insignificance over time.”93 After a period of
adjustment, these departments were just as effective if not better at deterring both violent
crime and property crime. Researchers suggest that this uptick in street crime may stem
from reform “that [] is virtually all stick and no carrot,” and may be avoided by recognizing
and rewarding officers who engage in proactive policing of high-crime areas while adhering
to reforms.94
Police departments that voluntarily implemented more restrictive use-of-force policies also
saw lower crime rates.95 Cities that placed limits on officers’ use of force, without
addressing training or accountability, maintained similar levels of violent crime and
property crime as cities that did not change their policies.96 But the more comprehensive
the reforms, the more crime rates dropped. For example, in New Jersey, Camden County’s
new training program and restrictive use-of-force policies accompanied a 42% reduction in
the overall violent crime rate.97 Homicides also decreased 63%, and robberies by 60%.98 In
short, public safety typically increased after police departments reformed how officers used
force and trained officers on effective alternatives to force.
5.2.

Policy Restrictions on Uses of Force Are Associated With Improved
Officer Safety

Several studies show that policy reforms limiting an officer’s use of force are not associated
with increased risk to officers—instead, quite the opposite. In cities that placed greater
limits on when officers could use force, officers were less likely to be assaulted or killed in
the line of duty.99 A recent study compared the policies large-city police departments had
Id.
Robert C. Davis, et al., Turning Necessity into Virtue: Pittsburgh’s Experience with a Federal Consent Decree, Vera
Institute of Justice, 54-56 (2002).
92 Stephen Rushin & Griffin Edwards, De-Policing, 102 CORNELL L. REV. 721, 765-66 (2017).
93 Id. at 759.
94 Lawrence Rosenthal, Good and Bad Ways to Address Police Violence, 48 URB. LAW. 675, 724 (2016).
95 National Institute of Justice, How Police Supervisory Styles Influence Patrol Officer Behavior (2003).
96 Samuel Sinyangwe, Examining the Role of Use of Force Policies in Ending Police Violence, Fig. 10, The
Police Use of Force Project, Sept. 20, 2016.
97 Josiah Bates & Karl Vick, America’s Policing System Is Broken. It’s Time to Radically Rethink Public
Safety, Time, Aug. 6, 2020. The article notes that economic growth may also play a role in decreased crime
rates.
98 Id.
99 Samuel Sinyangwe, Examining the Role of Use of Force Policies in Ending Police Violence, Fig. 8, The
Police Use of Force Project, Sept. 20, 2016.
90
91

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implemented to limit use of force and then looked at corresponding FBI data on officer
assaults and deaths for each city. 100 In cities with more policy limits, officers experienced
fewer assaults—on average, one-third fewer assaults.101 Yet in cities that did not reform
their use-of-force policies, the risk of an officer being killed was nearly three times
higher.102
The research did not confirm whether officer safety was increased because of the new
policies or because of the training involved with implementing them. But it did confirm
that reforms to use-of-force policies generally do not place officers at higher risk of injury.
5.3.

Policy Restrictions on Uses of Force Are Associated With Increased
Safety for Justice-Involved Residents

Those same policy limits also correlate with fewer in-custody deaths without increased
crime rates.103 Cities that adopted four or more identified use-of-force policy reforms saw
54% fewer deaths in police custody than departments with only one or two policies in
place.104 Cities that had eight key policies in place saw 72% fewer deaths.105
The most significant decreases in resident deaths were found in departments whose use-offorce policies included de-escalation tactics, use-of-force continuums, and the requirement
for officers to exhaust all other reasonable means prior to shooting, which required that
officers undergo training to learn new critical decision-making tactics. Those departments
also added comprehensive reporting requirements on use-of-force incidents, which
required leadership to enforce the new policies and develop a culture of accountability.106
In short, when departments adopted a comprehensive approach to reform, including
policy revisions, training, transparency, and accountability, fewer residents were killed by
police, fewer officers were injured, and the crime rate went down.
5.4.

Policy Restrictions on Police Are Not Associated With Less Engaged
Policing

Although officers sometimes report that they fear that reforms in departmental policies
will make them more hesitant to intervene, the evidence shows that they remain highly
engaged after implementing these reforms. One study found that, in the wake of two
Id., at 2-3, Figs. 8-9. The study examined eight specific policies and their impact on both public safety and
officer safety. The policies required officers to (1) use de-escalation, (2) refer to a use-of-force continuum,
(3) exhaust all other means before shooting, (4) give a warning before shooting, and (5) intervene when other
officers violated policy; restricted officers from (6) firing at moving vehicles or (7) using chokeholds or
strangleholds; and (8) required comprehensive departmental reporting.
101 Id. at Fig. 9.
102 Id. The data used by the authors was averaged from multiple departments, and thankfully, not every
department loses an officer in the line of duty. Therefore, we have chosen to refer to this data as representing
the “risk” to officers.
103 Police Use of Force Project: How police use of force policies can help to end police violence.
104 Samuel Sinyangwe, Examining the Role of Use of Force Policies in Ending Police Violence, The Police Use of
Force Project, Sept. 20, 2016.
105 Id.
106 Id.
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consent decrees, “sick time—one indicator of low officer morale—had actually
declined.”107 Although officers “believed that discipline was frequently meted out,” the
number of disciplinary actions against officers following the decree went down.108 After
the consent decree in Los Angeles, officers reported that they were “more guarded in their
interactions,” but arrest rates actually went up and “the rate at which arrests resulted in
felony charges increased.”109 The researchers credited the increased felony clearance rate to
a policy requiring that officers document their reasonable suspicion for a stop, “reducing
the number of ‘weak’ cases.”110 So while officers protested the increased scrutiny, they
“adjusted to the new rules on stops, arrests, and use of force and actually increased their
enforcement efforts.”111
5.5.

Successful Reform Efforts Are Comprehensive

Finally, how much a city benefits from police reforms—through fewer resident injuries
from police use of force, fewer officer injuries, and lower crime rates—depends on how
comprehensive those reforms are. The most positive results come from policy changes
accompanied by officer training, support from senior officers and field supervisors, and
transparency of accountability measures.112
For example, training officers on how to interact with the public with dignity and respect,
giving residents a voice in encounters, appearing neutral in decision-making, and
communicating trustworthy motives—commonly called “procedural justice”—reduced the
number of use-of-force complaints against Chicago’s officers and the number of times
officers reported using force.113 “[W]hen police interact with citizens in a procedurally fair
manner, such as speaking calmly and explaining the reasons for their actions to the

Robert C. Davis, Nicole J. Henderson & Christopher W. Ortiz, Can Federal Intervention Bring Lasting
Improvement in Local Policing?: The Pittsburgh Consent Decree, Vera Institute of Justice, 25-26 (2005). The report
noted that officer morale was already low well before the pattern and practice investigation and subsequent
consent decrees, but officers associated their low morale with the scrutiny, not with the police department’s
culture. See also, Christopher J. Marier & Lorie A. Fridell, Demonstrations, Demoralization, and De-policing, 19
CRIMINOLOGY & PUB. POL’Y 693, 714 (2020) (“High officer cynicism is significantly associated with
withdrawal from police work, but cynicism on the part of police is high irrespective of periods of increased
public antipathy. Thus, although public demonstrations against the police do not present threats to the police
institution, some entrenched elements of police culture and morale may continue to challenge public
administrators.”)
108 Robert C. Davis, Nicole J. Henderson & Christopher W. Ortiz, Can Federal Intervention Bring Lasting
Improvement in Local Policing?: The Pittsburgh Consent Decree, Vera Institute of Justice, 25 (2005).
109 Samuel Walker, “Not Dead Yet”: The National Police Crisis, A New Conversation About Policing, and the Prospects
for Accountability Related Police Reform, 2018 U. ILL. L. REV. 1777, 1836 (2018).
110 Id.
111 Id. at 1836-37.
112 Samuel Sinyangwe, Examining the Role of Use of Force Policies in Ending Police Violence, The Police Use of
Force Project, Sept. 20, 2016.
113 George Woods, et al., Procedural justice training reduces police use of force and complaints against officers, Proceedings
of the National Academy of Sciences of the United States of America (May 5, 2020) (corrected July 6, 2021).
107

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individual . . . , citizens are more likely to comply and be respectful toward police officers,
thereby reducing the need for officers to resort to force.”114
On the other hand, when departments provided Crisis Intervention Training (CIT)—a
well-regarded de-escalation model—the rate of officer injuries and use-of-force incidents
remained unchanged.115 CIT reduced the number of arrests, mainly because officers
transported subjects to hospitals rather than jail, but use-of-force incidents and levels of
force remained the same.116
Most departments train only a select number of officers in CIT, so the majority of officers
have not been taught the same crisis de-escalation approach. And CIT training is largely
focused on communication, “but does not provide guidance on how officers should
combine communications with tactics.”117 When situations are evolving, or communication
is initially unsuccessful, officers may resort to defensive tactics such as the use of force.
Our own observation of CIT-trained officers supports this assessment. When confronted
with people in a mental health crisis, we observed CIT-trained officers either disregard
their CIT tactics or fail to intervene while other officers employed traditional, defensive
tactics that escalated the crisis, even when the situation was not rapidly evolving or
potentially violent. The lack of demonstrated commitment to CIT tactics meant that
Aurora Police’s investment in the training had little effect on resident encounters.
Successfully addressing the concerns raised in our investigation will require a
comprehensive approach that includes policy reform, supportive training of new and
existing officers, invested supervision, and accountability to sustain constitutional policing
that minimizes the need for force. Combining these strategies can create safer streets for
Aurora’s residents and officers alike.

Mawia Khogali, Redefining Standards of Excessive Force: Implications for Policy and Practice, 12 S. J. POL’Y & JUST.
105, 128 (2018).
115 Robert E. Worden, et al., The Impacts of Implicit Bias Awareness Training in the NYPD, IACP/UC Center for
Police Research and Policy & John F. Finn Institute for Public Safety, 145 (2020).
116 Id.
117 Critical Issues in Policing Series: Guiding Principles on Use of Force, Police Executive Research Forum,
26-27 (2016).
114

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6.

Pattern and Practice Findings: Legal Background

In conducting our investigation, we focused on federal and state constitutions and laws
relating to four areas: (1) limitations on discriminatory policing practices; (2) the standards
for stopping people on the street in Colorado, often called a Terry stop (after the U.S.
Supreme Court case that originally established the constitutional requirements for such
stops); (3) the law governing use of force and arrests; and (4) the requirements for
administering ketamine outside of a hospital.
6.1.

Limitations on Discriminatory Policing Practices

Colorado and federal constitutions and laws prohibit police officers from engaging in
biased policing, whether bias manifests through stops, arrests, uses of force, or other
policing activities.
The Equal Protection Clause of the United States Constitution provides that the
government shall not “deny to any person within its jurisdiction the equal protection of
the laws,” and article II, section 25 of the Colorado Constitution requires that all persons
receive “equal treatment under the laws.”118
Colorado law has, since 2001, barred the use of racial and certain other forms of profiling
by law enforcement officers.119 In its current form, Colorado law prevents the practice of
“relying solely on race, ethnicity, gender, national origin, language, religion, sexual
orientation, gender identity, age, or disability” to determine “the existence of probable
cause,” “reasonable and articulable suspicion that an offense has been or is being
committed,” or “the scope, substance, or duration of an investigation or law enforcement
activity to which a person will be subjected.”120
Colorado’s Anti-Discrimination Act states that it is a “discriminatory practice and
unlawful” for a person “to refuse, withhold from, or deny to an individual or a group,
because of [protected characteristics, including race], the full and equal enjoyment of the
. . . services . . . of a place of public accommodation.”121 A “place of public
accommodation” includes “any place offering services, facilities, privileges, advantages, or
accommodations to the public.”122 This definition logically covers police and fire
departments. A recent Colorado federal court decision held that these statutory provisions
“appl[y] to organizations that conduct activities in facilities . . . that are open to the public”

E.g., Flowers v. Mississippi, 139 S. Ct. 2228, 2241-42 (2019); Peña-Rodriguez v. Colorado, 137 S. Ct. 855, 867
(2017); Mayo v. Nat’l Farmers Union Prop. & Cas. Co., 833 P.2d 54, 56 n.4 (Colo. 1992).
119 § 24-31-309(3), C.R.S. (effective from 2001 through 2016) (“Any peace officer certified pursuant to this
part 3 shall not engage in profiling.”).
120 § 24-31-309(2)(b), (3), C.R.S.
121 § 24-34-601(2)(a), C.R.S.
122 § 24-34-601(1), C.R.S.
118

30

and that the law should be applied broadly.123 Members of Aurora Police and Fire may not
discriminate against members of the community while conducting policing activities.124
In addition, several federal statutes proscribe Aurora Police and Fire from racially
discriminating against members of the public. Title VI of the Civil Rights Act of 1964 and
its implementing regulations prohibit entities that receive federal funds from discriminating
against individuals on the basis of race, whether intentionally or through practices that
have the effect of discrimination.125 Similarly, the Safe Streets Act prohibits law
enforcement practices that intentionally discriminate against or that impose an unjustified
disparate impact against a particular racial group.126
These laws govern the following discussion of stops, arrests, and uses of force.
6.2.

Legal Requirements for Stops

Under the Fourth Amendment of the U.S. Constitution, when an officer stops a resident to
investigate a potential crime—known as a Terry stop—the officer must reasonably suspect
that the person is involved in criminal activity.127 And Colorado imposes similar
requirements for a lawful stop: the purpose of the stop must be reasonable, and the
character and scope of the stop must be reasonably related to its purpose.128 Officers must
be able to point to “specific and articulable facts” in support of their suspicion that the
person is involved in criminal activity; simply seeing someone walk away from police
officers in a high-crime area, for example, is insufficient.129 Further, the investigatory stop
must be limited to “a brief detention to confirm or dispel” the officer’s suspicion that a
crime was, is being, or will be committed.130 And under Colorado law, “reasonable
suspicion” cannot turn on racial or other profiling.131
Creek Red Nation, LLC v. Jeffco Midget Football Ass’n, Inc., 175 F. Supp. 3d 1290, 1298 (D. Colo. 2016).
In line with this interpretation, another state court, interpreting a public accommodations statute like
Colorado’s, found that police departments are places of public accommodation and that police departments
and their officers must comply with their state’s anti-discrimination provisions. See Ptaszynski v. Uwaneme, 853
A.2d 288, 297 (N.J. Super. Ct. App. Div. 2004) (“[W]e conclude that the Township police department—both
the building and the individual officers—is a place of public accommodation. A municipal police force is
nothing more than ‘an executive and enforcement function of municipal government[.]’ As a public entity, by
its very nature a police force is a place of public accommodation.” (citation omitted)). And at least two more
states’ courts have analyzed police conduct under their states’ public accommodations and anti-discrimination
laws. See Gazette v. City of Pontiac, 536 N.W.2d 854 (Mich. Ct. App. 1995); McKinney v. City of Tukwila, 102
Wash. App. 1033 (2000).
125 42 U.S.C. § 2000d (no person shall “be excluded from participating in, be denied the benefits of, or be
subjected to discrimination under any program or activity receiving [f]ederal financial assistance” based on
race); 28 C.F.R. § 42.104(b)(2) (recipients of federal funds “may not . . . utilize criteria or methods of
administration which have the effect of subjecting individuals to discrimination because of their race”); see
also Alexander v. Sandoval, 532 U.S. 275, 281-82 (2001).
126 28 C.F.R. § 42.203.
127 Terry v. Ohio, 392 U.S. 1 (1968).
128 People v. Threlkel, 2019 CO 18, ¶ 18.
129 People in Interest of K.D.W., 2020 COA 110, ¶¶ 16, 26.
130 Threlkel, ¶ 17.
131 § 24-31-309, C.R.S.
123
124

31

Starting in mid-2020, Senate Bill 217 required officers to report information about all
stops, including the stopped person’s perceived demographic information, reason for
contact, and result of contact.132 This provision is discussed further in Section 9.
6.3.

Legal Requirements for Use of Force and Arrests

If the stop progresses to an arrest, the law places additional limits on officers. When
making an arrest, the officer must have a warrant, probable cause to believe a person
committed a crime, or have personally witnessed the crime.133 As with reasonable suspicion
in stopping someone, probable cause for an arrest cannot be supported by profiling based
on race or other protected characteristics, though a physical description of the subject may,
of course, include the subject’s race.134 And an officer cannot use excessive force when
making an arrest or bringing a person into submission.135
If an officer uses excessive force, he or she is “subject to the criminal laws of [Colorado]
to the same degree as any other citizen,” including the laws on homicide and assaults.136
Force is excessive if it is greater than that necessary to carry out an arrest, prevent escape,
or prevent injury to the officer or others.137 And Senate Bill 217 now requires that officers
use nonviolent means instead of force if possible.138 Colorado law now also requires
officers to intervene when another officer is using excessive force and to report the
excessive use of force.139
In addition, the “mentally ill or disturbed condition of the suspect is a relevant factor in
determining reasonableness of an officer’s responses to a situation.”140 When a subject
exhibits diminished capacity, an officer’s conduct may be unreasonable if the officer was
not “in danger at the precise moment” that his or her conduct “unreasonably created the
need to use such force.”141 In other words, if an officer’s tactics cause a subject in crisis to
react aggressively, those actions may be “immediately connected to the suspect’s threat of
force,” and the officer’s defensive use of lethal force may be considered unreasonable.142
Officers, therefore, should avoid tactics that escalate an encounter with a person they
suspect is experiencing a mental health crisis.

§ 24-31-309(3.5), C.R.S.
U.S. Const. Am. IV; § 16-3-102, C.R.S.
134 § 24-31-309, C.R.S.
135 McDaniel v. People, 499 P.2d 613, 615 (Colo. 1972).
136 § 18-8-803(1), C.R.S.; see also Campbell v. People, 133 P. 1043, 1046 (Colo. 1913) (explaining that an officer
“stands upon the same plane” as a private citizen when committing criminal acts); Bourie v. Dep’t of Higher
Educ., 929 P.2d 18, 21 (Colo. App. 1996) (recognizing clear “public policy that law enforcement officers have
no immunity from criminal prosecution nor are they accorded any special status with respect to the use of
force except in making an arrest”).
137 See § 18-8-803(2), C.R.S.; § 18-1-707, C.R.S.
138 § 18-1-707(1)-(4.5), C.R.S.
139 § 18-8-802(1), C.R.S.; § 18-8-802(1.5), C.R.S.
140 Estate of Ceballos v. Husk, 919 F.3d 1204, 1214 (10th Cir. 2019).
141 Id. at 1215.
142 Allen v. Muskogee, Okl., 119 F.3d 837, 841 (10th Cir. 1997).
132
133

32

The Tenth Circuit Court of Appeals, in four cases, has explained what types of tactics
might be viewed as recklessly and deliberately escalating an encounter where a subject
exhibits diminished mental capacity.143
In each case, the officers were on scene to conduct a welfare check. The person in crisis
was armed but “posed harm to no one” when officers escalated the situation.144 But the
officers acted quickly, yelled commands, crowded the person and often trapped them, and
did not try to de-escalate the encounter.145 Officers on scene in one incident had received
Crisis Intervention Training (“CIT,” discussed above), but they did not use those tactics or
“tak[e] steps to calm the situation.”146
In each case, the person in crisis responded aggressively to the officers. One raised his gun,
another lunged with his knife, a third pointed a sword at the officers, and a fourth
approached with a raised baseball bat. All four were shot by officers who said they acted to
defend themselves. The officers’ tactics, rather than defusing the situation, contributed to
the person in crisis feeling defensive and acting aggressively. Particularly because the
subjects were not criminal suspects, these tactics may have “unreasonably escalated the
situation to the point deadly force was required.”147 The officers’ actions were “immediately
connected to the suspect’s threat of force,” and the use of lethal force was therefore
unreasonable.148
In all four cases, officers had been told by the dispatcher or people on the scene that the
person was experiencing a mental health crisis. For example, in the most recent case, the
court noted “the responding officers knew [the man’s] capacity to reason was diminished,
whatever the underlying reason might have been—mental health problems, emotional
distress, drunkenness, or drugs,” and so “an objective officer … would have taken those
facts into account before provoking a fatal encounter.”149 Knowing that a subject is
experiencing a mental health crisis, therefore, triggers an officer’s need to use modified
tactics and de-escalation to avoid provoking the need for a higher level of force.
The Tenth Circuit used this same analysis in another recent case to find that officers must
consider whether a person is inebriated or otherwise impaired, even if the service call was
See Estate of Ceballos, 919 F.3d 1204 (incorporating the analysis of incidents in Allen v. Muskogee, Okl., 119
F.3d 837 (10th Cir. 1997); Sevier v. City of Lawrence, Kan., 60 F.3d 695 (10th Cir. 1995); Hastings v. Barnes, 252 F.
App’x 197 (10th Cir. 2007)).
144 Est. of Ceballos, 919 F.3d at 1217.
145 In Hastings, 252 F. App’x at 203, the court explained how the officers’ tactics caused the man to react
defensively, provoking their use of force:
He was a potentially mentally ill/emotionally disturbed individual who was contemplating
suicide and had called for help. Rather than attempt to help [him], [the officers] crowded
themselves in [his] doorway (leaving no room for retreat), issued loud and forceful
commands at him and pepper-sprayed him, causing him to become even more distressed.
Hastings, an unpublished case, was referenced in Bond v. City of Tahlequah, Oklahoma, 981 F.3d 808, 817 (10th
Cir. 2020) and Est. of Ceballos, 919 F.3d at 1217.
146 Id. at 1211.
147 Id.
148 Allen, 119 F.3d at 841.
149 Estate of Ceballos, 919 F.3d at 1217.
143

33

for a trespass, and not a welfare check.150 Applying this law, a September 3, 2021 district
court order denied four Aurora Police officers qualified immunity when one of the officers
shot a man who had falsely reported to 911 that he had killed two people and was holding
two more hostage.151 According to a lawsuit filed by the man’s family, the officers were told
upon arrival to the apartment that the man was alone, unarmed, and had a mental health
issue. The district court found that the officer who shot the man had reason to know the
man was not a danger to anyone and was possibly experiencing a mental health crisis, but
proceeded to corner and confront him at gunpoint, provoking the man’s defensive
response. The other three officers were denied qualified immunity for failing to intervene
to prevent the shooting, which occurred within two minutes of the four officers entering
the apartment.
6.4.

Legal Requirements for Use of Ketamine

Finally, ketamine cannot be administered unless it is (1) used for bona fide medical needs,
and (2) administered by or under the direction of a person licensed or legally authorized to
do so.152 The unlawful administration of drugs constitutes second-degree assault and
occurs where a person “intentionally causes stupor, unconsciousness, or other physical or
mental impairment or injury” by administering a drug “for a purpose other than lawful
medical or therapeutic treatment.”153
6.5.

Recent Changes to Colorado Law

Senate Bill 217, signed into law on June 19, 2020, reformed law enforcement operations in
Colorado.154 Colorado lawmakers introduced the bill shortly after George Floyd’s death in
Minneapolis.155 It requires law enforcement agencies across Colorado to make significant
changes to their policies, training, and reporting requirements. The Colorado legislature
made additional changes in 2021: House Bill 21-1250 updated some of Senate Bill 217’s
requirements and deadlines and House Bill 21-1251 limited the use of ketamine.156 Both
became effective on July 6, 2021.
Senate Bill 217 created more specific statutory criteria for the use of deadly force. For
example, the law requires that an officer both believe and have an objectively reasonable
belief that the officer or another person “is in imminent danger of being killed or of

Bond, 981 F.3d at 824. Bond held that it has been clearly established law that officers who respond to an
agitated person and “unreasonably escalate[] a non-lethal situation into a lethal one through their own
deliberate or reckless conduct” violate the Constitution. The defendants in this case have filed a petition
asking the U.S. Supreme Court to hear this case which the Court has not yet decided.
151 Flores v. Aurora, No 1:20-cv-0018-RBJ, 2021 WL 4033117 (D. Colo. Sept. 3, 2021).
152 § 18-13-123(3), (4)(a), C.R.S.
153 § 18-3-203(1)(e), C.R.S.; see also People v. Nygren, 696 P.2d 270, 271-72 (Colo. 1985).
154 Colorado Senate Bill 20-217, Enhance Law Enforcement Integrity.
155 Colorado Governor Signs Sweeping Police Accountability Bill Into Law. Here’s How it Will Change Law
Enforcement, The Colorado Sun, June 19, 2020.
156 Colorado House Bill 21-1250, Measures to Address Law Enforcement Accountability; House Bill 21-1251,
Appropriate Use of Chemical Restraints on a Person.
150

34

receiving serious bodily injury” before using deadly force.157 Additionally, law enforcement
may not use deadly physical force to apprehend someone suspected only of a minor or
nonviolent offense.158 And the bill limited Colorado’s “fleeing felon law,” which previously
allowed officers to use deadly force to stop a person running away if officers suspected
them to be armed or to have used a weapon in a crime.159
As for less-lethal force, the bill bars officers from using carotid holds or other types of
chokeholds, which apply pressure to a person’s neck so that it becomes difficult for the
person to breathe or blood flow is cut off to the person’s brain.160 It requires officers to use
non-violent means before resorting to physical force where possible and permits the use of
force “only if nonviolent means would be ineffective in effecting an arrest, preventing an
escape, or preventing an imminent threat of injury to the peace officer or another
person.”161 It includes protest-specific provisions, barring officers from using chemical
agents such as tear gas without warning and from firing less-lethal projectiles
indiscriminately.162 And it imposes a new “duty to intervene” on law enforcement officers,
requiring officers to intervene if they witness another officer using excessive force against a
person.163 One method to ensure compliance with these provisions will be through the
bill’s body-worn camera provisions, requiring all Colorado law enforcement agencies to
outfit their officers with cameras by July 1, 2023.164 Officers must activate these cameras
when interacting with the public to enforce the law or investigate possible violations of the
law.
The bill requires law enforcement agencies to abide by new data collection and reporting
requirements. Agencies must collect demographic data on officers’ contacts with the public
when enforcing the law or investigating possible legal violations, including the location,
circumstances, and result of the interaction; data on when an officer unholsters their
weapon; and use-of-force data, including information about the type of force used,
injuries, and the basis for the encounter.165 By April 1, 2022, the agencies must report this
information to the state.166
Finally, Senate Bill 217 changed the law for police misconduct claims. It altered Colorado’s
qualified immunity provisions, allowing officers to be sued in their individual capacities and
liable for up to $25,000 in damages when their employer determines that “the officer did
not act upon a good faith and reasonable belief that the action was lawful.”167 And it
§ 18-1-707(4.5), C.R.S.
§ 18-1-707(2)(a), C.R.S.
159 Polis Signs Broad Police Accountability and Reform Bill Into Law After Weeks of Protests, CPR News,
June 19, 2020.
160 § 18-1-707(2.5), C.R.S.
161 § 18-1-707(1), C.R.S.
162 § 24-31-905(1), C.R.S.
163 § 18-8-802(1.5), C.R.S.
164 § 24-31-902, C.R.S.
165 § 24-31-903(2), C.R.S.; § 24-31-309(3.5), C.R.S.
166 § 24-31-903(2), C.R.S.
167 § 13-21-131(4), C.R.S.
157
158

35

authorizes the Colorado Attorney General to investigate and file a civil suit against any
governmental agency when the Attorney General has reasonable cause to believe that an
agency has engaged in a pattern or practice of violating state or federal law.168
The recent ketamine law prohibits officers from requesting that paramedics give any
chemical sedative to a suspect and requires other officers and paramedics to report when
an officer requests sedation.169 The new law restricts paramedics from administering
ketamine in the presence of law enforcement except in the case of a justifiable medical
emergency, and then only when trained personnel assess the patient’s weight and required
medical monitoring is available.170 The law also excludes “excited delirium” as a justifiable
medical emergency.171 Excited delirium, discussed in Section 10, is the diagnosis most
emergency medical services’ policies cite as triggering the urgent need to administer
ketamine to police-involved patients.

§ 24-31-113, C.R.S.
§ 18-8-805, C.R.S.
170 § 25-3.5-209, C.R.S.
171 § 25-3.5-103(8.6), C.R.S.
168
169

36

7.

Finding #1: Aurora Police Has a Pattern and Practice of Engaging in
Racially Biased Policing Against People of Color as a Whole and Black
People in Particular

As discussed above in Section 6, state and federal law prohibit police departments from
engaging in racially biased law enforcement activities. During the course of our
investigation, we examined a host of qualitative and quantitative evidence, all of which
point to a singular conclusion: Since at least 2018, Aurora Police has engaged in a pattern
and practice of racially biased policing against people of color as a whole and Black people
in particular. The racial disparities we observed extend to nearly every significant facet of
police contact with the community, from interactions to arrests to uses of force.
7.1.

Background

Statistics reported publicly by Aurora Police that predate our investigation already
suggested the possibility that Aurora Police’s law enforcement activities have been biased
against Black individuals172 and other minority groups. These statistics showed that Aurora
Police arrested and used force against Black individuals to a much greater extent than one
would anticipate based purely on the percentage of Black individuals living in Aurora.
For instance, according to data that Aurora Police provided to the FBI through its Uniform
Crime Reporting program, between the years of 2015 and 2019, Black individuals
accounted for nearly 40% of all reported arrests in Aurora.173 Yet, according to the U.S.
Census Bureau, as of July 1, 2019, Black individuals made up less than 17% of Aurora’s
population.174 By contrast, white individuals (non-Hispanic and Hispanic)175 accounted for
nearly 58% of reported arrests, which tracks their 60% population share.
Population vs. Arrest Percentages
(2015-2019)

80.0%

60.4%
60.0%

58.0%

40.0%
40.0%
20.0%
0.0%

-

16.5%

African Americans
■

Population

White (Hispanic & Non-Hispanic)
Arrests

Sources: FBI Crime Data Explorer; U.S. Census Bureau ACS Demographic and Housing Estimates

172 We use the terms “Black” and “African American” interchangeably, though most of the data sources use
“African American,” so many of the charts and graphics in this section use that term as well.
173 Federal Bureau of Investigation, Crime Data Explorer.
174 2019 ACS 5-Year Data Profile, Demographic and Housing Estimates, U.S. Census Bureau.
175 The U.S. Census and other government data often distinguish between white (non-Hispanic) and white
(Hispanic), and we likewise recognize that distinction throughout our analysis. However, for readability, in this
report we use the term “white” to refer to non-Hispanic white individuals, unless otherwise noted. White
(Hispanic) individuals are considered non-white in our analysis.

37

This means that from 2015 to 2019, the relative proportion of Aurora Police arrests
involving Black subjects was approximately 2.5 times higher than would be anticipated based
on the relative percentage of Black individuals in Aurora’s population alone. By contrast,
the relative proportion of Aurora Police arrests of white subjects (Hispanics and nonHispanics) was lower than would be anticipated based on that group’s relative percentage of
population.176
Publicly reported use-of-force data exhibited even greater patterns of disproportionality. In
its annual use-of-force reports, Aurora Police reported the following data177 for Black and
white individuals for the period of October 2015 to December 2020:
Percentage of Total Aurora Police Use-of-Force Incidents
Year
2015-16

2017

2018

2019

2020178

White

30.7%

33.9%

31.2%

34.5%

30%

African American

53.8%

44.2%

48%

47.3%

36%

Comparing the average reported use-of-force rates by ethnicity against the census figures
showed an even greater disproportionality than the one seen with arrests:

Population vs. Use of Force Percentages
(2015-2020)
50.0%
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%

45.9%

44.4%

32.1%

16.5%

White (Non-Hispanic)

African-American
■ Population

Use of Force

Sources: Aurora Police Use-of-Force Reports; U.S. Census Bureau ACS Demographic and Housing Estimates

176 The FBI’s arrest statistics for all crimes do not break out “white” into “Hispanic” and “non-Hispanic.” It
does give ethnicity information for certain violent crimes and property crimes.
177 APD, 2016 Use of Force Annual Report at 8 (Oct. 1, 2015 to Sept. 30, 2016); APD, 2017 Use of Force
Annual Report at 7 (Jan. 1, 2017 to Dec. 31, 2017); APD, 2018 Use of Force Annual Report at 7 (Jan. 1, 2018
to Dec. 31, 2018); APD, 2019 Use of Force Annual Report at 8 (Jan. 1, 2019 to Dec. 31, 2019); APD, 2020
Use of Force Annual Report at 7 (Jan. 1, 2020 to Dec. 31, 2020).
178 We note that, according to this report, the use-of-force rate for Black individuals appears to have gone
down in 2020. However, given the unique circumstances presented by the COVID-19 pandemic and other
events in 2020, we do not draw any conclusions from this data alone. Rather, our own analysis of use-offorce incidents, described below, focuses on a longer time frame (2018-2021).

38

Here, Aurora Police’s use of force against Black subjects was almost three times higher
than would be anticipated based solely on the relative percentage of Black individuals in
Aurora’s population. By contrast, use-of-force incidents involving white subjects were
about 25% lower than would be anticipated based on that group’s relative population share.
These publicly reported statistics align with feedback expressed by the community. We
heard from many stakeholders that officers engage in over-policing in certain
neighborhoods. We also heard anecdotal reports from Black community members about
unwarranted stops and other examples from personal and family member experiences.
But the above data have their limitations. For example, the FBI arrest data only report
arrests for white individuals as a whole, without breaking down the numbers by Hispanic
and non-Hispanic ethnicity. They also do not take into account individuals who are
arrested more than once; the data merely report all arrests in a jurisdiction during a given
year. As discussed below, the data we obtained from Aurora Police provided far more
information and granularity, allowing the investigation team to do a much more rigorous
and reliable analysis.
More importantly, however, arrest and use-of-force statistics are only one piece of the
puzzle. Along with the data, we had access to tens of thousands of police reports, ridealongs with police and fire personnel, interviews with police and fire leadership, body-worn
camera recordings of many uses of force, discussions with community members, as well as
input from law enforcement experts. This information, along with the data that we
gathered and analyzed, make clear that Aurora Police has engaged in a continuing pattern
and practice of racially discriminatory policing.179
7.2.

The Team’s Investigation of Aurora Police’s Data

Given the publicly reported data and other anecdotal evidence of biased enforcement
activities against people of color, we set out to perform a more robust statistical analysis of
Aurora Police’s internal data. Our goal was to determine whether there was statistically
significant evidence that Aurora Police had engaged in racially biased policing activities.
7.2.1. Assembling the Data Analytics Team
To accomplish this task, we put together a data analytics team comprised of professional
econometricians and statisticians to assemble and analyze available data from Aurora Police
on its activities. The members180 of the team are:
•

Dr. David K. A. Mordecai, president of Risk Economics, an advisory firm that
specializes in risk and liability management, as well as forensic analytics;

Limitations on available data from before January 1, 2018, prevent us from issuing findings for earlier
periods. This is not meant to suggest, however, that Aurora Police was not engaged in racially discriminatory
policing before 2018.
180 A complete description of the qualifications of each data analytics team member (including academic
credentials, professional experience, and research concentrations) is contained in the attached Technical
Appendix.
179

39

•

Ms. Samantha Kappagoda, chief economist at Risk Economics;

•

Mr. Michael Kwak, executive vice president at Compass Lexecon, a leading
economic consulting firm that provides support and analysis to law firms,
corporations, and government clients;

•

Mr. Mihir Gokhale, vice president at Compass Lexecon;

•

Mr. Noah Mathews, senior analyst at Compass Lexecon; and

•

Mr. Peter Horvath, senior analyst at Compass Lexecon.

Each of the individuals listed above donated substantial time and resources to this effort,
and we are grateful for their involvement.
7.2.2. Data Collection
Assembling a reliable data set on which to perform a statistical analysis was challenging.
The main repository of data capturing Aurora Police’s law enforcement activity resides in
the department’s “records management system,” or RMS, a database that is locally
maintained by the City of Aurora, but which employs third-party software provided by
Versaterm, a Canadian company that develops software for fire, police, and other public
agencies. The RMS database contains, among other things, the information commonly
found in police reports, such as the details of an event, the names and ethnicities of parties
involved, the officers’ narrative description, and photos of an incident.
But there are also other important sources of data that track Aurora Police activities. Chief
among these is Aurora Police’s Administrative Investigations Management (AIM) system,
which stores data related to use-of-force incident reports and officer performance data. In
addition, Aurora Police’s computer-aided dispatch (CAD) system contains information
related to officer locations and response times, as well as call notes from dispatchers and
officers that are entered as events unfold.
The goal of the data analytics team was to assemble data from these three repositories into
a single data set against which they could run queries. Discussions with relevant personnel
at Aurora Police revealed that the portions of the CAD database relevant to our
investigation also existed within the RMS environment. The AIM system, however,
remained separate. The team therefore focused on obtaining access to the RMS and AIM
databases. We discussed several alternatives with Aurora Police and the City of Aurora,
including creating a modified copy of the RMS and AIM databases for our statisticians to
use. Ultimately, the City of Aurora and Aurora Police agreed to provide our team with
virtual access to their servers, where we had direct access to the RMS and AIM databases
containing the raw data used and created by Aurora Police.
Using a statistical programming language called R, the data analytics team queried the
joined RMS and AIM databases to extract police incident data recorded by the system. The
extracted data was joined as a single dataset, further anonymized to remove personal

40

identifying information (e.g., names of individual officers or witnesses), and subjected to
standard data cleaning procedures.
The result was a preliminary dataset of over three million records, comprised of
anonymized fields of interest for about 20 years’ worth of Aurora Police incidents.
Importantly, to our knowledge, neither Aurora Police nor the City of Aurora restricted the
data analytics team’s collection efforts by time or subject matter, so the team had essentially
unfettered access to the available incident data from Aurora Police. However, because our
investigation focuses on current practices, and because record-keeping practices were not
as thorough for older periods, the data analytics team’s queries typically focused on data
from 2018 to 2021. Along with the Aurora Police dataset, the data analytics team also relied
on data from the Census Bureau and U.S. Department of Housing and Urban
Development supporting estimates of population level demographics (e.g., race, ethnicity,
age, gender, and median income).
The resulting data set enabled a more detailed empirical analysis of Aurora Police activity
using established statistical methodologies, which is described in greater detail in the
attached Technical Appendix to this report. The investigation team used this analysis, along
with other evidence, to reach the conclusions set forth below.
This analysis would not have been possible without extensive assistance and coordination
from data professionals at the City of Aurora and Aurora Police. We are extremely grateful
for their cooperation and professionalism.
7.3.

Data Analysis

Based on our review of the data, we conclude that there is statistically significant evidence
that from at least January 2018 through February 2021, Aurora Police disproportionately
interacted with, arrested, and used force against people of color, particularly Black people,
as compared to white individuals.
Specifically, the data show that Aurora Police’s interactions with, arrests of, and uses of
force against people of color were disproportionately higher than would be anticipated
based on a racial or ethnic group’s percentage of Aurora’s overall population. These
disparities persist across income, gender, and geographic boundaries. They even persist
when accounting for individuals who have multiple interactions with police, arrests, and
uses of force. Furthermore, the disparities persist even when Aurora Police’s arrest and
use-of-force activities are compared to the demographic makeup of the subpopulation
who police interact with in the first place (as opposed to the city’s population as a whole).
In short, no matter how one looks at the data, it is clear that observed law enforcement
outcomes for people of color in Aurora differ significantly from those experienced by their
white counterparts. These data—particularly for Black individuals—are deeply troubling.
7.3.1. Interactions
Police cannot arrest or use force against individuals who they do not first interact with.
There is statistically significant evidence that Aurora Police disproportionately interacted

41

with individuals of certain races and ethnicities, particularly Black people, as compared to
other races and ethnicities, including white residents.
For purposes of this analysis, an “interaction” was defined broadly to include any recorded
interaction with an officer that was related to a call for service of any kind.
Many individuals had multiple interactions with Aurora Police during the relevant time. The
data analytics team looked at both (1) the overall number of interactions Aurora Police had
with individuals, without accounting for individuals Aurora Police interacted with more
than once, and (2) the number of specific individuals Aurora Police interacted with during
the same period. The data show that Aurora Police disproportionately interacted with
people of color, particularly Black people.
Over the three-year period from January 2018 to February 2021, the data analytics team
found that the number of interactions Aurora Police had with people of color versus white
individuals was far higher than would be anticipated based on relative population
percentages alone, particularly for Black individuals.
Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander

Population
3,203
23,917
60,909
101,562
1,296

Interactions
259
2,793
39,873
31,629
272

(as % of
Population)
8.1%
11.7%
65.5%
31.1%
21.0%

190,887
163,765

74,826
47,745

39.2%
29.2%

Non-White (All)
White/Non-Hispanic
Source: Technical Appendix, Figure 1.D

The data above show that, from 2018 to 2021, Aurora Police had 74,826 interactions with
non-white individuals.181 During the same period, they had 47,745 interactions with white
individuals.182 In other words, Aurora Police had nearly one-and-a-half-times the number of
interactions with people of color than with white residents during this time frame, which is
far higher than would be anticipated based on relative population alone.
As the graph below shows, the number of non-white interactions amounted to 39.2% of
Aurora’s non-white population, while interactions with white subjects equaled only 29.2%
of Aurora’s white population.

Technical Appendix, Fig. 1.D. As explained in Section V of the Technical Appendix, each interaction with
the same individual is counted as a separate interaction, meaning the total number of interactions likely
includes multiple interactions with the same people.
182 Id.
181

42

Aurora Police Interactions as a Percentage of
Each Group's Population Qanuary 2018 - February 2021)
80.00%
65.5%
60.00%

39.2%
40.00%
29.2%
20.00%

0.00%
White

Non-White

Black/ African American

Source: Technical Appendix, Fig. 1.D

The data for Black individuals are particularly revealing. From 2018 to 2021, Aurora Police
had 39,873 interactions with Black residents, which was equivalent to 65.5% of Aurora’s
Black population.183 That number contrasts with the 47,745 white interactions, which as
noted above was equivalent to only 29.2% of Aurora’s white population.184
This does not mean that 65.5% of Black individuals or 29.2% of white individuals living in
Aurora had interactions with Aurora Police during the relevant time frame. The number of
interactions referenced above includes multiple interactions with some individuals, as well
as interactions with people who do not live in Aurora.185 However, as explained in more
detail in the Technical Appendix, comparing the number of interactions to the relative
population size provides one useful metric for assessing whether Aurora Police
disproportionately interacts with Black and other minority groups, as compared to the city’s
white population.
Some may argue that the disproportionate interaction rate for minority groups is not a
useful metric if attributable to the fact that certain members of the community will have
multiple interactions with the police over time. If those with multiple interactions are
disproportionately members of a minority community (for race-neutral reasons), then
interaction data would likewise be skewed towards minorities as well.
There are two problems with that criticism. First, if police disproportionately focus
policing activities on minority neighborhoods, it is more likely that individuals in those
Id.
Id.
185 Given that Aurora has a higher percentage of Black residents than the combined surrounding
communities, there is no reason to believe that non-resident Black individuals visiting Aurora could somehow
account for the disparity. If anything, it suggests the opposite.
183
184

43

neighborhoods will have multiple interactions with the police. Second, the data here do not
support the criticism. To account for individuals with multiple police interactions with
Aurora Police, the data analytics team also examined how many times Aurora Police
interacted with unique individuals from 2018 to 2021.186 The same pattern emerges:

Unique Interactions with Aurora Police as a Percentage of
Each Group's Population
CTanuary 2018 - February 2021)
60.00%
46.1%
40.00%
29.6%
23.9%
20.00%

0.00%
White

on-White

Black/ African American

Source: Technical Appendix, Fig. 10.B

From 2018 to 2021, Aurora Police had interactions with 56,571 different non-white
individuals, which equates to 29.6% of Aurora’s racial and ethnic minority population,
compared to 39,131 white individuals, which equates to 23.9% of Aurora’s white
population.187 The numbers are again particularly glaring for Black individuals. Aurora
Police interacted with 28,084 unique Black residents, which equates to 46.1% of Aurora’s
Black population.188
These results are robust from a statistical perspective. As explained in the Technical
Appendix, the data analytics team performed a series of statistical analyses known as “chisquared” tests on the data.189 One of these tests, the “chi-squared test for homogeneity,”
examines whether an observed deviation for a given cohort (e.g., Black individuals) relative
to a control group (e.g., white individuals) represents a statistically significant disparity.190
Application of that test to this data shows statistically significant evidence that Aurora
Police disproportionately interacted with individuals based on race, particularly for Black
individuals.

Technical Appendix, Fig. 10.B.
Id.
188 Id.
189 Technical Appendix, Section I.
190 See id.
186
187

44

Specifically, the analytics team calculated chi-squared statistics with p-values of 0.000 for
both (1) the number of interactions with people of color as a whole versus white
individuals; and (2) the number of interactions with Black individuals specifically versus
white individuals. 191
Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
Non-White (All)
White/Non-Hispanic

Population
3,203
23,917
60,909
101,562
1,296

Interactions
259
2,793
39,873
31,629
272

(as % of
Population)
8.1%
11.7%
65.5%
31.1%
21.0%

190,887
163,765

74,826
47,745

39.2%
29.2%

Chi-Squared
Statistic
P-Value
485.0
0.000
2,367.2
0.000
15,008.2
0.000
82.8
0.000
29.5
0.000
2,573.2
N/A

0.000
N/A

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 1.D

The analytics team found 0.000 p-values both for the number of overall interactions
(shown above), as well as for the number of unique individuals interacted with, as
compared to their group’s percentage of overall population.192
The lower the p-value, the less chance any disparity can be explained by random chance. A
p-value of less than 0.05 is statistically significant, providing a 95% confidence level that
the data do not result from random chance, rather than some other factor (such as race or
ethnicity). The 0.000 p-values here mean there is less than a 1 in 1,000 chance that the
disparity in number of interactions by race and ethnicity could be explained by random
chance alone.
These observations are critical because, again, interactions determine the population of
individuals who may be subject to arrest, use of force, or other enforcement actions.
7.3.2. Arrests
There is also strong statistical evidence that Aurora Police disproportionately arrested
people of color between 2018 and 2021, particularly Black individuals. In fact, Aurora
Police arrested more members of non-white racial and ethnic groups than would be
expected not only based on each group’s relative overall population, but also based on the
number of people of color with whom Aurora Police interacted.
Below is a chart comparing frequency of arrests by race and ethnicity compared to
Aurora’s racial and ethnic make-up generally for 2018 to 2021.

191
192

Technical Appendix, Fig. 1.D.
Technical Appendix, Fig. 10.D.

45

Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander

Population
3,203
23,917
60,909
101,562
1,296

Non-White (All)
White/Non-Hispanic

137
1,075
16,904
11,846
106

(as % of
Population)
4.3%
4.5%
27.8%
11.7%
8.2%

30,068
18,334

15.8%
11.2%

Arrests

190,887
163,765

Chi-Squared
Statistic
P-Value
135.9
0.000
906.0
0.000
7,760.4
0.000
12.1
0.001
10.5
0.001
1,340.9
N/A

0.000
N/A

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 1.E

The data show that over a three-year period, Aurora Police arrested 30,068 racially and
ethnically diverse individuals, which equates to 15.8% of Aurora’s non-white population, as
compared to 18,334 white individuals, which equates to 11.2% of Aurora’s white
population.193 In other words, based on relative population percentages, Aurora Police
arrested people of color more than 1.4 times more than white individuals. That multiplier was
even greater for Black individuals, who were arrested almost 2.5 times more (27.8%) than
white individuals (11.2%) based on relative population percentages.194

Arrests as a Percentage of Each Group's Population
Qanuary 2018 - February 2021)
30.00%

27.8%

20.00%
15.8%
11.2%
10.00%

0.00%

White

on-White

Black/ African American

Source: Technical Appendix, Fig. 1.E

As with the preceding data showing disproportionate interactions by race and ethnicity, the
arrest data shown here also have chi-squared statistics with p-values less than 0.050, and are
thus statistically significant evidence of a racial disparity that is not the result of random
chance. Furthermore, even when accounting for individuals who were arrested more than
once (i.e., measuring the ratio of unique arrests to population counts), statistically
193
194

Technical Appendix, Fig. 1.E.
Id.

46

significant disparities persist for both the non-white cohort as a whole and Black
individuals.195

Unique Arrests as Percentage of Each Group's Population
Ganuary 2018 - February 2021)
25.0%
20.6%
20.0%

15.0%

10.0%

12.5%
9.7%

5.0%

0.0%
White

Non-White

Black/ African American

Source: Technical Appendix, Fig. 10.D

These data cannot be explained by the fact that Aurora Police disproportionately interacted
with people of color more than whites. Even among the universe of people interacted
with, Aurora Police arrested a higher percentage of people of color than white individuals
with whom they interacted.
To reach this conclusion, the analytics team looked at all the police interactions from
January 2018 to February 2021 and isolated instances when an arrest was made. It then
subdivided that data by race and ethnicity and calculated how often an interaction with a
member of a given minority group led to an arrest. The disproportionate treatment of
people of color, and Black individuals in particular, persisted.
Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
Non-White (All)
White/Non-Hispanic

Interactions
259
2,793
39,873
31,629
272

137
1,075
16,904
11,846
106

(as % of Interactions
During The Period)
52.9%
38.5%
42.4%
37.5%
39.0%

30,068
18,334

40.2%
38.4%

Arrests

74,826
47,745

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 2.D

195

Technical Appendix, Fig. 10.D.

47

Chi-Squared
Statistic
P-Value
22.3
0.000
0.0
0.941
144.0
0.000
7.2
0.007
0.0
0.896
38.7
N/A

0.000
N/A

Specifically, Aurora Police arrested 42.4% of Black subjects interacted with, but arrested
only 38.4% of white subjects interacted with.196 Again, these differences are statistically
significant and cannot be explained by chance, particularly for Black individuals. The data
analytics team calculated a p-value of 0.000 for the disparity in the number of arrests per
interaction for Black versus white subjects.197
7.3.3. Reported Uses of Force
Finally, there is strong evidence Aurora Police used force disproportionately against people
of color, particularly Black people, as compared to white residents.198
Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
Non-White (All)
White/Non-Hispanic

Population
3,203
23,917
60,909
101,562
1,296

5
12
605
310
2

(as % of
Population)
0.2%
0.1%
1.0%
0.3%
0.2%

934
374

0.5%
0.2%

UoF Incidents

190,887
163,765

Chi-Squared
Statistic
0.7
32.2
596.1
14.4
0.3

P-Value
0.395
0.000
0.000
0.000
0.578

162.7
N/A

0.000
N/A

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 1.F

As shown in the data above, Aurora Police used force on members of non-white racial or
ethnic groups 934 times, which equates to 0.5% of the non-white population in Aurora.199
It used force on white subjects only 374 times, which equates to 0.2% of Aurora’s white
population.200 In other words, Aurora Police used force against members of non-white
racial and ethnic groups 2.5 times more than white individuals based on relative percentage
of the population.
Again, the numbers were even more glaring for Black residents. From 2018 to 2021,
Aurora Police used force 605 times against Black residents, which equates to 1.0% of
Aurora’s Black population.201 This means that Aurora used force against Black individuals

Technical Appendix, Fig. 2.D.
Id. Interestingly, the data also show statistically significant evidence that Hispanics or Latinos were arrested
less than would be anticipated based on their relative share of Aurora Police interactions. This may be
because of differences in frequency of arrests between Hispanic/Latino males and females. When gender is
accounted for, there is statistically significant evidence that Aurora Police disproportionately arrested
Hispanic and Latino males interacted with at a higher rate as compared to white males interacted with (44.5%
versus 42.8%). Technical Appendix, Fig. 7.C.
198 Police departments sometimes have differing definitions of what constitutes a use of force. For example,
some departments may consider a soft empty-hand control technique to be a use of force, while others may
not. In addition, use-of-force severity classifications often differ across police departments. To avoid
confusion here, the data analytics team only considered a given encounter to be a use of force if it was so
designated by Aurora Police.
199 Technical Appendix, Fig. 1.F.
200 Id.
201 Id.
196
197

48

roughly 5 times more than they did against white individuals, based on the relative percentage
of each group’s population:

Uses of Force as a Percentage of Each Group's Population
Qanuary 2018 - February 2021)
1.5%

1.0%
1.0%

0.5%
0.5%

-

0.2%

0.0%

White

Non-White

Black/ African American

Source: Technical Appendix, Fig. 1.F

Once again, the data analytics team found p-values of 0.000 for these results, representing
a statistically significant disparity involving the use of force against people of color that
cannot be explained by chance alone.202 And similarly, the racial disparities persist even
when the accounting for instances where Aurora Police used force against the same person
multiple times (i.e., measuring the ratio of unique uses of force to population counts).203 In
fact, when measured as a percentage of population, for every unique use of force on a
white subject, there were 2.5 times as many uses of force on a non-white subject and 5 times
as many unique uses of force on a Black subject.204 Again, these disparities are statistically
significant and are not the result of random chance.205
Furthermore, as with the arrest data discussed above, the disproportionate use-of-force
data is not due to the fact that Aurora Police interacted with people of color more often
than they did with white individuals. When looking at Aurora Police interactions from 2018
to 2021 during which a use of force occurred, statistically significant racial and ethnic
disparities persisted:

Id.
Technical Appendix, Fig. 10.F.
204 Id. The data analytics team observed 893 unique uses of force against non-white subjects, which amounted
to 0.5% of that group’s population, and 579 unique uses of force against Black individuals, which amounted
to 1.0% of Aurora’s Black population. In contrast, the team observed only 359 unique uses of force against
white subjects, which was 0.2% of Aurora’s white population.
205 Id.
202
203

49

Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander

Interactions
259
2,793
39,873
31,629
272

Non-White (All)
White/Non-Hispanic

5
12
605
310
2

(as % of Interactions
During The Period)
1.9%
0.4%
1.5%
1.0%
0.7%

934
374

1.2%
0.8%

UoF Incidents

74,826
47,745

Chi-Squared
Statistic
3.0
3.9
105.3
8.4
0.1

P-Value
0.084
0.048
0.000
0.004
0.798

59.2
N/A

0.000
N/A

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 2.F

For instance, Aurora Police used force on roughly 1.2% of members of non-white racial
and ethnic groups who had at least one interaction with police from 2018 to 2021
compared to 0.8% for white individuals.206 That disparity appears to have been driven in
large part (though not exclusively) by Aurora Police’s more frequent use of force against
Black subjects. Aurora Police used force against 1.5% of Black subjects who had at least
one interaction with police from 2018 to 2021. That is nearly double the corresponding
figure for white subjects.207
Racial differences in arrest rates also cannot explain the use-of-force disparity, at least as to
Black individuals.
Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
Non-White (All)
White/Non-Hispanic

137
1,075
16,904
11,846
106

5
12
605
310
2

(as % of Arrests During
The Period)
3.6%
1.1%
3.6%
2.6%
1.9%

30,068
18,334

934
374

3.1%
2.0%

Arrests

UoF Incidents

Chi-Squared
Statistic
1.0
4.0
76.6
10.6
0.1

P-Value
0.307
0.046
0.000
0.001
0.815

48.9
N/A

0.000
N/A

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 2.E

The above table examines arrests during which a use of force occurred between 2018 and
2021. The data show that Aurora Police used force roughly 3.6% of the time when a Black
individual was arrested, as compared to 2.0% of the time for arrests involving white
subjects.208 This difference is again statistically significant with a p-value of 0.000.209

Technical Appendix, Fig. 2.F.
Id.
208 Technical Appendix, Fig. 2.E.
209 Id. The data analytics team calculated a p-value of 0.000 for the disparities in uses of force per arrest for
Black versus white subjects, as well as for non-white subjects as a whole versus white subjects. There is also
statistically significant evidence that Aurora Police used force incident to arrest against Hispanics and Latinos
more often than against whites.
206
207

50

7.4.

Explanations for the Data

The above analysis makes clear that Aurora Police have disproportionately interacted with,
arrested, and used force against people of color, particularly Black individuals. These
disparities cannot be explained by random chance. The data analytics team consistently
calculated chi-squared statistics with p-values of 0.000—much lower than the 0.050
necessary to suggest a statistically significant disparity—showing that the racial and ethnic
disparities in interactions, arrests, and use of force were not coincidental.
Having identified these disparities, the data analytics team next looked to see whether these
findings were persistent when controlling for certain factors other than race or ethnicity,
such as geography, gender, income, or severity of crime. The data reveal that the racial
disparities persist in almost all circumstances, particularly for use of force and particularly
for Black individuals.
7.4.1. Geography, Gender, and Age and Use of Force
Geography cannot explain the racial and ethnic disparities observed in Aurora Police’s use
of force. Aurora is divided into three police districts, each with different demographic and
socio-economic characteristics. Yet the statistically significant relationships between race
and ethnicity and use of force—both as a percentage of interactions and a percentage of
arrests—remained consistent for non-white individuals as a whole and Black individuals
specifically across all three Aurora Police districts.210
As to gender, there is statistically significant evidence that Aurora Police disproportionately
used force against Black males and females as compared to white males and females—both
as a percentage of interactions and as a percentage of arrests.211
As to age, there is statistically significant evidence that Aurora Police disproportionately
used force against Black subjects as compared to white subjects for all age groups between
18 and 49, both as a percentage of interactions and as a percentage of arrests.212 The
disparity goes away for individuals over 50, which is not surprising given the much lower
frequency of uses of force against older individuals in general.213

Technical Appendix, Figs. 4.A & 4.B. The data analytics team calculated p-values of 0.000 for the
disparities in uses of force per interaction and per arrest for Black individuals versus white individuals in each
of the three districts. Statistically significant disparities for non-white individuals as a whole were found in all
three districts, with 0.000 p-values in districts 1 and 3.
211 Technical Appendix, Figs. 7.A & 7.B. The data analytics team calculated p-values of either 0.000 or 0.001
for the disparities in uses of force per interaction and per arrest for both Black males and females compared
to white males and females. As discussed above, gender did appear to play a role with regard to Hispanics and
Latinos: there is statistically significant evidence that Aurora police disproportionately used force against
Hispanic or Latino males but not against Hispanic or Latino females.
212 Technical Appendix, Figs. 8.A & 8.B. The data analytics team calculated p-values of 0.000 for the
disparities in uses of force per interaction and per arrest for Black versus white subjects in the following three
age groups: (1) 18-21, (2) 22-29, and (3) 30-49. Id. The data analytics teams looked only at age cohorts for
Black and white subjects.
213 Id.
210

51

7.4.2. Type of Offense or Level of Force Used
The statistically significant relationship between race and ethnicity and use of force also
persists across different use-of-force tiers and misdemeanor versus felony arrests. When
looking either at the population of individuals arrested or interacted with, the data show
that Aurora Police disproportionately used force against non-white subjects in general, and
Black individuals in particular, as compared to white individuals for uses of force
categorized as Tier 1 (lowest) and categorized as Tier 2 or 3.214 In other words, the
observed disproportionality in occurrences for non-white and Black subjects persists across
incidents involving use of force with differing degrees of severity.
Similarly, racial disparities exist regardless of the severity of the offense (i.e., misdemeanor
vs. felony). Specifically, the data show that Aurora Police disproportionately used force
against non-white subjects in general, and Black subjects in particular, as compared to
white subjects for uses of force incident to both misdemeanor and felony arrests.215
7.4.3. Income
It has been suggested that one of the reasons people of color may experience
disproportionate levels of police interaction, arrests, and uses of force is that police often
concentrate law enforcement activities in lower income areas, which tend to have higher
crime rates, and where populations of non-white individuals are also higher. Under this
theory, the observed differences in policing activities that members of non-white racial or
ethnic groups experience are more a function of income than race. The data do not
support this argument. For instance, if this argument were correct, one would expect the
disproportionate treatment of people of color to disappear at higher income levels. But
that is not at all what we found.
The data analytics team looked at data for interactions, arrests, and uses of force between
2018 and 2021 and assigned each observed event to an income quartile based on the
median household income of the zip code where the event occurred.216 For each of the
four quartiles, the data analytics team calculated whether racial disparities existed for

Technical Appendix, Figs. 3.A & 3.B. For Hispanics, there was not a statistically significant relationship
between Tier 1 uses of force against Hispanics versus whites. However, there was for Tier 2 and 3 uses of
force.
215 Id. Figs. 5.A & 5.B. With one exception, the data analytics team calculated p-values of 0.000 for the
disparities in uses of force against people of color as a whole, and Black individuals specifically, versus white
individuals for both felonies and misdemeanors—both as a percentage of interactions and as a percentage of
arrests. For felonies, the p-value was 0.006—still statistically significant—for disparities in uses of force
incident to felony arrests for people of color as a whole and for Black individuals specifically versus white
subjects. For Hispanics, there was not statistically significant evidence about the disparity in uses of force
incident to misdemeanors for Hispanics versus white subjects, but there was for uses of force incident to
felonies.
216 The income level of each individual subject is not observed in the data. However, the median household
income by region within each incident occurred can be assigned based on the zip code in which the incident
is recorded to have occurred. In other words, while the data do not allow for the identification of high
income and low income individuals, they do allow for the identification of high and low income areas in
which incidents occurred.
214

52

minority groups based on their relative share of the population within the income quartile,
versus white individuals in the same income quartile.
For example, for interactions that occurred in zip codes in Income Quartile 1 (median
household income between $45,431 and $58,992 annually), the data analytics team
observed that Black subjects had 27,484 interactions with police, which equaled 69.6% of
their population in zip codes corresponding to this income quartile.217 White subjects, by
contrast, had 24,910 interactions, which accounted for 30.1% of their population share in
zip codes corresponding to this income quartile:218
Panel A. Income Quartile 1

Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
Non-White (All)
White/Non-Hispanic

Population
3,736
14,081
39,480
130,076
415

Interactions
196
1,620
27,485
22,712
209

(as % of
Population)
5.2%
11.5%
69.6%
17.5%
50.3%

187,788
82,817

52,222
24,910

27.8%
30.1%

Chi-Squared
Statistic
P-Value
759.8
0.000
1,516.3
0.000
9,756.0
0.000
3,601.4
0.000
56.2
0.000
103.8
N/A

0.000
N/A

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 13.A

As shown above, Aurora Police interacted with Black subjects within Income Quartile 1
over two times more than they did with white subjects, when measured as a share of each
group’s relative population in the quartile (i.e., 69.6% for Black subjects versus 30.1% for
white subjects). This disproportionality was statistically significant, with a p-value of 0.000.
This disparity did not disappear at higher income levels. In Income Quartile 4 (median
household income between $105,658 and $136,144 annually), statistically significant
disparities in police interaction rates persisted for both Black and Hispanic individuals:
Panel D. Income Quartile 4

Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
Non-White (All)
White/Non-Hispanic

Population
1,365
24,165
15,201
32,467
466

5
333
2,009
1,584
17

(as % of
Population)
0.4%
1.4%
13.2%
4.9%
3.6%

3,948
6,230

5.4%
2.5%

Interactions

73,664
245,324

Notes: P-Values less than .05 represent statistical significance at the 95% confidence level.
Source: Technical Appendix, Figure 13.A

217
218

Technical Appendix Fig. 13.A
Id.

53

Chi-Squared
Statistic
P-Value
25.4
0.000
121.9
0.000
5,159.7
0.000
557.8
0.000
2.3
0.133
1,412.0
N/A

0.000
N/A

As shown above, for zip codes within Income Quartile 4, Aurora Police had 2,009
interactions with Black individuals, which equaled 13.2% of their population in zip codes
corresponding to this income quartile.219 This is over five times higher than the 2.5%
interaction rate for white subjects in Income Quartile 4. Once again, the observed
interaction disparity for Black individuals was statistically significant, as was a similar
disparity observed for Hispanics in Income Quartile 4.220
The data analytics team next looked at arrests and uses of force and found similar
disparities across nearly all income quartiles, particularly with respect to Black individuals.221
7.4.4. Officer Discretion
The data analytics team further investigated whether the statistically significant disparities
were indicated across cases where for which officers are granted greater discretion to act or
arrest versus cases for which they are not. If the disparities are greater where officers have
greater discretion, that is another strong indication that racial bias may be at play.
The data analytics team evaluated three types of cases: suspicious occurrence,
disturbance/noise complaint, and domestic dispute. Officers have the least discretion to
stop and arrest in domestic dispute cases, where officers must arrest a suspect if there is
probable cause to believe domestic violence has occurred.222 Suspicious activity cases fall
towards the other end of the spectrum. Officers may decide to stop an individual based on
a call or based on observing the individual directly, whether or not a complaint has been
made. Whether the stop proceeds to an arrest is subject to far greater discretion,
particularly if the stop reveals only potential misdemeanor activity. On our ride-alongs, we
observed officers using significant discretion as to whether to stop or arrest subjects even
where they observed a factual basis to do so. Disturbance/noise complaint cases fall
somewhere in between. In those cases, there has been a report or observation of potential
unlawful activity that impacts others, but officers still retain significant discretion over
whether to make an arrest.
The data analytics team identified statistically significant evidence that Aurora Police
disproportionately used force against Black individuals, as compared to white individuals, in
suspicious activity cases—both as a percentage of interactions (2.5 times more) and as a
percentage of arrests (2 times more).223 By contrast, the analytics team did not find

Id.
Id. (showing p-values of 0.000 in Income Quartile 4 for non-white subjects as a whole as well as Black and
Hispanic individuals in particular)
221 Technical Appendix, Figs. 13.B & 13.C.
222 § 18-6-803.6 C.R.S.
223 Technical Appendix, Figs. 6.A & 6.B. Aurora Police used force against Black subjects in 4.3% of
suspicious activity interactions, while it used force against white subjects in only 1.7% of such cases (i.e., twoand-a-half times as much). Aurora Police used force against Black subjects in 7.8% of suspicious activity
arrests, while it used force against white subjects in only 3.9% of such cases (i.e., twice as much).
219
220

54

statistically significant evidence that the uses of force in domestic violence224 or noise
disturbance/complaint cases225 were disproportionate across race or ethnicity.
The difference in use-of-force disparities between domestic violence cases and suspicious
activity cases is striking. Granted, the analytics team only compared uses of force for three
types of cases. But the fact that disparities in use of force all but disappear where officers
have little to no discretion provides more evidence that bias plays a role in the disparities
when officers have greater discretion.
That biased-based policing would reveal itself where officers have greater discretion is
unsurprising. When there is implicit or unconscious bias, it is more likely to make a
difference, even if unintentional, in discretionary decision-making. If there is intentional
bias, it is more likely to manifest when it is least likely to be detected—i.e., where the
decision-making is discretionary.226
7.4.5. Use of Population-Level Demographics
Some have suggested that comparing police activity to the relative demographics of a
community’s population as a whole—as we have done above—is not an appropriate way to
measure disproportionality. Instead, it has been suggested that police activity should be
compared only to the demographics of the criminal offender population (as opposed to
the population at large), under the theory that some non-white racial and ethnic groups
may commit crime at different rates. We disagree.
As an initial matter, the idea that individuals of certain races or ethnicities have a greater
propensity to commit crimes because of their race or ethnicity is unsupported by any reliable
evidence and contrary to law. While it is true that observed arrest and conviction rates can
and do differ among racial and ethnic groups, we recognize that these differences could
arise for many reasons, including income level disparities, differential policing efforts,
community willingness to report crime, or other factors.
To address this concern about the use of relative population percentages, we did four
things. First, we looked at what comparisons Aurora Police itself uses when evaluating uses
of force by its officers. In its Use of Force Annual Reports, Aurora Police compares the
race of those it uses force against with relative population percentages.227

Id. Aurora Police used force against Black subjects in 1.7% of domestic violence related interactions, while
it used force against white subjects in 1.4% of such cases. Aurora Police used force against Black subjects in
4.4% of domestic violence arrests, while it used force against white subjects in 4.1% of such cases.
225 Id. Aurora Police used force against Black subjects in 3.4% of disturbance/noise related interactions, while
it used force against white subjects in 2.5% of such cases. Aurora Police used force against Black subjects in
8.7% of disturbance/noise complaint related arrests, while it used force against white subjects in 7.8% of
such cases.
226 Whether officers are exercising discretion to stop, arrest, or use force more often against people of color
or are simply patrolling neighborhoods where people of color live more often, both constitute bias-based
policing.
227 See, e.g., APD, 2020 Use of Force Annual Report at 7.
224

55

Second, we examined the approaches used by other recent studies of policing. Population
level data analysis features prominently in this analysis.228
Third, as described above, we looked to see whether Aurora Police’s disproportionate
interactions with, arrests of, and uses of force against people of color could be explained
by income level. They could not. Instead, a pattern of statistically significant racial
disparities in interactions, arrests, and uses of force persisted across all income levels, even
though people of color make up a higher percentage of the lower-income population in
Aurora.
Fourth, we did not limit our statistical analysis to only population-level comparisons. As
noted below, our team also looked more narrowly at the subset of all Aurora Police
interactions between 2018 and 2021 (which is smaller than the overall population of
Aurora) and then identified instances during which an arrest or a use of force occurred.
Even among this smaller subset population, the data show that once an interaction with
Aurora Police had begun, people of color—particularly Black people—faced
disproportionate levels of arrest and use of force as compared to their white counterparts.
Other comparisons, such as to the reported crime rate by race or offender information
provided by victims, create significant uncertainty as not all crimes are reported, victims do
not always accurately describe offenders, and stereotypes often fill in gaps in uncertain
data. Though the comparison of arrests and uses of force to population levels does not
eliminate all error, we find it most reliable for our purposes, particularly when combined
with our other analyses.229
7.4.6. Excluding Incidents Where Race Information is Unknown or
Unavailable
Race and ethnicity information was not always available for each of the interactions,
arrests, and use-of-force instances that the data analytics team observed. Among possible
explanations, this may be because the officer recording the incident could not determine
the race or ethnicity of the subject, or because they simply failed to enter the information
when filling out a police report.230
The data analytics team decided to exclude such instances from their analysis after
confirming that doing so would not affect the validity of their results. Specifically, the data
analytics ran two alternate versions of each of their calculations, one in which the
“unknown race” instances were assigned to the “white” category and one in which the

See, e.g., Andrew Gelman, Jeffrey Faga & Alex Kiss, An Analysis of the New York City Police Department’s
“Stop-and-Frisk” Policy in the Context of Claims of Racial Bias, 102 J. OF THE AM. STATISTICAL ASS’N 813, 816
(2007) (discussing relationship between the race of those stopped and the racial breakdown of the city
population); Bocar A. Ba, et al., The role of officer race and gender in police-civilian interactions in Chicago, 371
SCIENCE 696 (2021) (comparing officer behavior among districts with different racial demographics).
229 See also Technical Appendix at 6 n.5.
230 Indeed, as we discuss below in Section 9, Aurora Police has failed to properly document its interactions
with the public as required by Colorado law, and part of that failure includes the lack of demographic
information in many Aurora Police records.
228

56

instances were assigned to the “non-white” category. Across these test results, the statistical
significance of observed disproportionalities with respect to race and ethnicity persisted.231
7.5.

The Data Combined With Other Evidence Shows a Pattern and
Practice of Race-Based Policing

While the data indicate that Aurora Police has engaged in racially and ethnically biased
policing, we do not rely on the data alone to conclude that Aurora Police engages in an
unlawful pattern and practice of race-based policing. When the data and other evidence
and information we gathered are combined, the unlawful pattern and practice becomes
clear.
All of the recent high-profile use-of-force incidents in Aurora involve non-white
individuals. We heard from community members about their experiences with Aurora
Police and what they perceived as Aurora Police’s focus on non-white residents. Defense
counsel reported that they often saw non-white residents face highly discretionary charges
such as for failure to obey a lawful order only to have those charges later dropped. We
personally observed differences in how Aurora Police officers engaged with the community
on our ride-alongs based on the race of the subject. We noted frequent escalations of force
against non-white residents as we observed the Force Review Board meetings.
These many observations, along with the data analysis, provide overwhelming support for
our conclusion that Aurora Police engages in a pattern and practice of race-based policing.
We do not believe that such a comprehensive data analysis is necessary to prove a pattern
and practice violation. But given the availability of the data and the capabilities of the data
analytics team, we performed such an analysis here.
7.6.

Changes Needed

To remedy and eliminate its practice of race-based policing, Aurora must make major
changes across the organization to improve its culture, including improving its policies,
training, recordkeeping, and hiring. These required changes all relate to contributing factors
that cause Aurora Police to violate the law.
7.6.1. Improved and More Detailed Policies and Guidance to Prevent
Racially Biased Policing
Aurora Police Directive 8.32 is a four-page directive that prohibits “biased based policing,”
defined as “enforcement action based on a trait common to a group.” 232 Such traits include
race, ethnicity, gender, national origin, language, religion, sexual orientation, gender identity,
age, and disability.233 Because “[b]iased based policing undermines legitimate law
enforcement efforts, alienates a significant percentage of the population and fosters
See, e.g., Technical Appendix, Fig. 1.D at n.6.
Aurora Police Department Directive 08.32 (revised Oct. 7, 2020) By contrast, the directive addressing
procedures for complaints and disciplining officers is a 32-page, highly detailed document. See Aurora Police
Department Directive 10.02 (revised May 19, 2020).
233 Aurora Police Department Directive 08.32 (revised Oct. 7, 2020).
231
232

57

distrust of law enforcement by the community,” the directive states that officers “will not
utilize biased based policing as a basis for a contact or the detention, seizure of persons or
assets.”234
This directive does not define impermissible “biased-based policing.” It merely restates the
constitutional requirements for a lawful Terry stop: “Reasonable suspicion must be
supported by specific articulable facts that persons contacted regarding their identification,
activity or location, has, is, or is about to commit a violation of the law or presently
constitutes a threat to the safety of themselves or others.”235 This is a common problem
throughout Aurora Police’s directives—they are too often cold recitations of statutes or
legal standards pulled from court opinions with no practical examples of what is and is not
permissible or any explanation of how to identify and avoid engaging in discriminatory
behavior.
Baltimore’s Policy 317, titled Fair and Impartial Policing, and associated policies provide a
model for Aurora Police to consider.236 Policy 317 has detailed sections on “Required
Actions,” “Prohibited Actions,” “Supervisory Requirements,” and “Training and
Compliance.”237 Beyond setting forth what does and does not constitute discriminatory
policing, Policy 317 requires officers who witness discriminatory policing to report it;
makes clear that violations of the policy will “result in discipline, re-training, counseling or
other remedial intervention”; provides for detailed collection and regular audits of data;
mandates that officers provide mechanisms for individuals to file and pursue complaints;
and makes clear that a history of discriminatory policing will be considered in performance
evaluations, hiring, and transfers.238 Policy 317 does not stand alone. Aspects of the policy
are woven into every major Baltimore policy.239
7.6.2. More Specific Standards and Expectations on When Officers
Should Stop, Arrest, or Use Force
The data, coupled with additional observations, showed differences among race are most
pronounced when officers’ discretion over whether to stop and arrest is greatest. One way
to address that problem is, as other major departments have done, to develop policies that
provide more specific standards and expectations for stops and arrests and require officers
to specifically articulate why they chose to stop or arrest. For instance, policies that permit
and generally expect officers to stop an individual only when certain, clearly articulated
conditions are met create more specific standards. Under such policies, officers can only
arrest an individual if certain, clearly articulated conditions are met—and if those
conditions are met, the officers should generally arrest that individual.

Id.
Id.
236 Baltimore Police Department Policy Number 317, Fair and Impartial Policing. This report cites several
policies that were developed by cities under consent decrees. Because the policies were written in
collaboration with federal policing experts, many are considered models in police reform.
237 Id.
238 Id.
239 Id. (identifying 17 associated policies).
234
235

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Aurora Police must adopt policies and training that more clearly articulate when stops and
arrests can and should happen.240 For instance, Aurora Police does not have a written policy
dedicated to when officers may stop an individual. The only place it is addressed is Aurora
Police Directive 8.32 on “biased based policing,” which recites the high-level constitutional
requirements for a lawful investigative stop but does not incorporate the additional
requirements necessary under Colorado law:
Sworn members must have a legal basis for making a contact, whether
consensual or non-consensual, for the purpose of enforcing the law or
investigating possible violations of the law. Legal basis can be consent or
reasonable suspicion or probable cause. Consent must always be truly
voluntary. A consenting individual is always able to withdraw his/her
consent at any time and is always free to stop talking and/or leave the
encounter with the member whenever he/she desires.
Reasonable suspicion must be supported by specific articulable facts that
persons contacted regarding their identification, activity or location, has, is,
or is about to commit a violation of the law or presently constitutes a threat
to the safety of themselves or others.
Probable cause refers to the reasonable belief that evidence exists
establishing a basis to arrest, conduct a personal or property search or to
obtain a warrant.
Members will not utilize biased based policing as a basis for a contact or the
detention, seizure of persons or assets.241
The policy provides no detail about what circumstances or activities satisfy the
constitutional requirements, let alone the additional, more stringent state requirements.
More importantly, there is nothing at all about when a stop should be made. Under the policy,
once minimum constitutional requirements for a stop exist, the officer has complete
discretion over whether to make the stop. Aurora Police must amend its policy to reflect
Colorado law and provide additional support to officers in how to make these decisions.
Aurora Police’s directives about arrests similarly do not provide specific guidance. Directive
6.01 (“Arrest Procedure”) states, “[o]fficers may arrest without a warrant only upon
determination that probable cause exists to believe that a crime was committed and that the
individual to be arrested committed the crime or for a crime committed in the officer’s
presence.”242 This tells officers when an arrest may be made but does not make clear when
an arrest should be made. It does not differentiate between crimes—e.g., it does not set
different standards for non-violent misdemeanors or status offenses (except in some cases
for juveniles) or violent crimes. Officers again have complete discretion over whether to
arrest once it appears a crime has been committed.

Aurora Police policies regarding the use of force are discussed below in Section 8.
Aurora Police Department Directive 08.32 (revised Oct. 7, 2020) (emphasis in original).
242 Aurora Police Department Directive 06.01 (revised Nov. 4, 2020) (emphasis in original).
240
241

59

Under these policies, whether or not a particular individual is stopped or arrested depends
not so much on the objective circumstances, but whether the officer on scene decides to
make the stop or make the arrest. These decisions will differ depending on the officer,
workload, directives from sergeants, and other factors leading to inconsistent policing and
similar offenders receiving variable treatment. For example, during ride-alongs, we
repeatedly observed that differences in policing and outcomes depended not on objective
circumstances, but on the individual officer’s approach. At least one officer admitted that
one of the things he liked most about the job was the discretion he had in the field—the
discretion allowed him to be lenient or develop creative solutions short of arrest where he
believed appropriate. While that sentiment is laudable and while some discretion can lead
to positive policing and a reduction in harsh outcomes, too much discretion across an
organization consisting of many different individuals with different training and
backgrounds will inevitably lead to unjustifiably different policing outcomes.
Baltimore again provides a good potential model for Aurora. For example, Policy 1112 is a
24-page document laying out, in detail, when officers may engage in different interactions
with residents—e.g., voluntary interactions, investigative interviews, stops, weapons patdowns, and searches.243 For stops, the policy not only provides a more detailed explanation
of what constitutes “reasonable suspicion” for a stop, but it also lays out specific
procedures for how to conduct a stop and the scope of what may be done during a stop. It
says that the “scope of the stop must be tied to the basis for it,” making clear that
additional justification must exist for taking certain actions (such as demanding the
individual’s ID, ordering a motorist out of a vehicle, applying handcuffs, conducting a patdown, or using any level of force).244 The policy prohibits officers from making “pretext
stops” based on race or where the justification is loitering or misdemeanor trespass.245 It
prohibits officers from stopping someone based solely on a person’s response to police
presence or proximity to the scene of a suspected or reported crime.246 It prohibits officers
from manufacturing a justification for a stop by provoking or trying to provoke a flight
response.247 And it requires officers to document every stop, using specific and descriptive
language detailing the reason for the stop rather than boilerplate or coded words.248 Policy
1106 contains similar detail and prescriptions for warrantless arrests.249
Because Colorado law prohibits using any force if it can reasonably be avoided, use-offorce policies similarly should provide more structure to support officer decision-making.
Aurora Police should give its officers more guidance in how to avoid force and, as
importantly, when force is an appropriate next step in an interaction with a resident.

Baltimore Police Department Policy 1112, Field Interviews, Investigative Stops, Weapons Pat-Downs &
Searches.
244 Id. at 1112.18-20.
245 Id. at 1112.25-26.
246 Id. at 1112.30, 1112.32.
247 Id. at 1112.31.
248 Id. at 1112.33-34.
249 Baltimore Police Department Policy 1106, Warrantless Arrest Procedures and Probable Cause Standard.
243

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7.6.3. Track Outcomes for Those Arrested for Misdemeanors
Baltimore’s focus on monitoring arrest outcomes for misdemeanor arrests provides useful
guidance here. The Baltimore report suggests monitoring misdemeanor arrest outcomes to
determine whether arrests are unconstitutional or discriminatory, because if booking
officers or the district attorney does not advance charges, that arrest was likely not
supported by probable cause. The report identified that central booking and district
attorneys declined to advance a disproportionate percentage of misdemeanor charges
against Black residents—an indication that many arrests of Black residents were unjustified
and based in discrimination. “Tracking arrest outcomes is an important tool for imposing
accountability as well as identifying officers who would benefit from additional training,
guidance, or other early intervention.”250 Aurora has no articulated process in place that
tracks outcomes of arrests or provides feedback to Aurora Police.
As we discuss below, we found that charges are often dismissed for those arrested for
failure to obey a lawful order in Aurora. Developing a process to track the disposition of
misdemeanor arrests will reduce the ability of these charges to be used in a race-based
manner.
7.6.4. Improved Academy and In-Service Training
As noted above, the Aurora Police training academy is undergoing major changes and is
shifting its focus away from militaristic techniques to an emphasis on empathy and
interpersonal skills. This philosophical shift is a good start. And Aurora Police can improve
its training (both at the academy and in-service level) in additional ways.
We conclude that improvements to Aurora Police’s training are required in at least four
areas: bias, deliberate decision-making, recordkeeping requirements, and specific
articulation of the basis for an encounter.
As to bias, while Aurora Police’s current in-service and academy training incorporate antibias components, such programming must more effectively incorporate scenario-based
training so that officers are presented with real-world scenarios rather than abstract
concepts. This is a concern that we heard repeatedly in interviews, and we agree with this
assessment. While we note that there appear to be efforts underway to increase and
improve scenario-based teaching (particularly for in-service training), specific, measurable
goals would ensure that these changes are implemented. We also note that there has not, to
our knowledge, been any widespread scenario-based training on the new requirements of
Senate Bill 217. In addition, training needs to include feedback from the actual experiences
of Aurora Police officers with critical incidents and the review of its officers’ uses of force.
With respect to avoiding unnecessary escalation, a consistent theme that we heard during
our interviews was that Aurora Police’s training needed to shift away from teaching officers
what they can do, and instead focus on what they should do. The emphasis on what was
permissible rather than proper was a chief contributor, according to several Aurora Police
interviewees, to the August 2020 incident where officers held a Black family (including four
250

U.S. Department of Justice, Investigation of the Baltimore City Police Department at 46, Aug. 10, 2016.

61

children between the ages of 6 through 17) at gunpoint.251 We agree that Aurora Police’s
training should focus more on what officers ought to do in a given situation, and not just
on what can be justified under department policies or the U.S. Constitution and Colorado
law.
Colorado state law requires, starting in June 2020, police officers to track and report
demographic information for every contact with civilians as well as requiring
documentation of the reason for the contact.252 Aurora Police failed to implement this
requirement as state law requires. This absence of required information prevented Aurora
Police from knowing who its officers contacted and why, and limited our ability to analyze
the full scope of Aurora Police’s interaction with the public. This failure to follow the law
hindered our data analysis. Aurora Police must take immediate steps to comply with state
law’s requirements for recording and tracking contacts.
Finally, Aurora Police must improve its training for officers on how to properly articulate
the basis for encounters. In our review of Use-of-Force and General Offense Reports, we
often saw vague, conclusory articulations for the reasons why an encounter occurred. For
example, an officer might vaguely report that a subject “resisted” without specifying what
specific actions or behaviors the subject did to resist. We note that Aurora has developed a
new in-service training on this issue, which must be a continued training focus going
forward. Greater detail from officers is necessary to ensure proper evaluations and to
develop necessary improvements to policies and training. One approach could include
having reporting included in scenario-based training where the reviewers know the full
facts of the scenario and can provide training covering both the officer’s conduct during
the scenario and the reporting of the scenario.
7.6.5. Better Timely Recordkeeping
One of the challenges we faced was in accessing comprehensive data reflecting the
activities of Aurora Police. Broadly, that data were split across three repositories: (1) the
Records Management System (RMS), which contained most of the police activity including
General Offense reports; (2) the Computer-Aided Dispatch (CAD) system, which had callspecific dispatch information and was partially (though not completely) integrated into the
RMS; and (3) Use-of-Force Reports stored in Aurora Police’s Administrative Investigations
Management (AIM) database. While CAD data is partially available in the RMS
environment, AIM is a separate system, and matching up AIM records to their
corresponding RMS data proved to be challenging.
Some of these systems have shortcomings that hamper Aurora Police’s ability to monitor
and understand the activities of its officers. For example, the AIM system used to track
use-of-force incidents was not designed for this purpose. Rather, it was designed as an early
intervention system intended to track a broad range of performance issues (including
absenteeism, complaints, and reprimands). Since its implementation with Aurora Police in
2011, the system has morphed into the primary tool by which Aurora Police tracks and
See Family Sues Aurora Police Over Botched Stolen-Car Response That Left Children Handcuffed, Held at
Gunpoint, The Denver Post, Jan. 25, 2021.
252 § 24-31-309(3.5), C.R.S.
251

62

measures its officers’ use-of-force incidents. Aurora Police personnel were candid with us
about the shortcomings of AIM. For example, the system often requires manual entry of
data, which can lead to errors and subjective bias. There was a broad consensus that AIM
needed to be replaced, and we agree with this assessment. Based on feedback from the
relevant stakeholders, a more comprehensive product would improve Aurora Police’s ability
to track metrics that are both sought by the community and required under Senate Bill 217.
More broadly, there is a critical need for Aurora Police to have better timely insight into the
activities of its officers. Currently, Aurora Police releases an annual Use-of-Force Report,
which is created from data extracted from AIM. That data requires substantial manual
intervention and clean-up before it can be presented in a user-friendly way. And an annual
review is not enough. Aurora Police’s use-of-force reporting should be done—at a
minimum—on a monthly or quarterly basis and, wherever possible, shared with the
community and oversight bodies. Aurora Police must also engage in similar real-time
reporting for the statistically significant racial bias we have uncovered for police
interactions and arrests.
At a minimum, supervisors should be able to access a robust dashboard of relevant
information about officers under their command to facilitate appropriate supervisory
intervention.253 And at the leadership level, the ongoing use of more sophisticated analytics
and dashboards is necessary to make sure that Aurora Police—and the public—can
appropriately understand the effect of police activity at the community and organization
level. Once an appropriate system is chosen, Aurora Police should establish a
corresponding policy to ensure supervisors are familiar with the system and officers
understand its role in both commendation and supportive intervention.254
7.6.6. Improved Hiring and Recruiting Procedures, Including Major
Changes to the Civil Service Commission Standards
Studies show that an officer corps that reflects the diversity of the community that it serves
promotes professionalism and builds community trust, confidence, and legitimacy.
In February 2021, researchers from four top universities published a detailed study
examining the role officer race and gender played in policing outcomes in Chicago.255 The
study examined records from 2.9 million officer shifts and 1.6 million enforcement events
by nearly 7,000 officers covering 2012 to 2015.256 Researchers concluded that Black,
Hispanic, and female officers made fewer stops and arrests and used force less often than
white, male officers. The authors found that “these enforcement disparities are
predominantly focused on relatively minor crimes, not violent offenses, suggesting little

Karen L. Amendola & Robert C. Davis, Best Practices in Early Intervention System Implementation and Use in Law
Enforcement Agencies, National Police Foundation.
254 New Orleans Police Department Operation Manual, Insight: Early Intervention System.
255 Bocar A. Ba, et al., The role of officer race and gender in police-civilian interactions in Chicago, 371 SCIENCE 696
(2021); see also Mark Hoekstra & CarlyWill Sloan, Does Race Matter for Police Use of Force? Evidence from 911 Calls,
National Bureau of Economic Research Working Paper 26744 (Feb. 2020).
256 Ba, et al. at 1.
253

63

trade-off in terms of public safety.”257 The largest contribution to the gap for each group
was attributable to interactions with Black civilians.258 For instance, Black officers made
12.55 fewer stops of Black civilians per 100 shifts than white officers, a reduction equal to
39% of typical white-officer volume. By contrast, Black officers made only 1.31 fewer
stops of white civilians per 100 shifts than their white counterparts, a reduction equal to
17% of typical white-officer volume.259 Black officers also had fewer interactions where the
underlying justification was discretionary—e.g., Black officers made 5.72 fewer stops per
100 shifts for “suspicious behavior” than white officers (a reduction equal to 31% of
average white-officer volume).260
While we lacked enough information on officer race or gender to do a similar analysis in
Aurora, Aurora’s use-of-force statistics from 2019 suggest at least the possibility that Black
officers are less likely to use force than their white counterparts. Black officers were
responsible for 2.5% of use-of-force incidents, while making up 3.9% of the sworn staff.
That was the lowest use-of-force ratio for officer race/ethnicity tracked.261 Obviously these
data do not prove a relationship in Aurora between officer race and policing outcomes, but
they are consistent with findings from the Chicago study.
Aurora must do more to attract and hire a more diverse group of qualified police officers.
Aurora Police releases basic demographic information about sworn officers each year.
Below is a graph with race and ethnic breakdown for sworn staff for 2016 to 2019262
compared to percentage of Aurora’s overall population:263
Aurora Police Sworn Staff Versus Population of Aurora
90%

80.8%

80%

70%
60%

50%

44.4%

40%

I

30%

20%
10%
0%

White

28.6%

1 4.1% 1 9.4%

16.5%

Black

- 1.4%
6.5%

0.9% 0.8%

Hispanic/Latino
Asian
American Indian
■ % 2019 Population
% Sworn Staff

0.4% 0.1%

-

5.2% 3.4%

Hawaiian/ Pacific Two or More Races
Islander

Sources: Aurora Police Annua1 Rcpons; U.S. Census Bureau ACS Demographic :and Housing Estim:ues

Id. at 6.
Id. at 3-6.
259 Id. at 4. Similar though less pronounced effects were observed for Hispanic and female officers vis-à-vis
Black civilians. Id. at 4-5.
260 Id. at 4.
261 APD, 2020 Use of Force Annual Report at 7. White officers were involved in 78.8% of the use-of-force
incidents while making up 80.1% of the sworn staff in 2019. Hispanic officers were involved in 10.1% of the
use-of-force incidents while making up 9.7% of the sworn staff. Id. When it comes to gender, females were
involved in only 8.4% of the use-of-force incidents while making up 12.4% of the sworn staff. Id.
262 We have averaged the reported percentages for 2016-2019 taken from: APD, 2016 Annual Report at 7;
APD, 2017 Annual Report at 8; APD, 2018 Annual Report at 8; APD, 2019 Annual Report at 6.
263 2019 American Community Survey 5-Year Data Profile, Demographic and Housing Estimates, U.S.
Census Bureau.
257
258

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While Black residents make up over 16% of Aurora’s population and roughly 40% of
arrestees,264 only about 4% of sworn officers are Black. Similarly, while Hispanics and
Latinos make up over 28% of Aurora’s population, less than 10% of sworn officers are
Hispanic or Latino. By contrast, over 80% of the sworn officers are white—nearly double
the percentage of non-Hispanic white civilians in the general population.
There are multiple steps Aurora and Aurora Police must take to attract and hire a more
diverse group of qualified police officers.
First, Aurora and Aurora Police must improve outreach and recruiting procedures to target
diverse new and lateral hires.
Second, Aurora must improve the Civil Service Commission’s hiring and promotion
requirements and procedures for police officers and firefighters. If the current structure
remains in place, a neutral, third-party expert should evaluate and make recommendations
for revisions to any requirements or procedures that impair the recruitment, hiring, and
promotion of female and minority candidates but are not otherwise necessary to ensure
individuals are qualified for the job.265
Statistics presented by the Civil Service Commission in September 2020 suggest there is
substantial room for improvement on this score.266 Below is a chart showing the number of
individuals—by race, gender, and ethnicity—who (1) applied for positions with the Aurora
Police, (2) then met the minimum qualifications, (3) then passed the ergometrics exam, (4)
then underwent a full background check, and finally (5) were offered a job.267
Race/Ethnicity
White

Black

Hispanic
or Latino

Asian

2+ or
Other

Total

Applied

3,267

591

1,317

165

624

5,964

Met Minimum
Qualifications

2,809
(86%)

454
(77%)

1,037
(79%)

139
(84%)

510
(82%)

4,949
(83%)

Passed
Ergometrics Exam

975
(30%)

122
(21%)

297
(23%)

48
(29%)

179
(29%)

1,621
(27%)

Subjected to Full
Background Check

413
(13%)

42
(7%)

112
(9%)

18
(11%)

80
(13%)

665
(11%)

Made Formal
Job Offers

119
(3.6%)

5
(0.8%)

32
(2.4%)

5
(3%)

22
(3.5%)

183
(3.1%)

Federal Bureau of Investigation, Crime Data Explorer.
Aurora’s hiring requirements and procedures are set forth in the Rules and Regulations of the Civil Service
Commission.
266 Aurora Civil Service Commission 2020 Overview and Recent Entry-Level Hiring Summary (Sept. 9, 2020)
at 56-60.
267 Id.
264
265

65

Only 0.8% of Black applicants (5 out of 591), as compared to 3.6% of white applicants
(119 out of 3,267), were offered a job. Only 1.1% of Black applicants (5 out of 454) who
met minimum qualifications were offered jobs, as compared to 4.2% of white applicants
(119 out of 2,809) who met minimum qualifications. Indeed, at every stage of the process,
a lower percentage of Black applicants than white applicants made it to the next step.268
This racial winnowing at every step of the process strongly suggests a problem with
Aurora’s recruitment and hiring standards and procedures.
Though the Civil Service Commission made some changes in response to the 2009
Department of Justice investigation, the way the current process works in practice shows
that those changes were not substantial enough.
We do not suggest that white officers cannot police in an unbiased way, or that the racial or
ethnic make-up of a police force must precisely mirror that of the population policed. But
law enforcement agencies—particularly those with a demonstrated history of racially
biased policing—should strive to make their force more representative of the community
they serve. Communities are more likely to trust police departments with cultural
awareness, language skills, and similar backgrounds to the members of the community that
they serve.269 And having such diverse officers help the entire law enforcement agency
improve its approach to working with the public.

Only 27% of Black applicants who met minimum requirements (122 out of 454) passed the ergonomics
exam as compared to 35% of white applicants (975 out of 2,809). Only 34% of Black applicants who passed
the ergonomics exam (42 out of 122) were subjected to a full background check as compared to 42% (413
out of 975) of white applicants. Only 12% of Black applicants subjected to a full background check (5 out of
42) were made formal job offers as compared to 26% of white applicants (109 out of 413).
269 How to Support Trust Building in Your Agency, U.S. Dept. of Justice & VERA Institute of Justice, 15
(2016).
268

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8.

Finding #2: Aurora Police Has a Pattern and Practice of Using Force
Excessively

We found that Aurora Police has a pattern and practice of using force excessively.
Aurora Police generally approaches the use of force with a what-can-be-justified-underthe-outer-limits-of-the-law approach rather than a what-force-is-necessary approach. We
observed officers using force to take people to the ground without first giving them
adequate time to respond to officer commands; using more force when people subject to
pain-control techniques respond with expected resistance; and generically reciting “stop
resisting” when trying to control subjects when body-worn camera footage and other
available information does not suggest such resistance. In our review of Force Review
Board meetings, we saw Aurora Police continuing to analyze force only under the
requirements of U.S. Constitution rather than also using the more limiting requirements of
Colorado law that generally do not permit the use of force unless officers first try other
possible alternatives.270
In addition, our investigation found that Aurora Police often views de-escalation as
requiring officers to calm down after using force rather than avoiding unnecessary
escalation in the first place. We observed that officers often approach scenes with a showof-force mentality, bringing many officers to the scene and using gunpoint and threatened
force often disproportionate to the risk presented.
Finally, many encounters we observed involved people undergoing mental health crises.
The way that officers responded to these calls varied dramatically. Sometimes traditional
high-show-of-force approaches were used, which tended to escalate the situation. Other
times, much more low-key, problem-solving approaches were used that generally led to
quicker and safer outcomes. Aurora Police must improve its method of approaching
people undergoing mental health crises.
8.1.

Law and Aurora Policies

Aurora Police Department Directive 5.03, the current version effective August 6, 2021,
summarizes Senate Bill 217’s use-of-force standard and states, in part: “when sworn
members use force, they will de-escalate the amount of force used when that force is
successful, and control is gained.”271 But then it says that “[p]hysical force may be used as
allowed by State statutes” and then repeats the Senate Bill 217 language. This permissive
language instructs officers that they may use force whenever it does not violate state
statutes.

§ 18-1-707(1), C.R.S.
Aurora Police Department Directive 05.08, (revised May 6, 2021) titled “Less Lethal Devices, Weapons
and Techniques,” also contains a section on de-escalation techniques.

270
271

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Other policies, such as those recently adopted by Boulder,272 Colorado Springs,273 and
Denver274 provide a structure for critical decision-making and de-escalation that requires
officers to try to determine why someone may not be complying with a command (mental
condition or impairment, language barrier, drug or alcohol impairment, developmental
issue) and, if able, attempt de-escalation alternatives. Rather than just set the outer bounds
of permissible force, these policies require de-escalation throughout encounters and set
forth guiding principles for the use of force.
While other Colorado agencies275 include a subject’s mental state or diminished capacity as
a factor officers should consider before applying physical force, Aurora’s policy does not
address the need to consider de-escalation for people undergoing mental health crises. The
only policy addressing mental health evaluations is Directive 6.13, which applies only when
the subject is gravely ill or an imminent danger to themselves or others. But mental health
issues exist on much more of a continuum, and assessment of the subject’s mental health
should occur in almost all interactions where officers may use force.
We spoke with several members of the Colorado law enforcement community who raised
concerns that if a department’s use-of-force policy included restrictions beyond those
mandated by state or constitutional law, officers and Aurora Police might be vulnerable to
litigation. This concern of creating additional grounds for liability is not founded in our
state or federal laws. Although an officer can be disciplined for violating policy, “[i]t is clear
that a Fourth Amendment excessive force claim, whether arising out of deadly or nondeadly force, cannot be based upon violation of police department or city policy.”276 The
Supreme Court held that police policies, which “vary from place to place and from time to
time,” are too unreliable to use as a standard for constitutional policing.277 Colorado alone
has over 250 different law enforcement agencies, most with their own unique use-of-force
policy. True, some courts in other jurisdictions have included an officer’s policy violation as
a factor in their analysis of whether the force used was reasonable. But in those cases,
policy was just one factor of many, and that practice has not been adopted in Colorado’s
jurisdictions. And Colorado law limits personal liability of officers only to those situations
where the officer’s employer determines “that the officer did not act upon a good faith and
reasonable belief that the action was lawful,” so whether or not an officer complies with a
more restrictive policy than the law requires does not affect their potential personal
liability.278

Boulder Police Department Policies & Procedures.
Colorado Springs Police Department Policies & Procedures.
274 Denver Police Department Operations Manual.
275 See policies from Boulder County, Canon City, Durango, Englewood, Erie, Fort Collins, Jefferson County,
Lafayette, Longmont, Northglenn, and Pueblo.
276 Martin A. Schwartz, Section 1983 Litig. Claims & Defenses, § 3.12 Excessive Force Claims: Fourth
Amendment Protections (4th ed. Supp. 2020).
277 Whren v. United States, 517 U.S. 806, 815, (1996); See also Thompson v. City of Chicago, 472 F.3d 444, 455 (7th
Cir. 2006) (“because police rules, practices and regulations vary from place to place and from time to time,
they are an unreliable gauge by which to measure the objectivity and/or reasonableness of police conduct.”).
278 §13-21-131(4), C.R.S.
272
273

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Rather, Colorado courts permit police agencies to create more restrictive use-of-force
policies, and have held that departments are “free to adopt a policy that applies a more
stringent standard than the baseline constitutional standard.”279 “[P]olice departments
may—indeed, they should—impose higher internal standards on their officers than simply
not violating state criminal law and avoiding federal damages liability.”280 Aurora’s policy,
unlike other jurisdiction’s policies that emphasize limiting force, does not provide a
structure for officer decision-making and leaves it to the officer to interpret the statute
while in stressful and complex situations.281 This lack of structure could leave officers more
open to civil liability.
8.2.

Data and Information Reviewed
8.2.1. Documents Relating to the Use of Force

We reviewed Aurora’s Use of Force Annual Reports from 2016 to the present, which
summarize at a high level the use of force by Aurora Police each year.282 We also collected
and reviewed over 2,800 Use-of-Force Reports from 2016 through 2020. For many of
these reports, we requested and received the General Offense reports that provided more
detail.
8.2.2. Force Review Board and Other Meetings
We also attended nearly every Force Review Board meeting for the past ten months, where
the Board discusses all significant uses of force. These weekly reviews typically examined
General Offense reports for each incident, body-worn camera footage, and documentation
of injuries. For the uses of force associated with Aurora’s support of Denver law
enforcement’s response to the protests following the killing of George Floyd, the Force
Investigation Unit prepared abbreviated presentations that generally focused only on bodyworn camera video.
In addition, we attended several Internal Review Board meetings, where a mix of civilian
members and police personnel assist the Chief of Police in imposing discipline, sometimes
for use-of-force violations.283
8.2.3. Ride-Alongs
We also spent over 190 hours in ride-alongs in all three districts, concentrated during high
demand afternoon and evening times. During the ride-alongs, we followed a particular
officer or sergeant for an entire shift, and observed how the officers interacted with the
public and approached the use of force in a wide range of situations. We accompanied
Johnson v. Civil Serv. Comm’n of City & Cty. of Denver, 2018 COA 43, ¶ 30.
Turney v. Civil Serv. Comm’n, 222 P.3d 343, 350 (Colo. App. 2009).
281 Denver updated their use-of-force policies to include a decision-making model, explanations of the force
continuum, de-escalation requirements, and a requirement that officers exhaust all non-force alternatives
before using force.
282 APD, 2016 Use of Force Annual Report; APD, 2017 Use of Force Annual Report; APD, 2018 Use of
Force Annual Report; APD, 2019 Use of Force Annual Report; APD, 2020 Use of Force Annual Report.
283 City of Aurora, Independent Review Board.
279
280

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officers and witnessed first-hand as they, among other things, intervened in domestic
violence incidents, encountered and took into custody someone undergoing a mental
health crisis who threatened self-harm, used force to remove a resident from his home
when he did not fully cooperate with officers investigating an assault by a relative, and used
force to handcuff a witness who observed a subject in an escaping car that endangered an
officer.
We observed that the situations officers encounter vary dramatically and require quick
judgment under uncertain information. Many officers were thoughtful, careful, and hesitant
to escalate force. Others were quick to draw their weapon and escalate situations.
8.2.4. Community Concerns Based on Interviews
Aurora stakeholders’ opinions of the police ranged from anger to distrust to support. The
following themes arose during our interviews with community members.
Accountability. Many in the community perceive that Aurora Police does not hold
accountable officers who use excessive force or otherwise engage in racially biased actions.
This perception underscores the tension created when disciplinary decisions made by
Aurora Police are reversed or reduced by the Civil Service Commission. Many observe that
Aurora Police leadership are not able to hold officers responsible for policy violations
which undermines the credibility of the agency, leads to low morale, and erodes public
trust. Community members observe the inequity in allowing officers who engage in
unlawful conduct to remain employed with few, if any, consequences.
Another related concern is Aurora Police’s internal investigation process. Community
members believe that Aurora Police polices and investigates itself, resulting in inadequate
investigations and presumptions of policy compliance. The perception is that
investigations into excessive use of force are designed to exonerate the officers, regardless
of the actual facts. Until 2021, Aurora Police had an agreement with the Denver Police
Department to support each other in critical incident review. Many in the community
criticized the way that Aurora and Denver implemented this agreement. Aurora Police has
since ended this agreement with Denver and, in April 2021, joined the Critical Incident
Review Teams with other law enforcement agencies in the 17th and 18th Judicial Districts.
Since the change occurred recently, we have not had a chance to evaluate its operation.
Transparency. Many community members expressed a desire to have more information
about critical incidents promptly disclosed. Many felt that the way Aurora Police conducts
internal affairs investigations and excessive use-of-force reviews is largely hidden from the
public. Additionally, many stated that the Civil Service Commission’s influence on Aurora
Police is opaque and undermines confidence in the disciplinary process.
Over-Policing. Most of the Black community members we interviewed felt that their
neighborhoods were over-policed. Increased surveillance and enforcement actions that
involved confrontation and use of force were thought to be common. In contrast, mostly
white or affluent neighborhoods had less police activity, and the interactions were
perceived to be public-safety focused. One Black man stated that his children were
detained by Aurora Police and transported home without justification, even though they

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were just kids walking in their own neighborhood. Another Black woman described how
she often saw youth smoking marijuana near two fast food restaurants in different Aurora
neighborhoods. She said that police did not engage with the white youth although their
conduct was obvious and illegal. However, she said police repeatedly confronted Black
youth for the same behavior.
Visibility. By contrast, many non-Black community members expressed the perception
that Aurora Police is not reachable or visible in the community. They did not feel that
Aurora Police has made an effort to engage with their communities—for example, an
LGBTQ+ advocacy organization was unaware that Aurora Police has an LGBTQ+ liaison
officer until finding the person’s name buried on Aurora Police’s website. A director of a
shelter for individuals experiencing homelessness expressed the wish that officers would
come by to chat and get to know those individuals, not just respond to calls for service.
And other community members expressed the opinion that Aurora Police seems
disengaged and likely to not take certain incidents—such as street racing or a dispute
between two gay men—seriously, leading to community members avoiding calling the
police.
Response to Mental Health Calls. Aurora community members expressed concerns
about officers responding to calls involving people experiencing a mental health crisis. At a
fundamental level, members of the public question whether officers should respond to
such calls. When people are having a mental health episode, it may be more suitable to
respond with medical professionals who can provide treatment. One stakeholder talked
about the scope of officers’ responsibilities creeping beyond appropriate boundaries. Other
stakeholders worried about the lack of training officers receive and suggested that more
education about mental health issues and response would be beneficial. Additionally,
increasing community outreach should help familiarize officers with individuals who are
likely to have increased contact with police due to their mental health status, which should
lead to more treatment-based interactions.
8.3.

Findings

We found several types of encounters where Aurora Police used force in what appeared to
be an excessive manner that did not satisfy federal or Colorado law. We set out the two
specific categories of force where we find Aurora has a pattern and practice of violating
the law and find that its general approach to the use of force leads to excessive force in
other cases.
8.3.1. Force and Threatened Force Used Against Those in Mental Health
Crises
We observed a pattern of using force against those in mental health crisis without trying
less confrontational ways to reduce the risk of force. This pattern of using force in this
way violates applicable Colorado law because officers do not, as the law requires, “apply
nonviolent means, when possible, before resorting to the use of physical force.”284 And our
review of prior use-of-force incidents before Senate Bill 217’s effective date in 2020 shows
284

§ 18-1-707(1), C.R.S.

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that, based on information available to us, there was a prior pattern of using force against
those in mental health crises that did not satisfy even the then-applicable, less-stringent
requirement of being objectively reasonable. Inaccurate and confusing policies—both old
and recently updated—likely contribute to this pattern.
In May 2021, Aurora Police updated its use-of-force reporting policy to require that
officers document when they used any force if the subject was not a criminal suspect. The
old policy had many deficiencies. It did not require officers to file a report “when
restraining persons solely for medical, emotional, or mental health purposes,” because
“[t]hese situations do not involve an application of the criminal law.”285 Aurora Police
properly no longer exempts these uses of force from reporting requirements.
A separate policy on civil commitments authorizes officers to initiate a 72-hour medical
hold if a person in a mental health crisis appears gravely ill or suicidal. Under the old useof-force policy, if officers determined that civil commitment was needed, they could use
force to take the subject into custody, but only had to report the incident as a use of force
if it resulted in injury. This policy wrongly created a separate category of residents who had
force used against them by Aurora Police without the same level of review or scrutiny,
leading to reduced accountability.
Aurora Police updated this policy in May 2021 and again in August 2021, but the updated
policy still does not comply with Colorado law and creates confusion by giving the wrong
guidance to officers. It maintains the separate category of residents in crisis by specifically
identifying persons who need restraining for “medical, emotional, or mental health
purposes” who are “potentially causing or imminently threat[en]ing to cause Serious Bodily
Injury or death [to] another individual.”286 First, Colorado law does not permit the use of
force against anyone who just “is potentially causing” or “imminently threat[en]ing to cause
Serious Bodily Injury.” Rather, officers can use force, as applicable here, only to prevent
“an imminent threat of injury” and “shall apply nonviolent means, when possible” before
using any force.287 Second, the policy does not define what “potentially causing” or
“imminently threat[en]ing” mean. It does not provide guidance about whether verbal
threats to harm someone, however remote, qualify or whether any possibility, however
small, meets the “potentially causing” standard. Nor does it give any assistance to officers
to understand what “medical, emotional, or mental health purposes” mean. Finally, this
policy fails to address the authority officers have to act when someone is in a mental health
crisis and there is probable cause to take that person into custody for purposes of a mental
health hold. The use-of-force policy should be read in harmony with the civil commitment
statute.288

Aurora Police Department Directive 05.04 (revised May 13, 2019).
Aurora Police Department Directive 05.04 (revised Aug. 12, 2021).
287 § 18-1-707(1), C.R.S.
288 § 27-65-105, C.R.S.; Aurora Police Department Directive 09.06 (effective Sept. 7, 2021) on coordination
with Aurora Fire, addressed below in Section 10, similarly fails to harmonize the use of force statute with the
requirements of the civil commitment statute.
285
286

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Our team could not locate another use-of-force policy that applied different reporting
standards or use-of-force standards to different categories of residents.289 The new policy
also strongly discourages officers from assisting paramedics should a patient become
combative.290 But Senate Bill 217’s limitations on when an officer can use physical force
reflects the limitations on when an officer should initiate an emergency mental health
hold.291 And Colorado law does not permit paramedics to initiate an emergency mental
health hold.292 This means that police and paramedics must work together to assist
individuals who are experiencing a profound mental health crisis that places themselves or
others in danger.
Because Aurora Police implemented this new policy after almost all of our ride-alongs, our
team could not observe how the new policy may have changed the way officers and
paramedics worked together to assist a person in crisis, but this policy does not move
Aurora Police forward in how to engage with community members who face mental health
challenges.
Under the prior policy in place in 2020, we saw officers engage with significant threatened
force to those undergoing mental health crises. For example, when one of our team was on
a ride-along, a Black man walked into a gym in a strip mall and claimed he had a knife and
planned to kill himself. Several officers and members of the Crisis Response Team
(unarmed, specially trained professionals not in uniform who focus on mental health) met
in a nearby parking lot to plan the approach. In this meeting, and again on the radio, the
sergeant reminded everyone to stay safe and use deadly force only as a last resort given the
likely mental health profile of the subject.
But in this encounter, officers quickly took cover behind their vehicles and adjacent
vehicles and drew their weapons (mostly handguns with several tasers and at least one long
gun). By aiming their weapons at the man, they were all pointing their weapons at a
crowded gas station 25 yards behind the man. An officer started shouting at the man
asking him to stop and put his hands up. He stopped advancing but did not comply with
the “hands up” order. He started shouting that he didn’t want to live anymore, he had
a knife, and no one knew how hard his life was. After a tense standoff, he finally began to

We reviewed policies accessible to the public through law enforcement websites. Many Colorado law
enforcement agencies, Aurora included, provide online access to their policies for transparency and to
increase community trust. A few Colorado agencies include separate policies on emergency mental health
holds, civil commitments, and subjects attempting suicide, but none created a separate use-of-force or
reporting standard for civil custody encounters that deviated from their general use-of-force policy.
290 Aurora Police Department Directive 05.04 (revised Aug. 12, 2021).
291 An emergency mental health hold is permissible under § 27-65-105, C.R.S., only if one is gravely ill, or a
danger to themselves or others, which are defined as conditions where the person poses an imminent threat
of substantial bodily harm or serious bodily harm to themselves or others. The laws on when a civil
commitment may be initiated are consistent with Senate Bill 217’s prohibition on physical force unless there is
an imminent threat of serious bodily injury or death.
292 However paramedics may assist a patient who lacks capacity to give medical consent, which may include
patients who qualify for an emergency mental health hold. See Aurora EMS Protocols, General Guidelines
#0070.
289

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kneel and eventually lay down. Several officers swarmed him, handcuffing him and placing
him on a mental health hold.
The officers did not, as the law requires, appear to “apply nonviolent means, when
possible” before resorting to force. Rather, officers immediately escalated the
confrontation by displaying an overwhelming number of cars and officers and immediately
drawing their weapons, yelling at the subject to comply. The subject had all the hallmarks
of seeking just such a confrontation, and the team made no effort to consider alternative,
less confrontational approaches, particularly given the reports that he was armed only with
a knife. A recent report by the Police Executive Research Forum recognized the
importance of distinguishing between the threat posed by those likely armed with a knife
or other weapon only capable of serious harm at close distance and those armed with a
firearm.293
The next call on that same ride-along demonstrated a different approach. In the next call, a
white man was in crisis because he was very drunk and exhibiting mental health issues. He
was experiencing homelessness and had walked into a strip mall grocery store and asked
the store to call 911 to take him to detox. When our team arrived, he was belligerent
because Aurora Fire (who arrived before police) had told him he had to go to the hospital.
In the middle of a tirade, he threw his cane at the officers and fire personnel in the middle
of a tirade. Rather than drawing a weapon or yelling at the man, a junior officer who had
been on the force for about a year then walked up to him, extended his hand, and said,
“I’m [Joe]294, you look to be hurting. How can we help you?” The man replied, “It’s about
*** time that someone treated me like a human being instead of yelling at me. I’m a former
Navy SEAL and deserve some respect.” The officer then asked the man to sit down on the
gurney next to him to talk about what was wrong. The man got agitated again a couple of
times, but responded to the officer’s questions and within ten minutes the ambulance
departed taking the man to the hospital.
Though the first incident involved a man who claimed he had a knife and the second
incident did not, overall differences in the two approaches still stand out. In the first
incident, no effort for a less confrontational approach was considered or attempted as the
law requires. And many in the community observed several white police officers yelling at a
Black man held at gunpoint in the middle of a parking lot, potentially undermining faith in
the police. In the second incident, one officer tried a less confrontational approach in spite
of an agitated individual and, this time, it worked.
In the Force Review Board meetings, we observed additional instances when the failure to
recognize or address the mental health status of people led to unnecessary force. In one
instance, a large Black man was in crisis at a party. He had cut his bare feet by walking
through glass while in distress. Aurora Fire and Police responded but did not coordinate
their response to the scene, so many Aurora Fire and Police members stood idly around
Guiding Principles on Use of Force, Police Executive Research Forum, 2016. In reviewing other use-offorce reports, we often saw officers referring to the outdated “21 foot rule” that claimed an individual with a
knife can cover 21 feet and harm an officer before an officer can respond, justifying the use of force against
someone who was within 21 feet. The Police Executive Research Forum called this an “outdated concept”
that conflicts with required concepts of proportionality and critical decision-making.
294 The officer’s name is changed consistent with our practice in this report.
293

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the scene. The man remained agitated after Aurora Fire treated his feet, and after becoming
angry again he walked up and struck a Fire paramedic. The officers then tased him multiple
times. Though the taser use was likely consistent with policy if examined from the time
when the man struck the paramedic, the whole situation never had a coordinated approach
focused on avoiding escalation and recognizing the man’s volatile state. Such a strategy
would have avoided putting so many personnel near him and reduced the chance that
officers would use force.
We asked several members of Aurora Fire and Police on our ride-alongs about any joint
training or efforts to coordinate control on scene and learned that Aurora Fire and Police
do not train jointly on such on-scene coordination. Rather, personal relationships that
members of Aurora Fire and Police have developed on past calls often prompt
coordination. Aurora Police issued a new policy, dated Sept. 7, 2021, that addresses how
officers should coordinate with emergency medical providers. It prioritizes patient care
over policing, explains what information officers should give to assist paramedics, and
formalizes a transfer of care process.295 While the new policy ensures that the ranking
officers of both units make face-to-face contact to establish unified command for large
scale events, small scale events do not carry the same expectation.
The majority of interactions between Aurora Police and Aurora Fire are small scale events,
like the one above, and would benefit from face-to-face coordination between agencies. We
witnessed on ride-alongs, however, that it was often difficult even for officers to know who
was responsible for scene control, especially when numerous officers responded. As a
higher ranking officer appeared, control would theoretically shift to the new arrival, but
that officer may not understand the complexities of the scene yet. Without direction and
training on how to coordinate scene control during small scale events, the new policy will
not address these concerns.
In another incident discussed by the Force Review Board, a Black man was walking down
the street after a snowstorm hitting parked cars with a snow shovel. Officers responded
and at first did a good job of backing up and keeping distance between the man and
themselves rather than using force. But when the man started to walk away from the
officers against their command, one officer tackled him into the street and handcuffed him.
The man was on foot, posed no serious threat, and was in an obvious mental health crisis.
Rather than follow the man or see whether he would comply with the officers’ instructions
given more time, the officers chose to tackle him, violating the legal requirement that they
apply nonviolent means, when possible, before resorting to force.
In a final example, officers responded on a welfare check to a family dispute. They spoke to
the mother outside the home; she had called about her son, a Black man, who was inside
the home alone and throwing things. The man came outside, spoke to officers, and
voluntarily let them pat him down. But as the questioning continued, the man became
increasingly agitated and tried to go back inside the house. Officers refused to let him leave
and ultimately took him to the ground, punched him in the head twice, and handcuffed
him. The reports written by the involved officers did not articulate any potential crime that
they were investigating or a reason why they needed to detain him, but the prolonged
295

Aurora Police Department Directive 09.06 (effective Sept. 7, 2021).

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detention led directly to the uses of force. And because the initial call was to conduct a
welfare check, not to investigate criminal activity, the officers’ escalation of the situation
which precipitated the use of force was particularly unnecessary.
In all but one of these examples we saw officers respond to people having mental health
crises with significant, and based on information available to us, excessive force rather than
first trying less-confrontational methods as the law requires. The officers did not attempt
to de-escalate the person in crisis, and in several situations, their tactics escalated the
situation, creating the need to use force. We do not know if the officers could have
resolved the situation with less force because they never tried.
8.3.2. Using Force When the Only Criminal Violation is Failure to Obey
The justification for many of the arrest and use-of-force incidents we analyzed was an
alleged violation of Section 5 of Aurora’s Disorderly Conduct Ordinance, which outlaws
“[f]ail[ure] to obey a lawful order or command by a peace officer, firefighter, marshal, or
detention officer acting under the color of official authority which causes or is likely to
cause harm or a serious inconvenience.”296 A resident who has not otherwise committed any
crime can be arrested, and subject to use of force, if he or she does not obey a police
officer’s order and the officer decides such disobedience causes “serious inconvenience.”
Without a policy limiting how Aurora Police may use this ordinance, it provides officers the
ability to justify arrest, and force, when no basis would otherwise exist.
Based on information available to us, we conclude that Aurora Police has a pattern and
practice of using objectively unreasonable force to arrest those who police claim have
violated this ordinance.
We heard from community members that officers used this ordinance to escalate situations
and arrest, and use force against, residents. We also observed discussions in the Force
Review Board where members commented that officers should have given an order sooner
in the encounter so that they would have a lawful basis to use force more quickly. And
other departments have faced scrutiny for relying on similar ordinances that give broad
discretion to justify arrests and force.297
Less than a year ago, in December 2020, the ACLU announced a $285,000 settlement with
Aurora arising from Aurora Police’s 2016 use of force against a resident, who was arrested
for failure to obey a lawful order, resisting arrest, and disturbing the peace.298 According to
the lawsuit, Aurora Police officers responded to a noise complaint and ordered the man to
come out of his garage. When he did not immediately exit his garage (he said he was

City of Aurora Ordinance § 94-110(5) (emphasis added).
See U.S. Department of Justice, Investigation of the Baltimore City Police Department at 36-39; 55-58,
Aug. 10, 2016; U.S. Department of Justice, Investigation of the Ferguson Police Department at 19-22, March
4, 2015
298 See ACLU Settles Case With Aurora After Police Brutalize and Unlawfully Arrest Alberto Torres, ACLU,
Dec. 10, 2020. For the original complaint filed in Colorado federal court, see here.
296
297

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calling to his wife who spoke better English), officers brandished a firearm, grabbed him,
threw him to the ground, and handcuffed him, causing serious injuries.299
As part of our review of documents, we saw several use-of-force reports where the only
apparent underlying justification for escalation was the suspect’s failure to obey a lawful
order. Several examples are below.
In one incident an officer was responding to a report that a security guard saw a car back
into another car while trying to park, drive away, and then return to pull into the same
parking space front-first. The car had dark tinted windows, and the officer believed it was
empty. But as he approached the car, a man opened the driver’s door, “which caught [the
officer] by surprise.” The officer drew his weapon, pointed it at the man, and ordered him
out of the car. The man obeyed and got out of the car. The officer then ordered the man
to get on the ground. The man said that “he was not going to get on the ground” and
instead, walked to the back of the car and placed his hands on top of the trunk. Although
the man had substantially complied with the officer’s orders and was not resisting arrest,
the officer “performed an arm-bar take down on him and took him to the ground.” The
officer said he used force “[d]ue to the male not obeying my lawful order.”
A supervisor’s review of the incident stated that the “dark, crime ridden area, and the party
startling him” authorized the officer to use force against the man who “was not being
cooperative” and to “prevent him from escalating his behavior.” But the officer did not
report any concern about the man’s behavior or the possibility that he might resist arrest.
And resistance was unlikely because the startled officer still had his gun pointed at the man,
and another officer was on scene to assist if needed. When the man’s wife filed a
complaint, another round of review found that the responding officers “were calm and
professional during this incident,” and that the use of force was “reasonable and
appropriate for the circumstances.”
From our perspective, however, the use of force appears to have been retaliatory. The car
had been in a fender-bender, but was not otherwise connected to criminal activity.
Suddenly opening the car door, while surprising, was not obviously such dangerous
conduct to justify taking down a resident who was substantially complying with officer
requests. Once out of the car, the man signaled his willingness to comply by placing his
hands on the trunk where the officer could see them so he could be safely searched.
Because the officer could have searched the man without force, throwing the man onto the
ground was an unnecessary use of force and appears retaliatory for “not obeying.”
The following is a portion of the narrative from a Tier 1 use-of-force report for an
incident involving a Black female on January 16, 2018. The report states that the use of
force was “necessary to effect arrest” and “necessary to prevent a crime.”300
On January 16th, 2018 [Officer 1] was walking through the lobby of
Headquarters on her way to Municipal Court when she observed a female
ACLU Colorado keeps a list of the more severe alleged racially biased uses of force by Aurora Police on
its website. See here.
300 Incident-Report Case Summary, Tier 1: 2018-TIER-0025.
299

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that appeared to be sleeping in the entryway on one of the benches. This
area is out of view from the front desk but in direct view of anyone
entering the building.
Based on the female’s dress and position [Officer 1] contact[ed] the party to
see what business the person had in the building and if they needed
assistance. The female indicated she was waiting for her brother but was
not willing to answer any other questions. She had verbally identified
herself as [Person 1] which [Officer 1] believed to be a fictitious name. The
female was not able to provide any identification or an explanation as to
what name she gave.
The female attempted to leave and [Officer 1] detained the suspect. The
suspect requested a supervisor and again attempted to leave at which point
[Officer 1] requested a cover car and supervisor. [Officer 2] who was at the
Municipal Court house arrived to assist. The female again attempted to
leave and was advised to sit down. Because the female was not listening to
lawful orders [Officer 2] grabbed her arm and assisted her in a seated
position. The female then started pulling away from [Officer 2] and
swinging her arms in the direction of [Officer 1]. The female was taken to
the ground, where she continued to scream and kick her legs.301
The supervisor who first reviewed the incident concluded that “the use of force in this
situation was reasonable and appropriate to detain a suspect while attempting to leave and
giving a false name” and that “[Person 1’s] actions of pulling away and swinging her arms
‘wildly’ posed a danger of injury to the officers and placing her on the ground to arrest her
[was] appropriate.”302 Later reviewers all agreed the use of force was “necessary” and
“appropriate.”
From our perspective, there was no criminal activity before Officer 1 interacted with
Person 1. The report does not state why the officer believed the name was false. There was
no basis for officers to detain Person 1, much less put hands on her. But the report stated
that because she failed to obey lawful orders, officers believed they had justification to
detain, arrest, and use force against her.
Below are portions of another narrative from a Tier 1 use-of-force report for an incident
on December 1, 2017, involving a white male. This was six weeks before the incident
discussed above. The report states that the use of force was “necessary for subjects’
safety.”303
I spoke with [Officer A] who advised me that she contacted the male who
was lying down on the grass and at first was not responsive. She said when

Id.
Id.
303 Incident Report Case Summary, Tier 1: 2017-TIER-0432.
301
302

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he did respond she told him to get his hand out of his pocket and he
complied and he also complied with handing her his identification.
...
She advised the subject was cooperative until she began to clear him at
which point he began to get nervous and began to walk away. Herself and
[Officer B] told the male to stop and he did not comply with their orders to
stop. She advised they grabbed the male by the arms to get him to stop. She
then said the male went to the ground and that while on the ground she
had ended up with his right wrist in a wristlock.304
The supervisor who first reviewed the incident concluded that both officers’ actions were
“reasonable and appropriate,” noting that “[o]nce [Person A] found out he was being
cleared for warrants he became more nervous and in a hurry to leave (even ready to leave
his ID with officers).”305 Later reviewers agreed the use of force was “lawful, reasonable,
and within APD policy.”306
From our perspective, there was no basis for detention or any use of force. Yet, simply
because he failed to obey an order, officers believed they had a justification to detain and
use force. But unlike the other incident described above, however, the suspect was not
arrested and was allowed to leave, showing the considerable discretion officers have in such
situations.
As part of the investigation, the team spoke with Doug Wilson, the Chief Public Defender
for the City of Aurora. He told us that many clients his office defends were charged only
with failure to obey a lawful order—and that often the prosecutor’s office ultimately drops
the case shortly before, or on the day of, trial. Data provided by the Court Administrator
for the City of Aurora show just how often Aurora Police charges residents with violating
§ 94-110(5):307
Year

Count

2015

604

2016

569

2017

493

2018

390

2019

406

2020

264

2021 (through August)

118

Id. This portion of the narrative was based on discussions with Officer B.
Id.
306 Id.
307 Aug 23, 2021 Email from Court Administrator Shawn Day to Deputy Attorney General Janet Drake.
304
305

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Aurora Police officers’ over-reliance on “failure to obey a lawful order” to justify arrest and
uses of force must change. Aurora Police must adopt policies that carefully limit using
force against an individual where the only alleged crime is failure to obey a lawful order
unless that failure creates other risks that independently justify force.
8.4.

Causes of Violations

Based on our review of thousands of use-of-force reports, our interviews with the
community and members of Aurora Police, our ride-alongs, and our observation of the
Force Review Board, we find the following causes lead to Aurora Police’s use of excessive
force.
8.4.1. A Culture at Aurora Police That Emphasizes Justification for Force,
Rather Than Whether Force Was Lawful and Appropriate
We observed that Aurora Police generally approached force with a focus on why force was
justified, rather than what force is appropriate. Our review of thousands of use-of-force
reports found that the reports often emphasized what conduct or perceptions justified the
force, rather than describing why the officer thought that level of force was objectively
reasonable and appropriate. The Force Review Board discussions routinely focused on
finding reasons why the force could be justified, rather than whether the force met legal
standards. Almost no discussion occurred about Colorado law’s requirement that officers
shall apply nonviolent means when possible before using force.
We concluded that officers often focus on control and submission when engaging with
individuals. As described above, this focus led to arrests and force used for failure to obey.
This emphasis on control also led to encounters escalating quickly, particularly with those
who were not native English speakers, were impaired, or in a mental health crisis. While we
observed some encounters handled with patience and empathy, other encounters began
with officers behaving aggressively and quickly escalating to force.
We saw a pattern of officers “taking subjects to the ground” quickly, often for minor
reasons. We found this behavior arises out of a perceived need to immediately take control
of situations and establish dominance in interactions with members of the community.
Indeed, in the Force Review Board meetings, we heard several comments about how
officers should have given orders earlier to individuals so that when they violated those
orders they would have legal justification to arrest or take them to the ground. As the data
discussion reveals, this type of force is used with more frequency against non-white
members of the community. Because Aurora Police uses this tactic so often, we cannot
determine whether engaging with the community with a less-confrontational approach
would lead to fewer uses of force.
We also saw a pattern of officers reciting “stop resisting” reflexively during encounters
even when the body-worn camera videos did not show resistance. But officers did not use
specific language to describe why they felt the subject was resisting and the body-worn
cameras did not show any resistance. This purported resistance was often used to justify
force, both in the moment and later in the Force Review Board discussion. Because

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officers used this generic language, we often could not determine whether specific,
articulable reasons supported the officers’ use of force. In addition, when using pain
compliance techniques to control individuals, officers often treated the individuals’
expected pain response as active—not involuntary—resistance, to justify the use of even
greater force.
We also saw some body-worn camera video where officers used language that apparently
was designed to support an excited delirium diagnosis and potential chemical sedative use
by Aurora Fire. These officers used words like “superhuman strength” or “he’s jacked up”
during the encounter. As we discuss below, the decision of whether to use chemical
sedatives, even under old policies, lies with the medical professionals, not the officers.
Attempts by officers to narrate their encounter using catchphrases that appear to be
designed to influence a medical diagnosis, as opposed to describing the actual behavior of
the subject, are improper.
This focus on justification rather than appropriateness of force also leads to inconsistent
levels of force used for similar circumstances. For example, we saw several instances of
officers engaging with a sleeping person in a car reported stolen. Because the Force Review
Board did not review instances when force was not used, we did not see as many instances
when officers addressed the situation without using force. But where officers chose to use
force, they sometimes broke glass on one side or the other; often used tasers and pointed
weapons from different vantage points; and another time used pepper spray. But a
consistent pattern emerged from these encounters—officers acted differently in each case
with generally low levels of coordination, acted quickly when no need to do so was
present, and escalated the situation often resulting in injury to themselves and the
individuals. In one instance, the pepper spray surprised the person sleeping and caused him
to drive away and, because of pepper-spray-impaired vision, he sideswiped several police
cars and collided with another car in an intersection. By contrast, we saw a similar instance
when Aurora Fire, rather than Aurora Police, took the lead on interacting with a sleeping
person in a car. Despite circumstances which had resulted in Aurora Police’s use of force in
other similar situations—the car was running and the subject did not put it into park
immediately—no one used force and the subject, after reacting with surprise, quickly
calmed down and discussed the situation with Aurora Fire and Police.
Finally, because the Force Review Board generally focuses on a single question—Could the
force be justified under the policy?—the Board does not serve as a mechanism for
improving the operations of Aurora Police or addressing close calls. And because the
consequence for a policy violation is seen as severe—a referral to Internal Affairs—the
Board is generally reluctant to find policy violations. When the Board finds poor decisionmaking but no policy violation, no structured mechanism exists for Aurora Police to
improve—either through policy revision, training enhancements, or feedback to particular
officers.
For example, we observed several incidents during the Force Review Board meetings and
on ride-alongs where officers responded to domestic violence calls and failed to separate
the victim and suspect. In a recent incident, officers let the victim lead the way into her
home, where the suspect was. Officers believed that the suspect possibly had a gun and yet
there was no effort made to keep the victim away from the suspect. Instead, the victim
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remained present for much of the encounter, even as the suspect was backed into a corner
appearing to conceal something behind his back. The Force Review Board identified this as
a training issue—saying that the officers never should have let her into the house—but
there was no further discussion about follow-up on how to address this issue. Of course,
situations like these present safety concerns for the officers, victim, and subject, often
heightening emotions, escalating the urgency of the situation, and requiring the application
of force that may not have otherwise been necessary.
And the Force Review Board identified several other recurring tactical issues from their
use-of-force reviews—officers getting too close to subjects suspected to have guns or other
weapons; one officer drawing a taser and gun at the same time; sergeants on scene failing
to either coordinate the officer response or take control of the situation; and officers
deploying a taser when pressing it against a subject, often called drive-stunning, when a
subject was already on the ground, leading to increased resistance by the subjects and often
increased force by the officers, among other issues.
Force Review Board and Force Investigation Unit members reported that they would
follow up with officers and supervisors on an ad hoc basis but no structure or criteria
guided when such feedback should occur. Nor did we observe any follow-up to confirm
that it had occurred. Nor did we observe any accountability mechanisms that ensured that
others in Aurora Police heard of the issues identified in the Force Review Board. Training
Academy personnel confirmed that they do not collaborate with the Force Review Board,
even though recurring issues identified by the Force Review Board are necessarily those
that officers need to be trained on. Without having a systematic way to ensure that issues
identified in these types of reviews return to the organization in a structured manner—
through formal training (both at the academy and in-service), policy review, and in shift
briefings—Aurora Police will continue to repeat mistakes.
The recent development of the Force Investigation Unit and the development of a review
checklist for use-of-force incidents show movement in the right direction. In our limited
observation, the review checklist provides more structure to the Force Review Board
discussion and increases the chances that more thoughtful discussions occur. But we still
observed situations when the Force Review Board discussion was perfunctory, failed to
follow the checklist, and focused on condoning poor decision-making by officers. It is
unclear that the Force Review Board intends to have members discuss each element of the
checklist on a consistent basis going forward. And we continued to see an emphasis on
justification rather than need, and no systematic effort to utilize use-of-force reviews to
improve training or tactics.
How the Force Review Board handled the recent high-profile case where two officers were
charged with crimes from the pistol whipping of a resident by one officer and a failure to
intervene by another officer illustrates the residual profound shortcomings of Aurora’s
approach to reviewing force. In the Force Review Board meeting, many members stated
that pistol whipping a subject was not necessarily outside of policy, applied the wrong legal
standard to evaluate the use of force, and spent significant time trying to justify the force
used. The Force Investigation Unit’s presentation minimized the seriousness of the
incident, describing the repeated pistol whipping as the officer “jab[bing] [the resident] in
the face a couple of times with the barrel of his weapon” and characterizing the interaction
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as a “struggle” and “brawl,” despite there being no evidence of such events in the video
evidence reviewed. And none of the Force Review Board members mentioned the officer
choking the resident. Instead, members discussed their reticence to have a “knee-jerk
reaction” and determine whether the officer’s uses of force were compliant with policy
without knowing his perspective.
8.4.2. Use-of-Force Policy and Implementation Focuses on Maximum
Force Permitted Under Law
Aurora’s policy does not contain more specific guidance to structure officer decisionmaking when using force like policies from other Colorado police departments. Officers
encounter many challenging situations. Equipping them with a more detailed framework on
when to use force and what force to use helps them do their jobs well and reduces the
chance that their split-second decisions will result in excessive force.
8.4.3. De-Escalation is Misunderstood and Not Consistently Practiced
Aurora Police often views de-escalation as what happens after force is used, rather than an
alternative to using force in the first place. Repeatedly in the Force Review Board meetings,
members applauded de-escalation that occurred after officers had tased or tackled someone,
rather than focusing on whether the taser or tackle was necessary in the first instance. Deescalation, properly understood, focuses on tactics that reduce the need for force in the
first place, rather than decreasing the amount of force used after the fact.
In addition, at scenes with multiple officers, we often witnessed a lack of coordination,
with the most aggressive officer often setting the tone for use of force. We saw, for
example, officers
•

use pepper spray against a sleeping individual in a stolen car,

•

raise long guns for close encounters where the need for force had not been
established,

•

tackle someone who posed no immediate threat,

•

encourage a police dog to continue to bite well after an individual had been taken
to the ground,

•

fire two less-lethal shotgun rounds from close range at an intoxicated individual
who was not complying with commands because he did not understand English,

•

quickly draw a gun on an individual producing paperwork during a traffic stop
which ultimately led to a multi-officer takedown and taser deployment,

•

engage in a foot chase and tasing of a person who stole $30 worth of goods from a
store, and

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•

immediately draw weapons when dealing with an individual in a mental health
crisis.

Many of these incidents occurred despite a lack of urgency and even though officers had
time to coordinate and attempt engagement without using force.
Aurora Police officers’ frequent practice of having all officers on scene participate in
engagement with the subject leads to this lack of coordination reducing the ability to deescalate the situation. For example, we observed all available officers respond to a domestic
violence call where the subject was outside the home, yelling and disruptive but not
physically aggressive. At first, there were a handful of officers on scene. The man was
verbally aggressive, but one officer approached and spoke with him, and he began to calm
down. The man appeared ready to leave the scene, which would have ended the encounter.
But as more and more officers arrived, the man became agitated and started yelling again.
This was not an isolated incident. Rather than have one or two officers first engage with an
individual, Aurora Police often has all officers on scene engage, including drawing their
weapons, instead of first assessing whether less aggressive shows of force may lead to a
calmer situation without the need for force.
As other examples, we saw several incidents in the Force Review Board where foot pursuits
led to the use of tasers. Many times interactions quickly escalated from a routine
engagement and led to the use of force when alternatives to using force were not given a
chance. For example, we saw officers begin a foot pursuit that led to the use of a taser after
an individual had shoplifted an energy drink from a big box store and poor decisionmaking by store personnel allowed the individual to escape. Other instances of foot
pursuits leading to taser use arose from routine encounters that escalated when individuals
did not want to interact with police and fled. There was often little connection between the
basis for the stop and the pursuit leading to the use of a taser.
In general, we observed that Aurora Police officers were quick to use tasers to address
challenging situations. For example, we saw an incident where an officer tried to tase a
fleeing suspect who had climbed over a fence. The officer missed, but even if the taser had
been effective the suspect would have been on the other side of the fence, too far away for
the officer to handcuff him while he was subdued by the taser. While Aurora Police policy
describes tasers as less-lethal force, they still pose significant risk to individuals and, as we
saw, often do not work effectively in certain situations, including in the winter when people
wear heavy coats. The use of a taser escalates the situation dramatically, often foreclosing
other engagement requiring less force. In addition, tasers can cause serious injury or death
even when used appropriately.308 Although Aurora Police Department Directive 5.08 does
provide more guidance on the use of tasers, what we saw in practice was a pattern of
quickly resorting to threatened and actual taser use instead of, as the policy requires,
“exhaust[ing] all available non-physical means.”
We also observed that officers were often quick to escalate and use dangerous and
unnecessary tactics that led to unnecessary force. Aurora needs to change its approach to
Lethal Force? Tasers Are Meant to Save Lives, Yet Hundreds Die After Their Use By Police, USA Today,
Apr. 23, 2021.

308

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civilian encounters by using force as a last resort, not as the immediate option, as state law
requires.309
While the Force Review Board would often identify poor tactics in their meetings, that
information was not passed along in a standardized manner to the officers, their
supervisors, or the trainers. In many cases, that information was not passed along at all.
When the Academy trained recruits on de-escalation tactics, such as returning to their
patrol car and waiting for backup if a gun was visible during a traffic stop, that training was
not passed along to the Field Training Officers, who then misunderstood the new tactic
and did not reinforce it. It is not enough to identify a concerning tactic as a training need;
officers must then be given the training to understand why the tactic should be avoided and
what to replace it with. Aurora Police lacks a systematic method to flag bad tactics that lead
to unnecessary force, and then ensure that leadership highlights tactics to be avoided in
performance reviews, shift briefings, and in-service trainings. Aurora Police also lacks a
systematic method to meaningfully engage and train experienced officers on new deescalation tactics and their value. Without such clear direction, officers will continue to use
tactics that lead to unnecessary force.
8.4.4. Mental Health Issues Are Not Adequately Addressed
Aurora Police inappropriately responds to those in mental health crisis. Officers are not
adequately trained and often do not consider the mental health status of people they
engage with. Some officers have Crisis Intervention Training, a week-long course on
interacting with people facing mental health challenges, but other officers do not empower
those trained officers to take the lead in situations involving mental health crisis.
On our ride-alongs, officers told us that Crisis Intervention Training has a bad reputation
within Aurora Police, and some officers do not think it is effective. The use-of-force policy
does not emphasize de-escalation or explain that officers should consider a person’s mental
capacity in their decision-making. If officers are unconvinced that crisis intervention
techniques play an important role in de-escalating a person in crisis, they are unlikely to use
them. And if policy does not emphasize the need to attempt de-escalation, officers are
unlikely to allow CIT or similarly trained officers to use other tactics that often reduce the
likelihood that force will be used. It is unsurprising, then, that based on our observations,
the Crisis Response Teams seldom take the lead in encounters involving mental health
issues.
8.4.5. Force is Used Disproportionately Against the Black Community
Our observation of the Force Review Board noted that the targets of force by Aurora
Police were often individuals of color. Of course, because the Force Review Board only
reviewed incidents when force was used, our observations do not substitute for the robust
data analysis above. But the pattern was still striking. As we discuss above, Aurora uses
force disproportionately against Black residents.

§ 18-1-707(1), C.R.S. (requiring officers to “apply nonviolent means, when possible, before resorting to the
use of physical force”).

309

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8.4.6. Aurora Police Inadequately Documents the Use of Force
Aurora Police does not prepare or keep records that allow for review to understand why
force was used in a given circumstance. We saw a pattern of using conclusory, boilerplate
language to describe why force was used, rather than the required specific articulation of
the reason the officer actually decided to use force and why other approaches to
engagement were not used as required by Colorado law. Without this detail, it is difficult
for supervisors or others to evaluate the appropriateness of the use of force.
8.4.7. Aurora Fire and Aurora Police Do Not Adequately Coordinate
In both our Force Review Board observations and our ride-alongs, we observed how
Aurora Fire and Aurora Police interacted with each other. Generally, we saw poor scene
coordination with Aurora Fire and observed several encounters where there was too little
communication between Fire and Police personnel. At times, this lack of communication
and coordination led to unnecessary force.
And we learned that Aurora Fire and Police do not conduct joint training exercises that
would allow them to practice interagency communications. Some officers and fire
personnel talk to each other well, effectively communicating important information in
high-stress environments. Other times, the second agency to arrive will waste time
gathering information from civilians on scene rather than learning from the first agency.
We observed no standardization of this communication and no opportunity for teams to
debrief or discuss how to improve communication or coordination in the future. The new
policy adopted by Aurora Police does not address these concerns.
Finally, we saw a pattern of no specific, identifiable point when someone transitioned from
a subject of police investigation to a patient of Aurora Fire. While we generally observed
cooperation and professional engagement, we also often observed confusion on scene as
to how to handle unexpected developments that arose. Because of this confusing
transition, we observed, at times, delay in the provision of medical care to individuals. The
new coordination policy prioritizes medical care over custody concerns and requires
officers to facilitate prompt patient care. This is an improvement. But fire personnel
(including those from Falck) need to understand how Aurora Police are trained to try to
de-escalate a situation and must not hinder those efforts. Aurora Police, in turn, need to
train with Aurora Fire to support providing prompt medical attention to those in need.
Also, we observed one instance of an exceptional after-action debriefing by Aurora Fire
with members of an emergency room department after a single-car fatal accident. There,
paramedics from Aurora Fire engaged in extensive discussion with members of the
Emergency Department at the Medical Center of Aurora over how care was provided on
scene and how care could be improved to increase the chance of survival. This discussion
stood out because in our many ride-alongs, where we observed many scenes where Aurora
Fire and Police both responded, we saw no similar after-action discussion about how to
learn from recent experiences. Many of these situations involved high-stakes, joint
responses, such as responding to three different individuals in mental health crisis
threatening a household member with a knife, dealing with a drunk individual who was
reluctant to receive needed medical care, and responding to domestic violence incidents.

86

Aurora Fire and Police are partners in supporting the community, and they should train
and better support each other in doing so.
These shortcomings in how Aurora Fire and Police train and work together are particularly
surprising given their shared use of a joint training center that was developed, in part, to
improve how the two organizations work together. That facility went into service in early
2016, but does not appear to have supported a culture of joint training or coordination.
During our visit to the training center, police officers said that they have very little
interaction with fire personnel despite the shared space. The Training Academy plans to
incorporate joint Aurora Police and Fire training into academies in the future, but there
currently is no plan to implement coordinated in-service training for existing officers.
8.5.

Changes Needed

Based on our investigation, Aurora Police must make the following changes to ensure its
use of force follows the law.
8.5.1. Improve Use-of-Force Policies to Give More Specific Guidance to
Support Officers
Aurora Police must change its policy to provide more specific guidance to officers as to
when they may use force and what they must do before using all types of force. The
policies must require efforts to use alternatives to force whenever feasible. The policies
must focus on the entire encounter with the officer and information provided by dispatch
or bystanders, not just the immediate decision to use force. The policies must require
officers to have specific, articulable reasons for using force, and document those reasons in
the required reports. Examples of appropriate de-escalation and use-of-force policies
include the Baltimore310 policy, as well as policies from Boulder,311 Colorado Springs,312 and
Denver.313
8.5.2. Enhance Training on New Policies
Aurora Police must comprehensively train all of its officers under this new policy, both at
the academy and with in-service training. This training must include scenario-based training
that addresses a mental health crisis, critical decision-making, de-escalation, and the likely
use-of-force consequences of decisions like foot pursuits. In addition, Aurora Police must
substantially expand training that addresses bias.

Baltimore Police Department Policies.
Boulder Police Department Policies & Procedures.
312 Colorado Springs Police Department Policies & Procedures.
313 Denver Police Department Operations Manual.
310
311

87

8.5.3. Change the Focus and Purpose of the Force Review Board and the
Force Investigation Unit
The Force Review Board and Force Investigation Unit must review whether force was
necessary and legal, not just whether force could be justified in hindsight. The Board and
Unit must change its approach to reflect the values and requirements of the new policies.
8.5.4. Develop Measurable Goals to Improve How Officers Engage With
Those Experiencing Mental Health Crises
Aurora Police must set and meet specific, measurable goals on improving how officers
engage with those experiencing mental health crises beyond just making policy changes.
Options include significantly increasing officer participation in Crisis Intervention Training;
training officers to routinely request support from colleagues who have received Crisis
Intervention Training on calls with a mental health crisis; creating specific practices to
empower Crisis Response Teams, as opposed to officers, to lead on calls with a mental
health crisis; and similar efforts.
8.5.5. Develop a Joint Policy for Aurora Police and Fire to Coordinate on
Scenes and Conduct Joint Trainings
Aurora Police and Fire must develop and implement a joint policy for scene coordination
and conduct joint trainings so that, in particular, Aurora Fire personnel know and
understand Aurora Police’s approach to de-escalation and Aurora Police officers know and
understand Aurora Fire’s approach to patient care. Aurora Police issued a new policy on
patient care and transfer of custody that addresses some of the concerns raised in this
report. However, both agencies must adopt a more comprehensive policy and appropriate
training.

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9.

Finding #3: Aurora Police Has a Pattern and Practice of Failing to
Document Stops as Required by Law

We found that under policies that have been in effect since 2020, members of Aurora
Police conduct resident stops without documenting those stops as Colorado law requires.
This failure prevents Aurora Police from adequately supervising its personnel and
contributes to violations of the U.S. Constitution and Colorado law as discussed
throughout this report.
9.1.

Legal Background

Senate Bill 217 requires that officers have a legal basis for making any contact with an
individual, consensual or not, when they are conducting law enforcement or investigatory
activities. Whenever such contact is made, Colorado law requires law enforcement to keep
detailed records of the interaction, including: (a) the perceived demographic information
of the person contacted; (b) whether the contact was a traffic stop; (c) the time, date, and
location of the contact; (d) the duration of the contact; (e) the reason for the contact; (f)
the suspected crime; (g) the result of the contact; and (h) the actions the officer took
during the contact. Subsections (g) and (h) require more information, such as whether the
subject was released with no action taken, whether the officer sought and was provided
consent to search, or whether a weapon was unholstered during the encounter.314
These documentation requirements deter unnecessary and improper stops by requiring
officers to articulate their motives and describe their actions for every investigatory or
enforcement encounter with a member of the public. They allow for review by supervisors
and the state. And applying these requirements not just to formal arrests but also to
investigative-type Terry stops and other less formal interactions provides critical oversight
for the types of police activity that have been historically under-scrutinized and subject to
abuse.
9.2.

Aurora Police Fails to Document All Stops as Required by Senate Bill
217

Senate Bill 217’s expanded recordkeeping requirements took effect when the law was
enacted in June 2020, yet we found that Aurora Police failed to follow this law and record
this information about all stops.
Multiple members of our team witnessed incidents during our ride-alongs where non-white
residents were detained, and even handcuffed, before being released with no charges filed.
During those incidents, we saw no effort made to properly record the information required
by Colorado law. And we confirmed with supervisors and senior leadership that such data
was not recorded and that there was no way to determine how many other instances,
beyond those that we personally observed, occurred where people of color were detained,
handcuffed, and then ultimately released.

314

§ 24-31-309(3.5), C.R.S.

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This failure causes an entire category of Aurora Police activity (i.e., interactions that do not
lead to a formal charge being filed, such as Terry stops where the subject is ultimately
released) going unrecorded contrary to state law.
We therefore conclude that Aurora Police has a pattern and practice of violating the
recordkeeping requirements of Colorado law, which are contained at Colo. Rev. Stat. § 2431-309(3.5). Aurora Police must implement new procedures to ensure it is capturing all the
information required by Senate Bill 217 and must likewise begin training to inform its
officers of these requirements.
Understanding who Aurora Police interacts with and why provides the basic information
necessary to determine whether Aurora is following the law. This data collection allows
prompt analysis to discover patterns of police misconduct and proactively address
breakdowns in community policing. When departments do not record data, or keep it
siloed and disconnected, leadership cannot identify trends in unlawful practices, individual
officers or units who bear a disproportionate share of responsibility for illegal practices go
unnoticed, Aurora Police cannot identify real training needs, and illegal conduct and
practices remain harder to identify.
9.3.

Aurora Police Reports Do Not Include Required Detail Describing
the Reasons Supporting the Contact or Stop

Even in the instances when a written report is filed, Aurora Police officers frequently fail to
adequately describe the reasons supporting the contact or stop. Aurora Police Department
Directive 5.4 addresses the reporting requirements in cases involving a use of force.
Although sections 5.4.4 through 5.4.6 discuss the reporting responsibilities of officers and
their supervisors, there is no reference to what officers should record if a resident stop
involves or requires a use of force. Although section 5.4.4 directs an officer to “file a
written report detailing the justification for the use of such force, type of force used,
resulting effect of the force used and subsequent actions taken by the member,” the policy
fails to address the information that should be recorded where force is used after or in
connection with a stop—such as the specific articulable facts (reasonable suspicion) that
justified the resident contact in the first place.
We saw several examples of General Offense reports completed by an officer that failed to
describe a sufficient basis for the initial contact or continued detention—for example, an
officer wrote in one report that his reason for contacting and detaining a Black woman was
that she “appeared to be homeless” and refused to answer the officer’s questions. Other
examples of deficient reports include vague boilerplate language explaining the use of
force, such as “I observed [the suspect] clench up and become more aggressive”, “I could
feel [the suspect’s] body tense. [Suspect’s] body was stiff as a board and I needed to place[]
[suspect] into a rear escort wrist lock and placed [suspect] in handcuffs for my safety and
the safety of fellow officers”, and “[d]uring the contact, [suspect] began to resist and fail to
follow instructions.” We also saw General Offense reports with limited detail that describe
the report as a “summary” and direct the reader to the body-worn camera footage “for
more information.”

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The identified reporting deficiencies reflect a lack of officer accountability or failure by
supervisors to ensure officer reports are complete and include sufficient detail. Aurora
Police Directive 5.4.6 addresses the responsibilities of supervising officers to ensure that
reports “contain a description of events leading up to, during, and after the use of force,
which are relative to the use of force.” Despite the language in this directive, reports are
often completed without sufficient detail, which reflects a lack of critical review by
supervising officers. This lack of critical review undermines Aurora Police’s ability to
ensure officer accountability to conduct stops and arrests that comply with applicable
constitutional and statutory requirements.
9.4.

Changes Needed
9.4.1. Develop Policies and Create Systems to Comply With Colorado
Law on Documenting Stops

Aurora Police must immediately develop policies and systems that comply with Colorado
law on documenting encounters with the public. These systems should form part of a
robust and functional data dashboard that allows for real-time analysis of this information.
9.4.2. Amend Aurora Police Policies to Include a Separate Directive
Addressing Stops That Complies With both Colorado and Federal
Law
The directive should include at least the following provisions:
•

A clear and detailed statement of the key requirements of the Terry decision and
Colorado analogues and what those decisions mean, including the legal differences
between an “investigatory stop,” “consensual encounter,” and arrest.

•

Guidance on what constitutes “reasonable suspicion” supporting a stop—with
usable examples of how officers should articulate the specific factual basis
supporting their belief that a crime has been or will be committed. This guidance
must emphasize the importance of including detailed factual statements in reports
supporting “reasonable suspicion” and prohibiting the use of vague, canned, or
boilerplate language. In addition, this guidance must include a list of factors that
may not be used in making stops.

•

A requirement for supervisors to review stop reports to ensure reports avoid vague,
canned, or boilerplate language and to document deficiencies in a timely manner
with documentation of that review.

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10.

Finding #4: Aurora Fire Rescue Has a Pattern and Practice of
Administering Ketamine Illegally

We found that Aurora Fire has a pattern and practice of administering ketamine illegally.
Patients were routinely given ketamine in doses that exceeded the maximum allowed by
protocol, and paramedics often failed to estimate a patient’s weight. Once sedated, some
patients were not properly monitored, placing them at risk for life-threatening
complications.
In some instances, paramedics administered ketamine at the request of officers without
completely assessing the patient’s condition and over the patient’s stated objections. Patient
care reports were detailed when symptoms supported a diagnosis suggestive of ketamine,
but were scant on details when combativeness was the primary complaint. Aurora Police
often failed to document that paramedics sedated a person in their custody, so supervisors
were unable to review whether sedation was requested and should be reviewed as a use of
force.
Finally, medical supervisors did not intervene when paramedics failed to follow agency
protocols to prevent future violations. Despite reviewing every instance of ketamine
administration, the medical directors did not flag a single case of excess dosing or failure to
properly monitor a patient as triggering the need for additional training or remediation.
Aurora Fire must improve its training, protocols, and case-review policies to prevent the
unnecessary use of chemical sedatives.
10.1.

Ketamine and Its Use by Aurora Paramedics
10.1.1. Ketamine Use by Paramedics

Ketamine is a short-acting “dissociative anesthetic that has some hallucinogenic effects.”315
The Colorado Department of Public Health and Environment regulates the use of
ketamine by paramedics outside the hospital setting, providing waivers to medical directors
who deliver the appropriate training, oversight, and review for the emergency medical
providers under their supervision.316 It announced a review of the ketamine waiver
program for administration in patients with symptoms of excited delirium in August 2020
that is still ongoing. A suspension of all waivers was initiated in July of this year while it
works to develop a program that complies with House Bill 1251.317
The waiver program had permitted paramedics to use ketamine to sedate patients with “a
presumptive diagnosis of excited delirium” or “extreme or profound agitation.”318
Ketamine Drug Fact Sheet, Drug Enforcement Administration (2020).
Press Release, State health department announces plans to review the ketamine waiver program, Colorado
Department of Public Health and Environment (CDPHE) (Aug. 22, 2020, updated Apr. 15, 2021).
317 Colorado Suspends Ketamine Use on Agitated People as New Law Takes Effect, Fox 31 News (July 7,
2021).
318 Ketamine Waiver Guidance, Emergency Medical Practice Advisory Council, CDPHE; Non-medical
personnel use “excited delirium” to describe a variety of agitated or violent behaviors, but the medical
community defines it as “delirium with agitation (fear, panic, shouting, violence and hyperactivity), sudden
315
316

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According to the waiver guidance, “[e]xcited delirium is [a rare] medical emergency in
which a person develops extreme agitation, aggressiveness, overheating, and exceptional
strength that cannot be managed by routine physical or medical techniques.”319 Other
health organizations, such as the American Medical Association and American Psychiatric
Association, do not recognize “excited delirium” as a diagnosis.320
Across the country, doctors had recognized a pattern of people who showed signs of
excited delirium who then died suddenly in police custody.321 The individuals were
excessively combative and resisted arrest with abnormal strength. A few individuals had
pre-existing mental illness, but most were under the influence of stimulant drugs, especially
cocaine and methamphetamine.322 Everyone died while restrained and lying down; many
had both their hands and feet restrained behind their backs.323 By 2010, about 250 people
died each year in custody while exhibiting signs of excited delirium.324
The spike in custodial deaths alarmed the medical and emergency responder community,
which issued recommendations for “rapid sedation” to prevent the bizarre “multisystem
failure.”325 The recommended drug was ketamine because it was fast-acting when “victims
may not have minutes to spare as they continue to struggle against law enforcement or
physical restraints in a state of hyperthermia and metabolic acidosis.”326
By 2017, a nationwide study revealed that nearly all paramedics had received training on
ketamine and one-third of EMS agencies “allowed prehospital use of ketamine” or had
protocols permitting its administration.327 Chemical restraint and sedation accounted for
more than half of all ketamine use.328 The appearance of ketamine administration in
Minneapolis police reports filed between 2010 and 2018 demonstrated its increased use
from 0 to 2 incidents per year early in the decade to 62 incidents in 2017.329

cessation of struggle, respiratory arrest and death,” Asia Takeuchi, M.D., et al., Excited Delirium, 12 W. J.
EMERG. MED. 1, 77 (2011).
319 Ketamine Waiver Guidance, Emergency Medical Practice Advisory Council, CDPHE.
320 Position Statement on Concerns About Use of the Term "Excited Delirium" and Appropriate Medical
Management in Out-of-Hospital Contexts, American Psychiatric Association, Dec. 2020; New AMA Policy
Opposes “Excited Delirium” Diagnosis, American Medical Association, June 14, 2021.
321 Michael S. Pollanen, Ph.D., et al, Unexpected death related to restraint for excited delirium: a retrospective study of
deaths in police custody and in the community, 12 CANADIAN MED. ASSN J. 158, 1603-07 (June 1998).
322 Asia Takeuchi, M.D., et al., Excited Delirium, 12 W. J. EMERG. MED. 1, 77-78 (2011).
323 Pollanen, et al., at 1604.
324 Lt. Col. Edward L. Hughes, Special Panel Review of Excited Delirium, Institute for Non-Lethal Defense
Technologies (Dec. 2011).
325 Excited Delirium, at 80.
326 Id. at 81.
327 Daniel M. Buckland, M.D., Ph.D., et al., Ketamine in the Prehospital Environment: A National Survey of
Paramedics in the United States, 33 PREHOSPITAL AND DISASTER MEDICINE 23, 25 (Feb. 2018).
328 Id. at 26. The other uses for ketamine were primarily for therapeutic pain management.
329 MPD Involvement in Pre-Hospital Sedation (July 26, 2018), MINNEAPOLIS POLICE DEPARTMENT, at 10.

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Falling methamphetamine and cocaine use in the past decade should have led to fewer
cases of excited delirium and less need for ketamine.330 But the rise in ketamine use during
the last half of the decade, especially in connection with police-involved patients, raised
concerns that officers were asking for ketamine to help subdue suspects.331
10.1.2. Changes to Colorado Law on the Use of Ketamine
In June 2021, Colorado lawmakers passed House Bill 21-1251, a bill preventing paramedics
from giving ketamine to police-involved patients unless a justifiable medical emergency
required its use.332 The law specifies that excited delirium is “not a justifiable medical
emergency.”333
The new law, which became effective on July 6, 2021, prohibits police officers from
directing paramedics to give ketamine to an individual.334 Should an officer make such a
request, the bill includes mandatory reporting provisions for both police and emergency
medical personnel. Police are also mandated to intervene and prevent officers from
directing paramedics to administer ketamine to effect an arrest or “to facilitate ease and
convenience in law enforcement encounters.”335
Officers are permitted, however, to provide paramedics and emergency medicine service
providers with “information about the individual or the scene of the emergency that may
assist … assessment of the need to administer ketamine.”336 But paramedics may not base
their “medical decision or diagnosis exclusively on information provided by a peace
officer.”337
In addition, House Bill 1251 outlines statewide regulations on ketamine administration in
the presence of law enforcement. Before giving ketamine to a patient, paramedics must
weigh the patient to ensure accurate dosage. If a patient cannot be weighed, paramedics
must have three trained personnel estimate the patient’s weight and try to receive verbal
permission from a medical director. Paramedics must be trained in ketamine administration
and advanced airway support techniques, provide urgent transport to a hospital, and record
any complications arising from the ketamine. The drug cannot be given unless there is
proper monitoring and respiratory management equipment immediately available.

Methamphetamine Research Report: What is the scope of methamphetamine misuse in the United States?, National
Institute on Drug Abuse (Oct. 2019); Cocaine Research Report: What is the scope of cocaine use in the United States?,
National Institute on Drug Abuse (May 2016).
331 Ketamine That’s Injected During Arrests Draws New Scrutiny, Associated Press, Aug. 22, 2020.
332 House Bill 21-1251 was passed on June 22, 2021.
333 § 25-3.5-103(8.6), C.R.S.
334 § 18-1-707(1.5), C.R.S.
335 § 18-8-805(3), C.R.S.
336 § 18-8-805(2)(c), C.R.S.
337 § 18-8-805(2)(b), C.R.S.
330

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10.1.3. Aurora’s Suspension of Ketamine Use in 2020
The Aurora City Council suspended the use of ketamine for patients exhibiting excited
delirium on September 14, 2020, pending the outcome of an independent investigation
into the death of Elijah McClain.338 The Council’s suspension expired at the end of March,
thirty days after the investigation report was released.339 Chief Gray shared his intention to
keep the ban in place indefinitely. And the scope of practice waiver authorizing Aurora Fire
to use ketamine expired in June 2021. Because ketamine was not authorized for use during
our period of observation, we could not see first-hand how ketamine is used in the field.
10.1.4. Structure of Aurora Emergency Medical Services
Falck Rocky Mountain contracts with the City of Aurora to provide ambulance services in
Aurora. Both agencies might respond to an emergency, but all transport is conducted by
Falck. Aurora Fire, however, is responsible for all emergency medical services in Aurora
and drafts the emergency medical protocols used by both agencies. Aurora Fire and Falck
share the same medical director, who submitted a scope of practice waiver in 2018
permitting both agencies to use ketamine.
10.2.

Findings on Aurora’s Practices of Ketamine Use

To evaluate the agencies’ practices, we reviewed Aurora Fire Rescue and Falck Rocky
Mountain ketamine administration records which are provided to the Colorado
Department of Public Health and Environment as required by the waiver program. We
reviewed redacted patient care reports for these incidents and the few Aurora Police
reports that identify or correspond with ketamine administration. We also spoke with the
medical director.
10.2.1. Records of Past Ketamine Use Show Disparate Dosing of
Ketamine Not Based on Weight and a Failure to Follow Monitoring
Protocols
The ketamine administration records we reviewed covered 21 months, from January 2019
through September 2020. During that period, Aurora Fire reported administering ketamine
for excited delirium 22 times.340 These records show that in more than half the incidents,
paramedics failed to follow ketamine monitoring protocols or administered ketamine at
doses above the maximum allowable dose.
Proper ketamine dosing is based on a patient’s weight, and medical experts connect high
doses of ketamine with increased risk of medical complications.341 The records show that
Aurora City Council Minutes of Sept. 14, 2020 Council Meeting 4-5.
Id.
340 Colorado Health Facilities and Emergency Medical Services Division, Denver Metro Waivered
Administration of Ketamine for Excited Delirium and/or Extreme or Profound Agitation.
341 Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement (Aug. 27,
2020). The statement represents the collective consensus of The American College of Surgeons Committee
on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association
338
339

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nine patients experienced adverse complications following ketamine administration,
including sinus tachycardia (fast heart rate), hypoxia (low oxygen supply), and bradypnea
(slow breathing rate).342 One patient was given assisted ventilation while in transit, and
placed on a ventilator at the hospital. All but one patient who experienced an adverse
complication was either given the maximum dose of ketamine, 500 mg, or given ketamine
following the administration of another sedative.
The risk of adverse complications borne out in the patient records raises concerns about
the agencies’ frequently high dosing of ketamine. Aurora Fire records show that at least
three patients from the table below were given too much ketamine for their weight, 50 mg
above the maximum dose. A review of redacted patient care reports, however, showed that
paramedics failed to document a patient’s weight five different times. Failure to document
this information makes it impossible to determine whether proper ketamine doses were
administered. Moreover, each time a report failed to include the patient’s weight,
paramedics gave patients 500 mg of ketamine, the maximum dose permitted for any
patient.
Perhaps more concerning is that even though these weights were not recorded in the
patient care reports, Aurora Fire reported those patient’s weights in the records they
provided to the Department of Public Health. For these patients, the reported weight was
not always enough to justify the maximum dose given. And in five other instances, the
weights listed in Aurora Fire’s care reports did not match the records they gave to the
Department of Public Health.
Literature from Aurora Fire’s excited delirium training emphasizes the need to accurately
estimate a patient’s weight to administer the correct dosage.343 Hospitals where patients
were transferred, however, do not submit data confirming patient weights, so there is no
way to verify whether paramedics are overestimating patient’s weight, or not estimating it at
all, as the information we reviewed suggests.
In July 2020, Aurora Fire included guidance on how to estimate a patient’s weight to their
protocol manual.344 The guidance recommends paramedics “use your own size and weight
in comparison to your patient,” and suggests several crew members independently assess
the patient’s weight and compare to establish an accurate estimate.345 The protocol was
adopted after most of the administrations we reviewed and shortly before the City Council
suspended all ketamine use, so we cannot know if it would have prevented excess dosing.

of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the
National Association of EMTs (NAEMT).
342 Colorado Health Facilities and Emergency Medical Services Division, Denver Metro Waivered
Administration of Ketamine for Excited Delirium and/or Extreme or Profound Agitation.
343 Nick Anderson, Ketamine and Versed 22, on file with authors.
344 Aurora EMS Protocols, Summer 2020, 9000 General Guidelines: Medication Administration.
345 According to the protocol, “If there is discrepancy in weight estimation among the crew members, the
lead medic should discuss the weight estimations with the crew and choose the lower weight estimate if the
discrepancy persists.” Id.

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House Bill 1251 now requires paramedics to weigh or triple-check a patient’s estimated
weight through a process similar to Aurora Fire’s protocol outlined above. The law does
not address the pattern of overdosing patients even when paramedics properly estimate
and record a patient’s weight.
Additionally, in eleven incidents below Aurora Fire reported that medical observation
protocols were not completely followed.346 Generally, protocols require paramedics to
begin capnography (carbon dioxide levels), pulse oximetry (oxygen saturation), and cardiac
monitoring after ketamine is administered.347 Aurora Fire’s records show that five patients
did not receive capnography monitoring, eleven patients did not receive cardiac
monitoring, four patients did not receive oximetry monitoring, and two of these patients
received no medical monitoring. The patient care reports document at least one instance
when patient behavior prevented the paramedics from conducting proper medical
monitoring. But most care reports do not explain the failure to follow protocols.
And, of course, when Aurora Fire and Falck reported that they followed the monitoring
protocol, that does not mean that the monitoring protocol was, in fact, followed. In at least
two instances, Aurora Fire’s care reports do not show proper monitoring, but the reports
to the Department of Public Heath list that monitoring was followed. Because we
observed only the records for these incidents, we cannot independently verify in any
circumstance whether Aurora Fire and Falck did, or did not, follow the monitoring
protocols.
Ketamine Administrations as Reported by Aurora Fire Rescue
from January 2019 through September 2020.348
Date

Recorded Patient
Weight / Conversion

Dose
Given

Protocol
Dose

ExcessDosage

Monitoring Protocol
Followed?

Jan. 2019

weight not recorded

500 mg

unknown

unknown

No

Feb. 2019

150 lbs / 68 kg

300 mg

350 mg

–

No

Feb. 2019

weight not recorded

500 mg

unknown

unknown

Yes

Feb. 2019

weight not recorded

500 mg

unknown

unknown

Yes

Feb. 2019

weight not recorded

500 mg

unknown

unknown

No

Feb. 2019

90.72 kg / 200 lbs

500 mg

450 mg

+ 50 mg

No

Mar. 2019

90.72 kg / 200 lbs

450 mg

450 mg

–

Yes

Mar. 2019

170 lbs / 77.1 kg

200 mg

400 mg

–

No

Mar. 2019

81.66 kg / 180 lbs

450 mg

400 mg

+ 50 mg

No

Apr. 2019

weight not recorded

500 mg

unknown

unknown

No

Id.
Aurora Fire Rescue and Falck Rocky Mountain, Aurora EMS Protocols: Summer 2019, 226.
348 The data from this table was compiled from Aurora Fire documents created to comply with state law. As
mentioned earlier, this information excludes the reported information for Mr. McClain’s ketamine
administration.
346
347

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Date

Recorded Patient
Weight / Conversion

Dose
Given

Protocol
Dose

ExcessDosage

Monitoring Protocol
Followed?

Apr. 2019

280 lbs / 127 kg

500 mg

500 mg

–

Yes

June 2019

250 lbs / 113.4 kg

500 mg

500 mg

–

Yes

July 2019

250 lbs / 113.3 kg

500 mg

500 mg

–

Yes

July 2019

190 lbs / 86.2 kg

500 mg

450 mg

+ 50 mg

Yes

July 2019

220 lbs / 99.8 kg

500 mg

500 mg

–

No

Aug. 2019

170 lbs / 77.1 kg

400 mg

400 mg

–

No

Sept. 2019

220 lbs / 99.8 kg

500 mg

500 mg

–

No

Dec. 2019

170 lbs / 77.1 kg

400 mg

400 mg

–

Yes

Jan. 2020

81.65 kg / 180 lbs

400 mg

400 mg

–

Yes

May 2020

113.4 kg / 250 lbs

500 mg

500 mg

–

Yes

Aug 2020

160 lbs / 72.6 kg

350 mg

350 mg

–

Yes

Sept. 2020

160 lbs / 72.6 kg

200 mg

350 mg

–

No

The Department of Public Health ketamine waiver program requires the medical director
to review every ketamine administration incidence within seven days.349 Cases with adverse
reactions must be reviewed within 24 hours. According to the medical director overseeing
ketamine administration for Aurora Fire and Falck, those reviews were conducted either by
himself or one of three assistant medical directors, who also reviewed other types of EMS
cases. The ketamine review included ensuring that the protocol was indicated by the
patient’s symptoms, proper dosing was administered, and appropriate medical monitoring
was initiated.
Each month, the four physicians met to discuss the cases and identify any concerning
trends or training needs. But the monthly meetings were not limited to ketamine reviews,
and did not include a longitudinal analysis beyond what the medical directors recalled from
the previous month. Absent a systematic process to review all ketamine administrations
over a three or six month period, trends in excess dosing or failure to follow monitoring
protocols may have been difficult to identify from memory alone.
Even so, the medical director stated in his waiver application that paramedics whose cases
fall outside the protocol would have to repeat the initial ketamine training.350 Despite
evidence showing paramedics often failed to follow the agencies’ ketamine protocol, the
director said that no ketamine calls triggered a further case review and no remediation or
training needs were identified.

Colorado Department of Public Health and Environment, Ketamine and RSI Waiver Reporting
Guidance, 2021.
350 Dr. Eric Hill, Application for Excited Delirium Ketamine Administration Waiver, on file with authors.
349

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The only change to emerge from the reviews was to include in the general medication
guidance protocol that paramedics independently assess a patient’s weight and then
compare their estimates. Aurora Fire training reports confirm that only one online training
on excited delirium was offered in 2020, and it was prepared by a paramedic, not a medical
director or experienced trainer.351 The protocols for ketamine remained unchanged during
the period of administration.
Our review of the patient care reports also showed that not all paramedics included
detailed summaries of the patient’s presentation. To be sure, some of the patient care
reports cited symptoms consistent with descriptions of excited delirium, including patients
removing their clothing while actively fighting with police—a possible indication of
hyperthermia—fast pulse, incoherence, and increased strength. But several care reports
lacked important details to confirm that patients met the protocol for ketamine. The same
was true in the corresponding Aurora Police records for these incidents. Both departments
thoroughly documented when a subject demonstrated behaviors were consistent with a
diagnosis of excited delirium. But when the subject’s behaviors mainly consisted of
aggressive resistance, the records are more spare, and it is hard to confirm that patients
were thoroughly assessed before paramedics administered ketamine.
The training provided to Aurora paramedics emphasizes that the most likely cause of
excited delirium is stimulant drug misuse, although psychiatric disorders coupled with drug
use may also place a patient at risk.352 Paramedics identified “overdose” as the suspected
cause of excited delirium in only seven patients. For the other patients, paramedics listed
“psychiatric/behavioral” as the suspected cause.353
These data points neither align with the training provided to Aurora paramedics nor with
the medical literature on the etiology of excited delirium. When the reported symptom is
psychiatric or behavioral, the patient care reports emphasize the patient’s combativeness,
suggesting that patients who are resisting treatment or arrest while experiencing psychosis
may be administered ketamine instead of slower-acting, but perhaps safer, chemical
sedatives. It also raises the question of whether ketamine has been used to transport a
patient who refused treatment, in violation of the constitutional right to reject medical
care.
10.2.2. Officers Sometimes Requested Chemical Restraints and Failed to
Document That Paramedics Chemically Restrained the Person
We found that officers often failed to document paramedics’ use of chemical sedatives—
ketamine or otherwise—in their general offense and use-of-force reports. We found five
incidents of ketamine administration that corresponded with a use-of-force review. The
investigators did not include chemical restraints in their reports, despite the constitutional
implications of giving a person medication without their consent or, in some cases, over
Aurora Fire Rescue, Active Training Events for period 01/01/2018 Through 12/31/2020, on file with
authors.
352 Travis Chambers, Pre-Hospital Ketamine, on file with authors.
353 Colorado Health Facilities and Emergency Medical Services Division, Denver Metro Waivered
Administration of Ketamine for Excited Delirium and/or Extreme or Profound Agitation.
351

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their objections. Officers did not report their own requests for paramedics to sedate
suspects. And investigators who reviewed the body-worn camera footage documenting
officers’ requests failed to include that information in their use-of-force reports.
A review of use-of-force reports for dates corresponding to ketamine administrations
shows that Aurora Police conducted only five use-of-force reviews out of the 24 times
paramedics used ketamine. Aurora Fire’s patient care reports, however, show that Aurora
Police were involved in most ketamine administrations. Because the use-of-force policy in
place during the period of ketamine administration did not require officers to file a report
“when restraining persons solely for medical, emotional, or mental health purposes,” this
failure to document chemical sedation was policy-driven.354 The lack of documentation by
Aurora Police has prevented oversight on officers’ interaction with paramedics, which may
have led to blurred boundaries between medically necessary interventions and unnecessary
chemical restraints.
The Colorado EMS Chiefs, Managers and Directors and the Emergency Medical Services
Association of Colorado issued a statement that “paramedics must make the critical
determination if [a] person is experiencing a medical emergency.”355 The American Society
of Anesthesiologists issued a statement that the organization “firmly opposes the use of
ketamine or any other sedative/hypnotic agent to chemically incapacitate someone for a
law enforcement purpose and not for a legitimate medical reason.”356 In response to the
precipitous increase in ketamine administrations in Minneapolis, the police department
issued a policy prohibiting officers from making “any suggestions or requests regarding
medical courses of action to be taken by any medical personnel.”357
But Aurora Police have requested sedation for combative suspects, and Aurora paramedics
have complied. Our review of patient care reports shows that police-involved patients
sometimes received scant documentation that would confirm the medical need for
sedation. During our ride-alongs with Aurora Fire, paramedics said that police officers used
to feel comfortable telling paramedics to restrain patients. The paramedics were quick to
add that this was no longer common practice.
We matched the date-stamp from body-worn camera footage aired on a television news
report to ketamine administration records, the patient care report, the general offense
report, and the use-of-force report for that incident. The body-worn camera footage shows

Aurora Police Department Directive 05.04, May 13, 2019. This policy has been updated to require officers
to document when force is used when a person is in medical and not police custody. The new policy does not
require officers to document when paramedics sedate a person who had been in police custody.
355 Statement on Sedation of Prehospital Patients, July 18, 2020. This statement was adopted by most
Colorado EMS physician associations, including the Denver Metro EMS Physicians, but it has since been
removed from the Emergency Medical Services Association of Colorado’s website. The Association replaced
the July 2020 statement with a similar statement on November 5, 2020 with a substantially similar
recommendation that “Medical emergencies must be handled by emergency medical professionals.” The July
2020 position statement is still available here. The November 2020 position statement is available here.
356 ASA Statement on the Use of Ketamine for a Non-medical Purpose, July 15, 2020.
357 See MPD Involvement in Pre-Hospital Sedation, (July 26, 2018).
354

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an officer repeatedly asking paramedics to sedate a suspect.358 The officer asks “can we get
this guy like some Versed or something and get him to calm down?” A few seconds later he
asks, “can we get like Versed and calm this dude down or Haldol or something? Let’s give
him some juice to go to sleep … and then we can deal with him.” And again, “If we give,
if we give him some meds, he’ll probably, yeah we’ll give him some calm-down juice.”
According to the body-worn camera footage, the paramedic on scene does not appear to
evaluate the man, but asks the officers if “he’s still fighting you guys?” The paramedic then
returns with an injection, and the suspect protests: “No. You’re not hitting me with
nothing. I said no.”
Records show that Aurora Fire paramedics injected the man with 450 mg of ketamine. The
patient care report states the man had a one-inch laceration on his left forehead when they
arrived. It says the man was showing “signs of excited delirium --hyper-aggression /
increased strength.” The report notes the patient had been tased, handcuffed, and hobbled,
but was “still combative and a danger to himself and others.” Combativeness, however, is
not by itself an emergency medical condition.
The use-of-force investigation reported that the man already had a cut on his face when
officers first approached him. The report documented that the man was “being
uncooperative” as officers held him on the ground. An officer on scene reported that the
man was “actively trying to fight his way out of soft restraints, and needed to be
transported to the hospital for his injuries.” But the only documented injury, other than the
taser barbs the paramedics removed on scene, was a one-inch laceration that was not lifethreatening.
The officer reported that “Aurora Fire issued a chemical restraint,” and identified the
restraint as ketamine. But no one documented that police had requested paramedics sedate
the man so “we can deal with him.” None of the officers on scene reported their
interactions with paramedics in the general offense report, either. The news report
included a statement from Aurora Police that “officers have already been reminded they are
not to suggest or attempt to direct medical treatment.” But Aurora Police did not have a
written policy confirming this verbal admonition at the time. In the statement, the Chief of
Police also said that while the officer’s choice of words were “not ideal,” he was “trying to
get the man in crisis help.” This clarification appears to undermine the verbal policy,
because officers cannot both refrain from suggesting medical treatment and try to get the
man medical help.
Aurora Fire also released a statement that “Aurora Police Department does not influence
our decision-making for treating patients,” and their paramedics “maintain medical
control.” That statement does not appear borne out in this incident or in other anecdotal
reports.
House Bill 1251 addresses some of these concerning interactions by preventing police
from directing paramedics to administer ketamine and preventing paramedics from relying
Aurora Body Camera Video Shows Police Asking Medics to Give Powerful Drugs to Suspect to Calm
Him, The Denver Channel, Dec. 3, 2020.

358

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solely on officers’ reports in assessing a patient. And paramedics reported that new verbal
policy requires the senior paramedic to announce to dispatch when they take over custody
of a patient from officers. Our observations of paramedics and officers, however, revealed
that when policy changes emphasized what should not be done, both paramedics and
officers were confused about how and what they should do instead. For example, when
Aurora Police changed their policy to require officers to report when they use any force on
a person who needs “medical, emotional, or mental health” assistance, we were told that
officers quit helping paramedics with these patients. Paramedics reported that they were
being trained to search patients for weapons, but had not been told what to do if they
found a weapon or who should take custody of a weapon. Both officers and paramedics
expressed frustration in the gaps in their training, which left them confused about how to
interact on community care calls. Aurora Fire’s restraint protocol recommends
coordination with officers, but it does not address how paramedics should interact with
officers or how to maintain medical objectivity when a person is resisting arrest.
Aurora Police released a new policy dated September 7, 2021 that attempts to address how
officers should coordinate with paramedics and EMS providers on scene.359 The new policy
prioritizes the medical needs of a person, regardless of their custody status, and describes
what information officers should provide to emergency medical personnel. It includes an
official transfer of care procedure for when paramedics take custody of a police suspect. It
outlines the limits on an officers’ ability to assist emergency medical personnel when a
patient resists medical care, has a weapon, needs restraint, and it suggests non-physical
assistance such as de-escalation or enlisting crisis response teams, mental health counselors,
or family and friends of the patient.
This recent policy is a substantial step in the right direction.
But the new coordination policy fails to address the authority officers have to act when
someone is in a mental health crisis and there is probable cause to take that person into
custody for purposes of a mental health hold. The complete prohibition on officers using
force to assist emergency medical providers is inappropriate when officers may need to
prevent a patient from escaping transport to a mental health facility.
The new Aurora Police coordination policy is designed to prevent the illegal use of
sedatives on combative suspects. Policy must be reinforced with training, practice, and
better documentation of patient restraints. Because police officers have routinely failed to
document when paramedics used chemical restraints, it is impossible to determine how
often paramedics illegally sedated patients in police custody. The new policy, however, does
not require officers to document when a police-involved patient was restrained or sedated
after they were transferred to Aurora Fire’s custody. Without documentation and
accountability measures, it will remain difficult to assess how effective the new policy will
be.
Additionally, Aurora Fire does not have a policy on how paramedics ought to coordinate
with officers. Aurora Fire’s restraint protocol recommends coordination with officers, but it
does not address how paramedics should interact with officers or how to maintain medical
359

Aurora Police Department Directive 09.06 (effective Sept. 7, 2021)

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objectivity when a person is resisting arrest. The Coordination with Aurora Police policy
covers radio communication and initial requests for police assistance, but does not address
on-scene coordination or care and custody transfers.360 Similarly, the policies on “Response
to APD request for Emotional/Psych Patient Assistance” and “Citizen Assistance
Notification” addresses how to report responses to dispatch and whether both Aurora Fire
and transport or transport only will respond.361
The above incident is one example of paramedics quickly administering ketamine to a
person who does not appear to present the protocol’s description of excited delirium
symptoms and who is capable of articulating their own symptoms and needs. Because
officers and paramedics will continue to work together on difficult calls, Aurora Fire must
also establish effective accountability measures to prevent paramedics from sedating
patients illegally, regardless of the type of sedative used. Aurora Fire and Aurora Police
must develop joint training to ensure patient care is prioritized and first responders adhere
to the expectations of the law and policies of both agencies.
10.3.

Findings on Aurora’s Ketamine Protocols
10.3.1. Protocols Did Not Emphasize the Need for Paramedics to Conduct
an Independent Examination of a Patient

The passage of House Bill 1251 in the summer of 2021 precludes the use of ketamine for
excited delirium “when a peace officer is present” and permits its use only in a justifiable
medical emergency, which is defined as “a medical, traumatic, or psychiatric condition
posing an immediate safety risk to the individual, emergency medical service provider, or
the public.”362 Because excited delirium is a diagnosis based on a set of symptoms without
a specified medical cause, the law also bans the use of ketamine for “any subsequent term
for excited delirium, or any acute psychiatric diagnosis not recognized in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders.”
The law does not prohibit ketamine administration for excited delirium when paramedics
are not in the presence of law enforcement.
Aurora Fire added a protocol for “control of excited delirium” in the summer of 2018,363
which it updated again in the summer of 2019.364 These protocols established how
paramedics were to administer ketamine to patients who were showing symptoms of
excited delirium. In September 2021, Aurora Fire released a new set of protocols, which
adds several measures to protect patients from unnecessary sedation. It does not include
ketamine as a drug paramedics may administer to patients. The medical director who
helped draft the new protocol said that Aurora Fire included a pre-sedation checklist based

Aurora Fire Rescue Manual of Procedures, Policy 6.14.
Aurora Fire Rescue Manual of Procedures, Policy 6.19: Unconventional Request for Service.
362 House Bill 21-1251
363 Memorandum from Fernando M. Gray, Sr., Fire Chief, regarding Prehospital Protocol Updates (Oct 2,
2018).
364 Aurora Fire Rescue and Falck Rocky Mountain, Aurora EMS Protocols: Summer 2020.
360
361

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on suggestions from the report issued by an independent review panel investigating the
death of Elijah McClain.365
The new protocols are another step in the right direction.
Because the new sedation protocol was released after our period of investigation, it is
impossible to know whether it would have prevented the violations we found. House Bill
1251 maintains the option for agencies to use ketamine. Aurora Fire could apply for a new
ketamine waiver and add it back into their protocols. It is important, therefore, to outline
how past policies impacted ketamine administrations to establish what steps Aurora Fire
would need to take before applying for a new ketamine waiver, should they choose to do
so.
The Aurora EMS manual includes excited delirium in the behavioral protocols,366 which is
hyperlinked to the Agitated/Combative Patient protocol and the restraint protocol.367 In
past manuals, these were linked to a protocol for ketamine.368
Both the old and the new protocols describe excited delirium in essentially the same
language: “These patients are truly out of control and have a life-threatening medical
emergency. They will have a severe metabolic acidosis which is life threatening. They will
have some or all of the following symptoms: paranoia, disorientation, hyper-aggression,
hallucination, tachycardia, increased strength, and hyperthermia.”369 The protocols instruct
responders to “assume the patient has a medical cause of agitation and treat reversible
causes” before moving to a potential diagnosis.370 They do not provide paramedics a
method to determine which symptoms in which combination are more likely to signify a
medical emergency.371
The restraint protocol, which includes both physical and chemical restraints and was
unchanged in the 2021 manual, permits paramedics to restrain a person “only when
necessary to prevent a patient from seriously injuring him/herself or others (including the
EMS providers), and only if safe transportation and treatment of the patient cannot be
accomplished without restraints.”372 It requires personnel to use “the minimum amount of
force necessary to control the patient and prevent harm,” and also precludes using
restraints “for the convenience of the crew.”373 It encourages alternatives to chemical

City of Aurora, Investigation Report and Recommendations at 123, Feb. 22, 2021.
Aurora Fire Rescue and Falck Rocky Mountain, Aurora EMS Protocols: Summer 2019 at 53.
367 Id. at 99.
368 Aurora Fire Rescue and Falck Rocky Mountain, Aurora EMS Protocols: Summer 2019 at 143. Aurora
Fire’s current manual now links the Agitated/Combative Patient and Excited Delirium Syndrome protocols
to the medication Benzodiazepines (Midazolam), which is the generic form of Versed. It does not include a
ketamine protocol.
369 Id. at 48; Aurora Fire Rescue and Falck Rocky Mountain, Aurora EMS Protocols: July 2021 at 105.
370 Aurora Fire Rescue and Falck Rocky Mountain, Aurora EMS Protocols: Summer 2019 at 143
371 See White Paper Report on Excited Delirium, American College of Emergency Physicians, Sept. 10, 2009.
372 Id. at 53.
373 Id.
365
366

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sedation, with verbal de-escalation the only listed technique.374 Coordination with law
enforcement is also encouraged to assist with patients who exhibit violent, combative, or
uncooperative behaviors and who do not respond to verbal de-escalation. Paramedics are
instructed to evaluate the patient “to determine his or her medical condition, mental status
and decision-making capacity.”375 Patients are to be treated with respect, and restraints used
only if safe transportation and treatment “cannot be accomplished without restraints.”376
Documentation on the justification for restraints and efforts used to de-escalate before
chemical sedation is required.377
The Agitated/Combative protocol in place when ketamine was used was a flow chart
which included as a general guideline the need for “safety, appropriate use of restraints and
aggressive treatment of the patient’s agitation.” Ruling out excited delirium syndrome was
the third step in the chart, which came before verbal de-escalation.378 It recommended
administering ketamine to induce “rapid tranquilization” and “minimize time struggling” if
a patient shows any of the listed symptoms.379 The rule-out process listed the common
symptoms of excited delirium and referred paramedics to the ketamine protocol.380
The protocols in place when Aurora Fire used ketamine called for a dose of 5 mg/kg IM
(intramuscular) with a maximum initial dose of 500 mg. Paramedics were required to
contact base before administering a second dose, which was set at one-half the initial dose.
No alternative medications were referenced in the ketamine or the excited delirium
protocols.381
In accordance with the waiver program, both the Agitated/Combative Patient protocol and
the ketamine protocol required paramedics to start medical monitoring of cardiac function,
carbon dioxide levels, and oxygen saturation. The Agitated/Combative Patient protocol
required paramedics to begin high flow oxygen and IV saline. The Ketamine protocol
required physical restraints once a patient was sedated and during transport. Both protocols
emphasized that patients were experiencing a medical emergency and required rapid
transport to a hospital.
All three protocols included mention of law enforcement involvement, but none discussed
how to coordinate with officers at the scene, when and whether to intervene on a patient’s
behalf, or that medical decisions are the exclusive province of the assessing paramedics.

Id.
Id.
376 Id.
377 Id.
378 Id. at 99.
379 Id. at 99.
380 Id. at 143.
381 The current protocol instructs paramedics to use Midazolam (Versed).
374
375

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10.3.2. National Ketamine Protocol Trends and Recommendations From
Medical Associations Conflict With the High Doses Permitted by
Aurora Fire’s Protocol
The National Emergency Physician and EMS Consensus Protocol considers administration
of ketamine at 5 mg/kg IM a “high dose” which is “associated with an increased
intubation rate.”382
In evaluating Aurora Fire’s Agitated/Combative Patient and ketamine protocols, we
examined ketamine protocols from rural, urban, and statewide regions across the United
States. We found many consistencies, including tiered intervention responses to agitated
patients and requiring documentation when paramedics administer ketamine. Most
protocols recommend requesting law enforcement assistance for combative patients.383
Many include medical monitoring protocols following ketamine.384 A few policies suggest
paramedics determine whether patients have been tased, which increases the likelihood of
cardiac arrest.385 Many protocols included a nuanced rating scale, such as the Richmond
Agitation Sedation Scale or the Altered Mental Status Scale to help paramedics assess
whether chemical interventions are indicated, and if so, which ones.386
The protocol survey showed that dosing recommendations for ketamine, however, are
inconsistent across the United States. For example,
•

Wentzville, Missouri (a suburb of St. Louis) and Minneapolis both permit initial
5 mg/kg ketamine doses.

•

The National Emergency Physician and EMS Consensus Protocol recommends a
dose of 3-5 mg/kg IM (intramuscular).387

Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement (Aug 27,
2020). The statement represents the collective consensus of The American College of Surgeons Committee
on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association
of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the
National Association of EMTs (NAEMT).
383 Policies from Connecticut; Houston, Texas; Kansas City, Missouri; Maryland; New York; and Wenatchee,
Washington recommend involving police when restraints are required. Minneapolis, Minnesota began a
review of police involvement in pre-hospital sedation and instituted several policies on officer interactions
with paramedics.
384 See protocols from Kansas City, Missouri; Pennsylvania; Portland, Oregon; New York; and Wentzville,
Missouri.
385 See protocols from Maryland.
386 Aurora’s newest protocol now includes the Richmond Agitation Sedation Scale. Exemplary scales and
explanations on how to assess a patient’s agitation are included in the protocols from Portland, Oregon;
Maine; and Pennsylvania. See also Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A
Joint Position Statement (Aug 27, 2020). The statement represents the collective consensus of The American
College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians
(ACEP), the National Association of State EMS Officials (NASEMSO), the National Association of EMS
Physicians (NAEMSP) and the National Association of EMTs (NAEMT).
387 Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient.
382

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•

The National Model EMS Clinical Guidelines and protocols in Albuquerque, New
Mexico; Connecticut; Flathead County, Montana; Maine; Maryland; Pennsylvania;
Vermont; and Central Washington limit ketamine doses to 4 mg/kg.

•

Miami and New York use a flat 250 mg initial dose.

•

Kansas City, Missouri; Portland, Oregon; and Houston, Texas do not permit
ketamine use for agitated patients.

The maximum dose permitted ranged from 300 mg to 500 mg. The survey revealed that a
5mg/kg dose, such as Aurora Fire’s protocol permits is at the highest level found in the
nation.
10.4.

Required Changes

Several stakeholders in Aurora have stated they do not plan to use ketamine in the future.
Before Aurora Fire uses ketamine or similar sedatives in the field, it must make these
changes.
10.4.1. Review Ketamine Dose Recommendations
The protocol for Aurora Fire Rescue and Falck Rocky Mountain instructs paramedics to
administer ketamine at 5 mg/kg. This dose falls at the highest end of national
recommendations. Medical directors should consider lowering the recommended dosage to
align with nationwide trends which limit ketamine dosage to 4 mg/kg or less.
10.4.2. Maintain a Uniform Method to Assess Patient Agitation
House Bill 1251 requires paramedics to record complications arising from ketamine use,
but protocols should also require detailed records of the symptoms supporting a
paramedic’s assessment that ketamine is necessary.
The new protocols now include the Richmond Agitation Sedation Scale, which is a
uniform method to assess the severity of a patient’s agitation, and requires paramedics to
document each patient’s scaled agitation level prior to using sedation. This is a substantial
step towards addressing this concern. Paramedics should be thoroughly trained in using the
scale to quickly assess whether ketamine is indicated.
House Bill 1251 requires medical directors to develop training for paramedics to ensure
their compliance with the new law. Frequent citing of psychiatric/behavioral causes for
excited delirium reflect that training is needed to help paramedics distinguish agitated states
caused by a choice to resist arrest, mental illness, intellectual disability, or other medically
less-dangerous situations from “a justifiable medical emergency.” Paramedics should be
given clear guidance on what constitutes an emergency requiring ketamine.
Current Aurora Fire protocols on coordinating with law enforcement are limited to
transporting handcuffed patients. As addressed above, Aurora Fire and Aurora Police
should develop a joint policy and training on effective coordination that includes the

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transfer of care and custody from officers to paramedics. House Bill 1251 makes clear that
paramedics alone should make medical assessments and decisions, such as if a person
becomes medically distressed and requires intervention or chemical sedation. But
emergency responders often turn to bystanders for clues on what might be causing a
patient’s medical emergency, and House Bill 1251 permits officers to provide pertinent
medical information that could help a paramedic assess whether the patient is experiencing
a justifiable medical emergency.388 The new Aurora Police policy on coordinating with
Aurora Fire lists the types of information officers should provide to paramedics.389 Joint
training is needed to ensure both officers and paramedics are comfortable requesting and
providing necessary medical information that complies with the new law.
10.4.3. More Stringent Review to Ensure Protocol Compliance
Because the use of ketamine can create life-threatening situations, Aurora Fire must engage
in rapid and thorough intervention when protocols are not followed. More stringent review
procedures are necessary to ensure that paramedics follow protocol dosing and conduct
complete medical monitoring during transport as required by House Bill 1251. To ensure
patient safety, Aurora Fire should conduct a Post-Incident Analysis for each ketamine
administration, create systems for addressing any violations of protocol or law, and develop
a formal method for evaluating chemical sedation over a period of months to catch
alarming trends.390
We observed several apparent policy violations in how Aurora administered ketamine.
First, records given by Aurora Fire to the Department of Public Health showed that 40%
of all ketamine administrations exceeded the maximum dose permitted by protocols.
Because Aurora Fire did not record all patient’s weights, we cannot verify how many
patients received an excessive dose. . But when the patient’s weight was recorded, the
excessive doses did not result from mis-identifying a patient’s weight.
Second, records also show that paramedics did not start required medical monitoring in
50% of administrations. Although some monitoring was reported in all but two instances,
incomplete application of the necessary monitoring protocols may place patients at risk for
complications. Coupled with the excessive dosing instances, the records reveal that more
than 60% of all ketamine administrations failed to follow existing protocols completely.
Third, Aurora Fire did not use a uniform method to assess the severity of a patient’s
agitation. The old ketamine protocol was indicated for “Adult patients with signs of excited
delirium where the safety of the patient and/or providers is of substantial concern.”391
House Bill 1251 bans the use of ketamine for excited delirium, but describes “a justifiable
medical emergency” authorizing ketamine as a “medical, traumatic, or psychiatric condition
posing an immediate safety risk to the individual, emergency medical service provider, or

National Registry of Emergency Medical Technician Patient Assessment.
Aurora Police Department Directive 09.06 (effective Sept. 7, 2021)
390 Aurora Fire Rescue Manual of Procedures, Policy 3.6 and 6.28.
391 Id. at 143.
388
389

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the public.”392 The law introduces an immediacy requirement for the safety risk which must
be part of any future ketamine protocol.
The old protocols did not include a scale for paramedics to rate the severity of a patient’s
agitation or combativeness. Without a uniform scale, determining the severity of a patient’s
agitation or the immediacy of any safety risk may differ based on who is conducting the
assessment. Improper ketamine administrations are more likely when paramedics must rely
only on individual judgment rather than judgment based on uniform assessment practices.
The new protocol addresses this concern, and the required documentation of a patient’s
agitation scale will help ensure patients meet criteria for sedation.
Fourth, failure to follow ketamine protocols, such as exceeding proper dosages or omitting
medical monitoring, did not trigger supervisory intervention and the medical directors had
no formal process to evaluate longitudinal trends which might have identified such failures.
The medical director’s waiver application included a plan to intervene with training if
paramedics did not follow ketamine protocols. But no interventions occurred during the
eighteen-month period despite a pattern of over-administering ketamine and under-using
medical monitoring.
Fifth, lack of documentation by Aurora Police of paramedics administering ketamine or
other chemical sedatives prevents adequate oversight into police and paramedic
coordination.
Aurora Police use-of-force reviews do not consistently include paramedics’ use of chemical
restraints on people in police custody. Lack of documentation or incomplete
documentation of these interactions makes it difficult for supervisors to address the full
spectrum of restraint on a subject. The lack of documentation also prevents review of
police and paramedic on-scene coordination.
Because both Senate Bill 217 and House Bill 1251 require detailed reporting on use-offorce incidents, and because House Bill 1251 identifies chemical restraint as a type of force,
Aurora Police must improve documentation of incidents that result in a paramedic’s
decision to sedate a person, even if no officer used any level of force during the encounter.
To ensure accurate reporting, Aurora Fire personnel should communicate to dispatch and
directly with the officer-in-charge on scene that chemical restraints were needed for a
patient. Aurora Police reports for such incidents must be shared with Aurora Fire. If the
chemical restraint occurred following police restraint or use of force, a joint review with
Aurora Police and Aurora Fire should be conducted to evaluate the agencies’ coordination
on scene and the care and custody transfer. Even if officers did not use restraint or force,
including the use of chemical restraints in general offense reports will enable leadership
from both agencies to evaluate the interactions, ensure accountability, and help identify if
training is needed to improve coordination and patient outcomes.

392

§ 25-3.5-103(8.6), C.R.S; § 25-3.5-209(3), C.R.S.

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11.

Facilitating Meaningful Reform

To ensure that the changes required above lead to real, meaningful improvements, we will
also require 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. This requirement includes providing transcripts or
public access for discipline hearings and deliberations on hiring and promotional
considerations whenever possible. When participants choose to exercise the option that
City Charter gives them for confidential procedures, the Civil Service Commission must
make the fact of the proceedings public and note that the individual chose to keep
proceedings confidential. The Civil Service Commission must publicly publish, on at least a
quarterly basis, a specific list of all proceedings where a participant denied public
participation.
Importantly, we will require Aurora, as a condition of any negotiated resolution, to have a
public assessment of the current structure of the Civil Service Commission and whether
changes to the city charter should be made to ensure that hiring, promotion, and discipline
review accomplish the overall goals of the city and ensure that Aurora Fire and Aurora
Police can quickly improve to meet the needs of the City.

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12.

Next Steps

Senate Bill 217 requires a negotiation period with Aurora so that the City and the Attorney
General can try to make these required changes part of a voluntary consent decree.393 We
want Aurora to succeed in these improvements and strongly believe that an agreement
provides the best way to do so. Initial conversations with Aurora Police, Aurora Fire, and
city management tell us they share that goal. We will work over the coming weeks with
Aurora and other stakeholders to create a consent decree that makes sure these
requirements are implemented promptly.

393

§ 24-31-113, C.R.S.

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13.

Acknowledgments

Our team included many professionals outside of our office who donated hundreds of
hours of their time. We thank them for their commitment to supporting this important
work:
•

Sundeep K. (Rob) Addy and Sean Grimsley of Bartlit Beck LLP

•

Dr. Theron Bowman of The Bowman Group

•

Mihir Gokhale, Peter Horvath, Michael Kwak, and Noah Mathews of Compass
Lexecon

•

Samantha Kappagoda and Dr. David K. A. Mordecai of Risk Economics

•

Wendy Olson of Stoel Rives LLP

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