An independent investigation has found that authorities in Aurora, Colorado were at fault in the case of Elijah McClain. According to the study, police officers and paramedics made a series of mistakes that led to the 23-year-old Black man’s death in 2019.

A panel of medical and legal experts appointed by the Aurora City Council released a report on the investigation’s findings on Monday (Feb. 22). In the report, investigators found that police had no reason to stop or forcefully detain McClain. Paramedics also sedated McClain with ketamine “without conducting anything more than a brief visual observation,” the report adds.

Police stopped McClain on Aug. 24, 2019 while responding to a call about a suspicious person in the area. When police stopped McClain, “none of the officers articulated a crime that they thought Mr. McClain had committed, was committing or was about to commit,” the report reads. According to the findings, “this decision had ramifications for the rest of the encounter.”

After stopping McClain, police detained him in a chokehold. Investigators said they did not find sufficient evidence to justify cops’ pat-down search, adding there was no evidence that suggested McClain was “armed and dangerous.”

“The panel also notes that one officer’s explanation that Aurora officers are trained to ‘take action before it escalates’ does not meet the constitutional requirement of reasonable suspicion to conduct a stop-[and]-frisk,” the report added.

Later, paramedics injected McClain with ketamine because authorities allegedly believed him to be in a state of excited delirium. Investigators found that paramedics gave McClain too much of the sedative. The dosage that McClain received was meant for a man weighing 190 pounds, while he only weighed 140.

“Aurora Fire appears to have accepted the officers’ impression that Mr. McClain had excited delirium without corroborating that impression through meaningful observations or diagnostic examination of Mr. McClain,” the report noted.

“In addition, EMS administered a ketamine dosage based on a grossly inaccurate and inflated estimate of Mr. McClain’s size. Higher doses can carry a higher risk of sedation complications, for which this team was clearly not prepared.”

McClain lost consciousness after the incident and was tragically taken off life support on Aug. 30.

Investigators stopped short of accusing the officers and paramedics of “implicit bias,” claiming they had “insufficient information to determine what role, if any, bias played” in McClain’s death.

“However,” they noted, “research indicates that factors such as increased perception of threat, perception of extraordinary strength, perception of higher pain tolerance and misperceptions of age and size can be indicative of bias.”

The Aurora City Council is set to meet today at 5 p.m. local time to discuss the findings. In the past, fire department and EMT officials claimed paramedics’ actions on the night of McClain’s death were “consistent and aligned with our established protocols.”