Parents say their mentally ill son was tortured and killed in county jail

February 25, 2017

Carty and Andrew Holland


Editor’s Note: This is part one in a two-part series about the death of Andrew Holland and the San Luis Obispo County Sheriff’s Department’s use of restraints and safety cells.

Andrew Holland knew he could not always control his schizophrenia, but he tried to explain his sometimes erratic behavior to guards at the San Luis Obispo County Jail. Following a psychotic break on Jan. 20, deputies strapped Holland naked in a restraint chair where he remained until shortly before his death, two days later, according to jail records.

While in restraints, blood clots formed in the 36-year-old man’s legs. Upon his release, the blood clots traveled to his lungs causing a pulmonary embolism and his death, according to a preliminary autopsy report. Holland’s parents say they believe sheriff deputies tortured and killed their 36-year-old son.

“I do feel like my son Andrew didn’t just die at the county jail, he was killed, said Sharon Holland, Andrew Holland’s mother. “He was not the first person with mental illness whose life has been taken there, and if something doesn’t change, he will not be the last.”

County employees, who requested anonymity because they fear retaliation, said that mentally ill inmates and patients are regularly mistreated and neglected by county staff. The mistreatment includes long-term isolation, incorrect medications and failure to provide adequate health care, the employees said.

After suffering a mental health episode in San Luis Obispo on Sept. 30, 2015, police arrested Holland for resisting arrest and battery of a peace officer. Instead of transporting Holland to a mental health facility as is protocol in many California counties, officers booked him into the county jail where he was permanently placed in isolation.

Several months ago, Holland’s parents pleaded with jail medical staff to allow their son to take the psychiatric medications that work for him. However, at the jail, medications are not chosen because of effectiveness, but the cost, sources said. Upon arrival at the jail, psychiatric technicians select which medications to give their mentally ill charges, and then county physicians sign the prescriptions, sources said.

As a result of being abruptly taken off their usual medications, many mentally ill inmates at the jail spiral downhill. Inmates complain of seizures and psychotic breaks as their bodies attempt to adjust to their changing medications.

For Andrew Holland, his problems with medications and a lack of psychiatric treatment appeared insurmountable. During a year and a half in isolation, Andrew Holland suffered several psychotic breaks that led to additional charges lodged against him for battery of a custodial officer.

On Dec. 30, guards took Andrew Holland from his isolation cell, stripped him down and threw him naked into a small concrete cell with rubber padding, no bedding and a hole in the floor for his waste, according to jail records.

On Jan. 10, San Luis Obispo County Superior Court Judge Jacqueline Duffy ordered the sheriff’s department to transfer Holland to Atascadero State Hospital (ASH). He was not transferred.

For years, the mentally ill have languished in the jail even though the court has ordered the sheriff’s department to either transfer the mentally ill inmates to ASH or the county’s psychiatric facility in San Luis Obispo.

The San Luis Obispo County Jail is run by Sheriff Ian Parkinson and houses about 600 inmates per day. The county health department, led by Jeff Hamm, is charged with the medical and mental health care of the inmates.

Under Hamm’s leadership, the county mental health facility on Johnson Avenue has refused to admit more than a few mentally ill transfers from the jail at a time claiming the mental health facility is at or above its 16-bed capacity.

However, in 2016, the county mental health facility was never at capacity and at times housed only two or three patients, according to the facility’s daily log sheets acquired by CalCoastNews through a public records request.

On Jan. 14, deputies moved Holland out of the rubber room and back to his isolation cell. Isolation that his family believe helped feed his psychosis.

“Andrew was kept in isolation for a year and a half,” Sharon Holland said. “Strapping him in a chair for 48 hours would be torture. If he had been at Woods Humane Society, he would have been treated with more compassion.”

At 5:40 p.m. on Jan. 20, guards spotted Holland punching himself in the face. Inside his cell, guards discovered Holland had blood on his face, chest, hands and legs as well as feces smeared on his hands and legs, according to jail records.

At approximately 6:30 p.m. on Jan. 20, guards transferred Holland to the drunk tank and strapped him naked into a restraint chair, dubbed the “devil’s chair” by critics. In the hard plastic chair, detainee’s ankles, legs, abdomen, chest, wrists and arms are strapped down.

Restraint chairs are intended to subdue violent detainees for a short period of time. Manufacturers warn of the dangers of pulmonary embolism if a person is detained in the chair for an extended period of time.

“Detainees should not be left in the Safety Restraint Chair for more than two hours,” according to Safety Restraint Chair Inc., a manufacture of restraint chairs. “The Safety Restraint Chair should never be used as a means of punishment.”

Though medical staff at the jail attempted to have Holland transferred to the county’s psychiatric facility, on Jan 21, Dr. Daisy Illano claimed the facility was full and denied a transfer. However, according to the daily logs, on Jan 21 there were beds open at the county facility.

For two days, Holland remained strapped in the chair, covered in urine and feces, and not permitted to leave the chair even to use the bathroom.

On Jan. 22 at 4:45 p.m., after restraining Holland in the “Devil’s chair” for more than 46 hours, guards released the straps, but left Holland in the frigid drunk tank without a bed or clothing, according to jail records.

Less than an hour later, at 5:20 p.m., guards noticed Holland lying motionless on the floor. A few minutes later, guards rolled Holland onto his back and discovered he was pale and cold to the touch, records show. The guards then initiated CPR.

At 5:30 p.m., an ambulance with medics arrived at the jail. At 5:36 p.m., lifesaving efforts were stopped and medics pronounced Holland dead, according to jail records.

When Holland’s naked body was removed from the drunk tank on Jan. 22, he had scars on his left wrist, bruises on his arms and legs, a swollen nose and dried blood and feces on his body, according to jail records.


Shortly after Holland’s death, the sheriff’s department sent out a press release that drastically contradicts custody records and a preliminary autopsy report. In his release, sheriff department spokesperson Tony Cipolla paints a picture of a detainee who died mysteriously without any bruising or marks on his body.

Sheriff Ian Parkinson

In the Jan. 22 press release, Cipolla claims Holland was under the care of a physician at the time of his death. However, according to Holland’s chart, while Dr. Illano spoke with jail staff over the phone, she did not examine Holland.

“Holland had been under observation and was monitored and checked approximately every 15 minutes,” the press release says.

But, three or more hours often passed between jail staff assessments of Holland, according to county records.

“Custody staff and jail medical staff immediately provided emergency lifesaving attention, including the use of an automatic electronic defibrillator (AED), however staff was unable to revive him,” the press release says.

Even though jail staffers hooked Holland up to the AED, it was never used to shock Holland’s heart because it was determined Holland was no longer receiving electrical impulses from his brain. The defibrillator requires that the heart is receiving electrical impulses in order to be effective, sources said.

In addition, Cipolla noted that Holland’s body showed no signs of trauma.

“There were no outward signs of trauma on Holland’s body,” Cipolla wrote in the press release.

However, Holland died with scars, bruising and swelling on his body, according to Holland’s chart and a preliminary autopsy report.

Neither Cipolla nor Sheriff Ian Parkinson answered questions about why the court order to transfer Holland was not followed or why there are discrepancies between official records and the department’s press release.

“Since this is an ongoing investigation, the sheriff’s office will not be releasing any further details about this case other than the information that was previously provided,” Cipolla said.


San Luis Obispo County Jail has now carried out more death sentences than San Quintin’s death row. Congratulations Ian.


He is too busy modeling at Phyllis Madonna’s fashion shows. Narcissistic puke that he is.


Why didn’t the parents bail their child out of jail and care for him? There has to be more to this story. The system obviously has it’s problems although the system is to be blamed more than individuals.


The judge ordered the man to be transferred to ASH. My guess is that this man was still considered a danger to himself because he was not properly medicated and therefore acting out. The article states he was never transferred, and it does not state a reason. County does have an inpatient MH facility, but they will not take patients if they are at their capacity. Having nowhere to take this man, he mostly likely HAD to be detained at jail, since the jail could not send him anywhere. So my point is this: it might be that the family was not given the option to bring him home.


From personal experience, I can tell you that a court order is only as powerful as those who choose to follow it. The supervising medical officer at the county jail does not have to follow that court order if he or she sees deems it unnecessary to the well-being of the patient. I know, it’s happened to me…

I was beat down by seven Orange County Sheriff’s Deputies for smoking in a restricted area, something I’ve never done (smoking). I was beaten on for over ten minutes in a vestibule between tanks in the old county jail (550 N Flower St., Santa Ana), on the 3rd floor between C and D tank. I was then put naked into the hole, without a mattress or blanket and made to lie on a concrete slab. I was left that way! The very next day my attorney showed up for a scheduled visit and I was brought down from the hole. He freaked at my appearance. He became angry after I disrobed (I was given a red jumpsuit for the purpose of the visit) and showed him the real damage to my kidney area, my back and legs. He took off and called the Presiding Superior Court Judge of Orange County, at that time I believe it was a Judge Cardines. That judge signed a court order to remove me IMMEDIATELY from the custody of the OCSD into the custody of the Santa Ana PD for the purpose of transport to the Orange County Medical Center for a medical exam and treatment. That court order was refused by the supervising medical officer of the county jail at that time. I didn’t see a doctor again until my five (5) day hole stint was over. The doctor I did see after five (5) days? The supervising medical officer of the jail. His explanation to me on why I wasn’t transferred as ordered? “That court order isn’t valid until I determine there is sufficient cause for your transfer, something I don’t see.”

I was very fortunate. The blood in my urine stopped after a day or two, the blood in my stool only happened once and nothing was broken. I was also the partial focus of an FBI investigation into OCJ, one that found years of this type of abuse with some causing death (very well publicized if you care to read about it).

I went to prison. I went to prison for petty theft with a prior (I stole a tire from a car). I received a two (2) year sentence. I should have never gone to prison, I should have walked out of jail a free man with some of the counties money in my pocket. Why I didn’t? Because I had no support system on the outside and a dump truck public defender that saw me as a hindrance to his “good” relationship with the DA’s office.

I understand you folks being afraid of the police, I do! I know the kind of retribution they can inflict on those that they see as a threat, the kind of retaliation that they are prone to use if you cross one of their cartel members; they can be as bad as any gang out there in their ways of giving out pay-back if crossed and all under the cover of law! Shit! It’s a bitch!

What you have that I didn’t? NUMBERS! Combine that with the type of coverage CCN gives this type of shit and you CAN effect change, you fuckin’ can! Just get off your dead asses and make it known you won’t stand for this shit in your Sheriff’s Office, a department that is suppose to reflect the values of YOUR community!

CCN has done its job and will continue to do so with follow up and this continued “series” of reports, BUT, you, the community, are responsible for any change that should occur afterward.

Do somethin’ good, somethin’ that can only be positive for all of your community! Make every effort you can to see that Andrew Holland didn’t die in vain and that his family isn’t left with one answer left unanswered while holding everyone accountable that should be. That’s your fuckin’ job!!!


Sorry… “one question left unanswered” is what it should have said…


The parents could NOT bail him out because he was under a court order to go to Atascadero State Hospital! This is so very HEARTBREAKING. I could barely look at the photo of his father and him. People at the county need to be held accountable! Really people!!! How many deaths is it going to take? Has anyone contacted NAMI? Why isnt this national news? Jeff Hamm needs to be gone, Ian Parkinson needs to be gone, Dr. Daily Ilano needs to be gone!!!!!


Correction “Daisy Ilano” (If that is really her name. Who names their kid “Daisy”?


LMFT Idee Shapiro. Who is a supervisor at the jail needs to be held accountable as well.


I’m not sure what went on , but Carty see’s all the angles he is a thinking man.. He is will speak his mind … every thing will come out… in due time I’m sure.. If you Know Carty , things were done for a reason.. He is very honest.. I’m sure he protects his family as well as expects them to stand on their own two feet..

Some mental people are a handful, and I’m sure in many cases ,what is it now .. happenes..The truth will come out.. the city ,county.state has a responsibility for peoples safety they have in their control ..


Dr Daisy Illano has blood on her hands as does her second in command Judy Vick. I hope this family goes after those two! How can this be a Sheriff-Jail issue when Dr Illano refuses patients?


Judy Vick has knowingly approved mistreatment.


You might want to look into who is actually in charge of the inmates that are ordered to ASH or SLO County Mental Health from the jail. And it is NOT Judy Vick. although she is another LMFT that was transferred due to her incompetency. (That is how the county works) Dont do your job? Useless in your current position? No problem…we will just transfer you. And if you have been really bad you have to go work at the jail!


This woman is USELESS! She is there to collect a paycheck and only that. She only cares about covering her own ass. It is no secret within the county that she is USELESS, UNCARING, and INEPT. When will this all end? When will people finally be held accountable? If ever?


Talking about Dear “DAISY”


Judy Vick is useless too!!! Justify her 6 figure salary please SLO County Mental Health!!!


No justification.






Cipolla doesn’t care . He is as USELESS as that TV station he used to work for here. You know KSBY, the local station that doesn’t have the balls to cover something like this. Just another PUPPET.


SO TRUE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!A failed newscaster on the county $$$$


Dirty pigs. Time to fire them all.


The restraint chair highlighted in this article is very seldom used for “protection” for either the restrained or those in charge of his or her care. The are predominately used for disciplinary purposes in the jail and prison setting. More often than not a person is strapped in and left without supervision or any type of scheduled check-ups to see if the person has calmed down or if the restraints are still properly placed. They are mechanical “babysitters”, nothing more and nothing less.

My experience is at the prison level and from other county jails and I cannot speak with any authority about SLO County Jail. I will say this though, if the staffing levels are as low as SLOCSO says it is at the county jail then in my mind that chair is used predominately for the purpose I described in prison and other county jail use.

I don’t know how many times I’ve heard correctional/custody staff tell a person restrained in one of those modern day torture chairs they’ll be back in 1 hour to see if they’ve calmed down and continually make that time longer each time they check even if the person is completely at ease. I don’t know how many times I’ve heard correctional/custody staff berate a person over their actions that got them in it and remind them it will be used again if they choose to act out anymore. And the one thing that disturbed me more than anything was how correctional/custody staff used this thing on a graduating scale; clothed, to partially clothed to butt ass naked and most times in a wide open area for all the world to see! I’ve seen persons urinate and defecate on themselves in that chair and I’ve seen correctional/custody staff throw cold water, spit on and physically assault persons confined in that chair!

It’s time we take these draconian punishments and toss them out.

Mr. Carty, for whatever it’s worth I am sorry for your loss, I truly am.


So you worked in a Prison and have stated: “I’ve seen correctional/custody staff throw cold water, spit on and physically assault persons confined in that chair!

It’s time we take these draconian punishments and toss them out.”

I’m curious, were you helpless to HELP and or REPORT the ABUSES you saw ?

Or did you remain SILENT?


Take a minute and read a few of my former posts and you’ll discover I’m at the complete other end of the spectra…

No, I wasn’t completely helpless to help or to report, no the problem was is that folks like you, Rawhide, wouldn’t give me the time of day let alone at least the benefit of the doubt when I did, and I did!

As I have said in the past, you, Rawhide, will not listen to those of us who have direct personal experience in these type of things! Even worse? You, Rawhide, would even go so far as to discredit me by calling me a liar without one wit of concern for the truth.

I’m a convict Rawhide… Bet that just chaps your hide!


You stated, “My experience is at the prison level and from other county jails.”

I went off you post…

Sorry I thought you worked in a Prison…

You are a “Convict” and I’ll keep that in mind.

Seems U have a lot of HATE built from your response.

By the way, “Nothing “chaps my hide.”


See, implying I have “hate” built into my response is just another way of discrediting what I have to say.

It’s not hate, not one bit! It’s real life experience that most just dismiss offhandedly (mixed with some well-fertilized anger).

I will say this, most of that abuse I witnessed and experienced was at the county jail level. That should chap everyone’s hide and law enforcement takes it for granted that it doesn’t and they act accordingly!

Andrew Holland’s death is the direct result of community neglect, pure and simple! This kind of shit has been going on for decades! Decades of apathy from the community has not only made it acceptable but the norm’ for this man and those like him to die in custody. It also is a direct result of not having enough mental health beds in the community, another result of the apathy shown by the community towards the mentally ill! And please don’t say it isn’t, you show it every time one of you shout out against those homeless folks with mental health issues, those with service animals you so quickly identify as “comfort dogs” and “security blankets” and the ton of other disparaging remarks you make towards anyone not in the “norm'” of SLO’s right-leaning thought process!

You want to stop this kind of fuckin’ inhumane treatment and death? Do you really? I doubt it!!! It’s just another thing you can BITCH, BITCH and BITCH about without any real involvement. Sit back, wring your hands AGAIN and like always do no real meaningful actions and it will happen again! Who cares, it’s just another sick mother f@##@ who dies! Less we have to pay for…

The community is a bunch of weak ass keyboard commandos that LEO’s know won’t do a damn thing about anything that they do wrong. Prove me wrong!!!!


One more thing to consider, something I’ve commented on before….

The community picks and chooses its fights, mostly hinged on the perceived value of the person and or issue they choose to fight for. SLO has shown that the mentally ill have no value to them while they’ll gather in the hundreds to support a fight against the corrupted SLO CPS when Karen Velie lost her grandkids to that bunch of idiots! Why is that? I know why and you do as well! It’s time for a gut check people, one that includes all of us as worthy of support and demonstration if wronged.

There should be hundreds if not thousands of you down at the county jail and the Sheriff’s Office RIGHT NOW demanding not only answers but change overseen by you, the community!

‘nough said…




If a stray dog were treated in this manner the community would be up in arms. Ian Parkinson continues to fail miserably at managing his department and should be held accountable for it’s unchecked violations and rising body count. Sheriff Parkinson’s job is oversight, which there seems to be none. At what point does it become incompetence or even murder? How many more deaths will it take? Why has there been no investigations when unnecessary avoidable deaths continue to rise under Parkinson’s watch? Tony Cipolla seems to be a student of the Kellyanne Conway school of alternative facts. The out right lies maintained by the department show a measured deliberate attempt to cover up Mr Holland’s and others deaths. Parkinson needs to be held accountable. Ian’s main concern seems to be personal appearances & photo ops, never missing a chance to show his sincere dedication to teeth whitening.

Kaiser Bill

Parkinson has no business running a Sheriff’s Department and County Jail. Parkinson had not led any Lew Enforcement Agency when he was elected Sheriff. Parkinson won because he had SLO city money backing him due to Parkinson being a native son, and Parkinson promised to promote from within the SLO Sheriff’s Department. The result has been this trainwreck, as the redneck good ole boys at the County Jail continue to sit on their butts and eat their yogurt instead of working and preventing tragedies like this.


Charges should be filed and licenses should be revoked. This sort of nonsense has no place in 21st-century America.


Who in the hell would give that a down vote?


I was wondering the same thing as you {givemeabreak}.


That whole SLO Sherriff staff (the complicit ones anyway) needs to be fired and held accountable for their history of cruelty.

Its not a one off incident, it’s a pattern.

That incarceration worthy for the alleged officers of the law.


Agreed. The investigation has to be from an entity outside the usual local political CYA network. And that includes state representatives and employees.

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