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.


The FBI needs to be brought in to investigate this Civil Rights violation. Dr. Daisy needs to be criminally liable for starters. Please CCN, stay on this.


PLEASE tell me her name is not really “DAISY” . When complaints are filed someone must know her real name. Surely it cant be “Daisy”


We can all moan and complain about this tragic incident but there is a really sad reality when it comes to liability of law enforcement. Our sick in the head state legislators have all but given law enforcement absolute immunity from any consequences of their actions. So in reality, Parke and the rest of them really don’t give a rat’s ass if some inmate died. “Hey, they were a prisoner, they have no rights” is their sick mentality. I am sorry, but I trust zero law enforcement because they are all above the law not only in their mind but according to f’d up state law. I respect none of them.


One last thing I will say is that in defense of the County, they are overfull beyond the capacity and capabilities of the jail. With the prison re-alignment bill, inmates that historically would have gone to prison now sit in the county jail to serve out sentences. The jail was not built to keep people for long periods of time (and it is OLD). So, that’s one thing that makes it hard-the volume. Another issue is the Mental Health problem. There are so many inmates at the jail with mental health issues. Again, the jail was not intended to manage inmates that are actively acting out like the man in the story. Historically, they were transferred out. So for me, I would want to know the following:

1. Why was the inmate not transferred to ASH when ordered by the judge?

2. What is SLO County’s policy of the use of restraints and mobility limiting devices?

3. What is the staffing in the jail? How many deputies? How many RNs/LVNs? How many psych techs, MH staff?

I am not excusing SLO County. I think the administration knows the jail is woefully ill equipped to accommodate all of the inmates and their complex medical needs. Hopefully they are making the needed changes since this happened in 2015.


Mental Health services in this county provides jobs as its number one function.

The County mental health used the money that voters intended to help the mentally ill fund social programs that had nothing to do with mental illness. However, the social programs do provide more jobs. They’re all paper pushers and meeting organizers.


I am so sorry for this family and the ill young man who lost his life.

There is so much wrong here I don’t know where to begin. Anytime a person is placed in restraints such as this chair, ideally someone “sits” with them. At ASH, they have 1:1 assignments for patients/inmates such as this for everyone’s safety. Also, they are assessed every 15 minutes, checking circulation. As the article says, after two hours, the patient/inmate needs to be allowed to move/use bathroom so they DO NOT GET BLOOD CLOTS and also for the human dignity of not urinating/defecating on themself. The no clothing no blanket no warmth is an added level of cruelty. If this man was cold and dead after being released from restraints from 4:45-5:20, his core temperature must have been cold to begin with-like standing in a walk in refrigerator for 2 days cold.

The County doesn’t think they have enough $$ to pay for well trained and adequate staff for the jail. They need for MH and medical people and not the overabundance of Sheriff guards with no medical training. But it’s hard to find staff who will work for slave wages, and really it just takes away from Jeff Hamm’s 250k ++ pay and take away from Board of Sup’s raises.

The County had better quit giving Ian Parkinson $$$$$$$$ for golf course outpost Stations and start saving $$$$ for the lawsuits they will have to pay out. $15 million sounds low to me based on the torture, denial of appropriate medications, inhumane treatment for days.

The County needs to work on expanding the MH inpatient unit if it only has 16 beds and they are turning people away. Like I said, less police, more MH treatment. It costs more up front, but it will help prevent all the lawsuits. If this were my kid, oh the County would be beyond screwed….


Your description of the care for “patients” at ASH looks good. The big difference between the treatment for those at ASH and the County Jail is that the cost to care for the “patients” at ASH is around $220,000 a year per “patient.” What is the answer, besides money?


The bulk of the money is used for the paper pushers. There’s almost nothing left for the patients.


$15 Million award is my guess. $10 Million of that is punitive damages.


And $7-$9 million of that towards the attorney’s.




Does ANYONE really believe that ANY correctional person assigned to the county jail has the knowledge, understanding, education, or experience to deal with mental illness?????

The county jail is the punishment closet….not a care facility. Wake up people.


People are amusingly naive. The depth of darkness that is at play here is much more than one could fathom. “Who would DO THIS?” people ask. Why…..people who enjoy it, of course. Sociopaths are everywhere. And when they have the upper hand–it gets very ugly. Happens all over the world–every day of the year. Who would be so bereft as to not know this? And who would think SLO would be any different?


San Quintin death row has executed only 13 men since 1978. How many prisoners have died at San Luis Obispo County Jail? Ive been unable to find the complete statistics before 2012 but facts show the San Luis Obispo County Jail inmate death rate is higher than the US average according to a report filed in 2015. Two deaths in 2012 and three in 2014. Mr. Holland’s death brings the count to six in just five years. The San Quintin prisoners were all convicted murderers. Mr. Holland was murdered for being mentally ill. I hope Mr. Holland’s parents receive a huge settlement against Ian Parkinson’s department in the hopes of having sheriff Parkinson removed from his prestigious position.


The problem would be any settlement received would come from the taxpayers and not from Sheriff Parkinson’s department. Parkinson will suffer not real consequences for his actions, just like his DUI deputies.


He’ll be done, this and the Kristin Smart debacle.