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.


While not a fan of Velie or CCN, this was a decent article that has been long overdue… Disconcerting to see Cippola lie for his cruel and insensitive masters…


And my sincere condolences to the Holland Family. Im so very sorry your son died in this fashion. I hope his story will draw attention to this issue and something gets done so he will not have died in vain.


Why doesn’t KSBY local news report on things like this? What a corrupt Good Ol Boys county this is! Not that anyone really watches them anymore. Just another reason I dont have cable TV


Im going to back to my earlier remarks. The jail is a jail and not a hospital. The mentally ill due to the nature of their illness get arrested. (This is unfair, as we don’t arrest people with heart disease or diabetes.but thats another post) The jail in its current state and with its current resources is way outdated and has not kept up with the increasing population and increase in mentally ill. Its time we dig into our pockets and update the facility staff it correctly and put actual health care policies in place.


I hope the Holland family look into all that work at the jail and how they ended up working there. The county is really big on hiring LMFT’s to do jobs they dont have a CLUE on how to do. Check out Idee Shapiro and her history, and how she ended up working at SLO County jail. Am sure you will find out an interesting history.


If this man had been admitted to ASH as had been ordered by Judge Duffy, he would be alive today and getting treatment for his mental illness. Our mental health system is far from perfect but I do know that ASH follows protocols that ensure the safety and health of the patients there are a priority. SLO County has gotten away with so much horror and it really needs to stop. I hope the Hollands prevail in a lawsuit against the county and that the death of their son is not in vain but helps to bring about justice for people with mental illness in this county. Those with a mental illness have been discriminated against, and had their civil rights trampled on by law enforcement and it is time that the entire culture of how the mentally ill are treated is changed. .


Demand that the FBI look into this. It appears to me, and I’m no lawyer, that’s this man’s civil rights were violated. Fuck the SD! The FBI will come in and if the SD is at fault heads will roll!

Forget about the community doing anything consequential about this, they have no spine for the fight that would occur if they took a stand, so let the people who do have at it!


-Remember Andrew Holland-


Hey county supervisors! Yeah, I’m taking to YOU!

How dare you approve a $14 MILLION dollar expenditure on the animal shelter while people are DYING in YOUR custody for, according to county employees, a lack of resources.

How disgusting that this issue was not even discussed today.

Shame on you all.


As politician like to say: the optics are bad.


Wow after reading the second half of this , very Sad, Looks like the County dropped the ball big time.. I guess because the Holland’s are good people they are not on the radar..

This is very difficult to read , I moved out of the area a few years ago, I spoke to Carty.. I had not spoken to him in a few was like we spoke the day before.. I asked about his brother..

You know I think SLO county would rather chase after people for DUI, and small time people on drugs then help , the normal people .. If I did not know these people it would be much easier to say hey thats the system.. From what I read here, the Sheriff Dept. and mental health dept. blew it , the facts that the chair MFG does not recommend long term use , and the poor man had blood clots in his lungs..

Sounds to me like Big ego Cops, being big Ego cops.. one time 25 years ago I got a DUI , from a short CHP, this guy did every thing in his power to get me to fight with him.. business men do not fight , Officer Short, that was his name , ” Dick short ” that was his real name..

I’m sure Mr & Mrs Holland’s son being 36, limited the amount of say they had , and the Sheriff dept. did every thing in their power not to abide by the family wishes.. I see a huge law suit coming Thats the only way these people learn.. This beyond sad.. its sick..I hope more then a few get fired, Why does the sheriff need a hired clown mouth piece just for this I guess..


The Holland’s are STANDUP people with a long history in this county. Its too bad this had to happen. And even worse that it has to take people like them to get things done and possibly hold people accountable. Just think of all that have died having their life history fall on deaf ears! To the Hollands. I am so SORRY. May you kick the ass of those responsible! From the top to the bottom!


NO! YOU do NOT get to get away with this! THIS can NOT just be brushed under the rug. TONY TONY TONY, WHY LIE?? WE have trusted you! Now can we No Longer trust your words? It is NOT the Sheriff nor his co-horts job to Punish or decide, that is the JUDGES Job, Why wasn’t Andrew taken to ASH??? IF his meds were taken away or not working anymore, it was NOT his fault! HOW in God’s name can you torture him?

This can NOT happen again!! The Mentally Ill deserve to be treated with compassion, and this is NOT Going to be forgotten!!


At What point did you forget you were elected to SERVE US???

My heart cries for Andrew and his family!! But what now? What do we do as the Community to make sure this is not allowed to happen again?? What can we do to support the Hollands?

SLO Jail I have heard is bad enough for the non mentally ill.( I have never been arrested) but I have heard, the inmates are NOT given care. Several stories of how medications disappeared…we know now about that frieko Nurse stealing drugs did but what about now? ..How can they NOT provide good drinking water? I;ve heard HOW bad the Water is? enough to give throat infections?? NOT uncommon?? And refusals to see the DR. for antibiotics to treat it? Are they mandated to give care or NOT?

I understand they are criminals but Do they have a right to clean drinking water or NOT?

They Can’t even buy bottled water in the commissary?

WHAT can WE do to help facilitate the changes that are needed?


ok, Let me reiterate my rant….

“Sheriff’s spokesman Tony Cipolla said that policies and procedures are the responsibility of the county health department and not the sheriff’s department.”

What responsibility does the Sheriffs dept. hold in making sure JEFF HAMM does his job? Where are the checks and balances? Why if the BOS is aware have they NOT made sure the changes Jeff said happened actually happened?

Obviously someone is sleeping on the job here, and we are paying for his nap!

Truth Hurts

Jana. You seem to have good….no….great insight….thanks for bringing things to light. Definitely seems as if the honeymoon is over.