Did county violations lead to Atascadero man’s death?

March 29, 2017

By KAREN VELIE

Editor’s Note: This is part two 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. Part one looked as Holland’s arrest, incarceration and death.

The death of a 36-year-old man at the San Luis Obispo County Jail is stirring debate over the treatment of the mentally ill while in county custody and raising questions about who is responsible for a failure to follow safety procedures.

State laws and sheriff department policies and procedures are supposed to regulate the treatment of those in restraints at a county jail. Nevertheless, it appears multiple rules and regulations were violated in the treatment of Andrew Holland, a mentally ill man who died in January after being restrained for two days in the San Luis Obispo County Jail.

On Jan. 20, deputies discovered Holland hitting himself in the face. Deputies then 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.

State laws and county policies and procedures regulate the usage of restraint chairs. But in the case of Holland, it appears the county sheriff’s department failed to abide by county or state regulations in their treatment of Holland.

“Restraints shall not be used as punishment, placed around a person’s neck or applied in a way that is likely to cause undue physical discomfort or restrict blood flow or breathing,” according to the sheriff’s department policy and procedure manual.

In 2016, SLO County Sheriff Ian Parkinson adopted policies and procedures that limit inmate confinement in a restraint chair to 12 hours.

Nevertheless, sheriff deputies left Holland strapped in the restraint chair, and not permitted to leave the chair even to use the bathroom, for more than 46 hours, according to jail records.

SLO County Sheriff Department procedures and policies and Title 15 require that a qualified medical professional physically check on an inmate held in a restraint chair within four hours. However, according to Holland’s chart, while a county physician spoke with jail staff over the phone, she did not personally examine Holland.

“As soon as possible, but within four hours of placement in restraints, the inmate shall be medically assessed to determine whether he/she has a serious medical condition that is being masked by the aggressive behavior,” according to the sheriff’s department policy and procedure manual. “The medical assessment shall be a face-to-face evaluation by a qualified health care professional and shall recur once every six hours of continued restraint thereafter.”

In addition, deputies are required to move the arms and legs of a person held in a restraint chair every two hours for ten minutes to help prevent blood clots. Deputies are required to note each time they check on the restrained person in a log.

During the 46 hours and fifteen minutes Holland was restrained, there are only three notations in the jail logs of deputies unstrapping and moving Holland’s extremities.

“Staff members shall conduct direct face-to-face observation at least twice every 30 minutes to check the inmate’s physical well-being and behavior,” according to the sheriff department’s policy and procedure manual. “Restraints shall be checked to verify correct application and to ensure they do not compromise circulation. All checks shall be documented, with the actual time recorded by the person doing the observation, along with a description of the inmate’s behavior. Any actions taken should also be noted in the log.”

In the six years since Ian Parkinson was sworn in as sheriff, 10 people have died while in San Luis Obispo County Jail custody, twice the number who died in the prior six years, according to the California Department of Justice.

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. While Holland was strapped in the restraint chair, county mental health official refused to transfer him to the psychiatric unit, according to jail logs.

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 and does not permit law enforcement to directly transport the mentally ill to the jail, Hamm said noting that it was an oversight that has since been corrected.

As a result of Holland’s death, county jail and mental health staffers, who have asked to remain unnamed because of concerns of retaliation, said they have been grilled by county human resources personnel seeking to find out who is talking to CalCoastNews. In addition, supervisors have ordered some employees to turn over their personal cell phones to the office of county counsel, sources said.

In a press release, the sheriff’s department said that at the time of his death, Holland was under the care of a physician and asked reporters to contact county mental health if they had questions about his death. Several county officials said Parkinson is blaming county mental health officials for Holland’s lengthy placement in the restraint chair.

However, sheriff department personnel made the determinations to place Holland in the restraint chair, leave him in the chair for two days and to release him without medical clearance.

In addition, Hamm said the county health department does not use restraint chairs in their treatment of the mentally ill.