Did county violations lead to Atascadero man’s death?

March 29, 2017

Carty (Andrew’s father) and Andrew Holland


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.

Man in restraint chair. Andrew Holland was also wearing a helmet during his time in restraints.

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.”

Sheriff Ian Parkinson

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.

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It doesn’t surprise me that counsel is asking employees for their personal cell phones. I would go to the union and would quit first.

I don’t know what is going on over there, but this young man’s death just should not have happened. He died because of prolonged immobility. How do they let that happen?

This is digusting that this happened to that man. Ian Parkinson should apologize and resign. The fact he hasn’t taken action shows his true character.

I agree with LA Rams. Also, dont let SLO county be a reflection for the whole area. People in north and south county are reasonable working people.

In a word…..YES.

I’m a law and order guy but looking at the picture of the guy in the chair makes my skin crawl. Somebody should pay for this and I don’t mean just taxpayers money!! also turn the heater on…

Let the finger pointing begin. Sheriff Ian Parkinson when will you terminate the monsters involved in this? If they work at the jail, they know the procedures. They all knew what was happening and did nothing to come to aid this man, not even a call to crime stoppers.

Who approved leaving this man in the chair for two days? Someone has to be responsible for this. It is not a solution to pay out a settlement to the Holland family and then pretend nothing is wrong at the jail.

Why not? that’s been Parkinson’s MO so far, why change it? It’s not like the payout will effect him, it doesn’t come from his budget, it’s only taxpayer money and there is always more, he just needs to scare more from the BOS.

SLO County jail serves old stale bread that they steam back to “fresh”. They serve rotten fruit, unidentifiable meat, cancer causing juice packets, etc.

I was once in the drunk tank and they had the temperature at 60 degrees. Upon asking for some blankets several times over the course of a few hours, the deputy placed 3 blankets in the cell with over a dozen inmates. When I got released, they became angry that I gave my blanket to another inmate. They became hysterical when I gave my food left overs to a transient as I exited the cell. They literally want to make you as uncomfortable and miserable as the law will allow. They joke and kid with their colleagues all day about this kind of thing. One deputy even sat in front of the drunk tank eating his Carls Jr lunch in front of the inmates with a shit grin on his face. This is just one of thousands of examples of what goes on out at Kansas Ave.

Parkinson should be ashamed to call himself a community leader. If only there was a way to clean house at SLOSD…

The Best Advise Is Not to be in the SLO County Jail system.. Call Dick Short .. CHP He will get you inside quick!

Right along the lines that I asserted in my post(s) in the first article…

When are YOU folks gonna get a clue? When the fuck are YOU gonna get tired of this kind of crap happening in YOUR community? When are YOU gonna hold these folks accountable? Don’t tell me it’s not YOUR job because we all know it is!

46 hours and fifteen minutes in that chair, naked?!! 36 hours without being allowed to use the bathroom?! No medical staff direct contact for further evaluation and or determination?! What the hell!!!

Your county jail and its staff are not only responsible to you they are a direct reflection of the morals and character of your community. Saying that and knowing the flack I’ve caught on this site for speaking out about this type of crap, my opinion is y’all don’t give one care about anything or anyone that isn’t some form of financial benefit to YOU! God forbid those who you see as a financial burden on YOU, because their fate in the same circumstances is all but sealed!

YOU are a bunch of elitist, entitled minded, privileged pieces of shit without a clue as to day-to-day life for the rest of us! Andrew Holland died because of YOU, all of those who suffered and or died before him was because of YOU and YOU are responsible DIRECTLY for any further shit like this happening in YOUR community!

Do somethin’ about it ya bunch of cowards!

Along with the “Community” ,you talk to the person in your mirror as well. Yes, You are within this group, and thus are admitting your own elitism, entitled minded etc without a clue.

It’s typical to confess as you did here.

You sound resoundingly like Adam Hill. But I agree with the anger and frustration. I agree with how DEVASTATING this is to our entire community, I Agree with the fact something must be done. SO, What time is the protest and where? The courthouse? The jail? Hamm’s office?

You can’t just pontificate here and then do nothing RamFan! Otherwise you are nothing but Hot air…and you know how badly that smells!

“The foolish and wicked practice of profane cursing and swearing is a vice so mean and low that every person of sense and character detests and despises it”

George Washington

I don’t want to sound like a prude or however, this will likely be portrayed but…. L.A.RamsFan: Your point would be taken more seriously if you did watch your language. You make some valid point but the expletives don’t help prove your points.

I’d say that 26 thumbs up votes L.A. Rams Fan got his fuckin’ point across pretty good. Cursing and all.

““If you can’t say “Fuck” you can’t say, “Fuck the government.”

― Lenny Bruce

Look back, look at all of your “socially acceptable” language used in the past with incidents like this and what do you really see in the form of progressive positive change? Absolutely fuckin’ nothin’!

You don’t take anything seriously in your little made up world until it comes knockin’ on your fuckin’ door(s)! Nothin’!!! While the likes of Andrew Holland die, families such as his suffer, you want to address my vulgarity? What a bunch of weak ass shit comin’ from a bunch of cowards.

Nah, LAH! I won’t be comin’ down to SLO anytime soon (can’t afford it! I live 600 miles away!)! And the main reason? Because folks like YOU don’t have the spine to do want it would take to change this kind of shit and would leave me hangin’ with my ass in the wind while you run the other way when things got uncomfortable! Yea, you would! It’s written all over your post! Grow a pair or shut up!!!

If you ever want to discuss this in real terms I’ll be glad to… I’ve got some real ideas that would institute some real change but you’ve got to show you have what it takes to get it done. Period!