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$5 Million Settlement After Mentally Ill Prisoner Dies in Restraint

by Christopher Zoukis

A 36-year-old California prisoner with a documented history of schizophrenia died in a jail cell on January 22, 2017, less than an hour after his release from a restraint chair where he had been held for almost two days.

Andrew Chaylon Holland was the eighth person to die in custody at the San Luis Obispo County jail since 2012 – a mortality rate higher than the national average. Another death followed on April 13, 2017, when Kevin Lee McLaughlin, 60, suffered a fatal heart attack in a jail unit after a nurse dismissed his complaint of pain in his shoulder.

According to media reports and court documents, Holland faced multiple charges – most often for assaulting jail staffers – during the nearly two years that he was shuffled between the jail and the county’s in-patient psychiatric facility. He was found incompetent to stand trial four times, but on each occasion he was transferred to the psychiatric hospital, “restored to competency” and then returned to the county jail.

His mother, Sharon Holland, told the San Luis Obispo Tribune that her son “was kept in isolation a year and a half.”

A court order that Holland be transferred to the county mental health unit for treatment was issued 12 days before his death. It was never followed. Nor was the court’s order that he receive antipsychotic medication. According to a Tribune review of the coroner’s toxicology report, Holland did not have any antipsychotic drugs in his system when he died.

On January 20, 2017, Holland was observed by jail guards “striking and inflicting injury upon himself.” Instead of transporting him to the mental health unit, they decided to place him in a plastic seven-point restraint chair.

With straps around both ankles and wrists, as well as over the hips and both shoulders, Holland remained in the same glass observation cell where intoxicated arrestees are held until sober, within sight of guards manning the jail’s command center.

Holland was placed into the so-called “devil’s chair” at 6:55 p.m. on January 20, and released 46 hours later, at 4:43 p.m. on January 22 – by then covered in his own urine and feces. He died less than an hour later.

According to the coroner’s review of security video footage, Holland was seen lying naked on his stomach at 4:55 p.m., 12 minutes after being released from the chair. At 5:02 p.m., he showed visible signs of respiratory distress, and by 5:08 p.m. he was no longer moving. Jail guards entered the cell and attempted CPR, but it was too late. Holland was pronounced dead at 5:36 p.m.

The county’s contracted medical examiner, Dr. Gary Walter, listed the cause of death as an intrapulmonary embolism, likely caused by a 5-centimeter blood clot found during the autopsy. According to the National Institutes of Health, that type of embolism usually begins as a clot in a leg vein before traveling to the heart, and can be caused by long periods of sitting. Dr. Walter, whose license to practice medicine was under review by the California State Medical Board due to a DUI conviction, determined that Holland’s death was “natural.” Walter was replaced as San Luis Obispo County’s coroner in September 2017.

Sheriff Ian Parkinson defended the actions of jail staff, as well as Dr. Walter’s finding that Holland’s death was “natural.”

In response to questions from the Tribune, Sheriff Parkinson said that even though Holland’s “seated position, dehydration, and self-inflicted injury were all possibly contributory to the cause of death, the formation of the intrapulmonary embolism was a natural response in the body.”

He did not elaborate as to how such a natural response developed during the almost two days that Holland was strapped into a restraint chair – an unnatural position.

“Calling Andrew Holland’s death ‘natural’ is like saying drowning is a natural death even though the decedent was held under water by another person,” Paula Canny, the attorney representing Holland’s family, told the Tribune. She added that blaming Andrew for his own death was “despicable.”

“Andrew Holland suffered from a well-known and well-documented mental illness,” Canny stated. “Placing a mentally ill person in a restraint chair for 46 hours is dangerous and cruel.”

She also claimed that jail staff violated a state statute by using the restraint chair as a “substitute for treatment.” California law states that if a prisoner cannot be safely removed from restraints such as the chair within eight hours, “the inmate shall be taken to a medical facility for further evaluation.” County policy further says that prisoners may not be held in restraints for extended periods without approval from managerial staff at jail facilities.

An investigation by the Tribune revealed that the jail was also in violation of rules published by California’s jail accreditation agency because it was holding restrained prisoners in the same “sobering cell” used to house intoxicated arrestees.

According to a spokeswoman for the Board of State and Community Corrections (BSCC), which uncovered the violation, there was no evidence that the jail had corrected that deficiency. A BSCC inspector told the Tribune it was “not uncommon” for jails to fail to correct such violations, since compliance with the rule is voluntary.

When asked how the agency regulates violations when compliance is voluntary, BSCC spokeswoman Tracie Cone stated, “You have asked the perplexing question of our existence.”

“The only remedy,” she added, “is a lawsuit.”

Andrew Holland’s family filed a wrongful death suit, and despite the medical examiner’s finding that Holland’s death was “natural,” San Luis Obispo County quickly settled the case for $5 million in July 2017. All but $10,000 of the settlement funds came from the county’s medical malpractice insurance. The Holland family plans to use the settlement to start a foundation in Andrew’s name; they also called on Sheriff Parkinson to resign.

In April 2016, the county’s Public Health Department Director, Peggy Borenstein, admitted that the jail’s medical facility “had not been fully staffed over the last 10 years.” An inspection at that time revealed guards without any medical training were providing medical screenings to detainees. Even when a prisoner was diagnosed with a mental health issue, the county’s mental health facility was often at capacity and unable to accept additional patients – again due to understaffing.

When announcing the settlement for Holland’s death, the county said it had instituted new policies to limit the amount of time prisoners can be held in a safety cell to 72 hours. Further, the use of restraint chairs at the jail was discontinued and the sheriff’s office was increasing communication with staff at the county’s health agency. 



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