Note to readers: This story contains graphic information.
After releasing an inmate who'd been bound naked in a restraint chair for 46 hours, sheriff's deputies at the San Luis Obispo County Jail watched as the man writhed on the floor, lost consciousness and later died, video obtained by The Tribune shows.
The footage contradicts county officials’ version of events leading to the death of inmate Andrew Holland in January 2017.
The Atascadero resident was pronounced dead on the floor of his holding cell at 5:36 p.m. on Jan. 22, 2017, roughly one hour after he was released following nearly two full days strapped to a plastic restraint chair, The Tribune’s review of more than 100 hours of jail surveillance footage confirmed.
The county's medical examiner ruled Holland's cause of death as "natural" due to an pulmonary embolism, when a blood clot in his leg traveled to his lung.
The video from that day shows deputies watching from outside the cell as Holland writhes on the floor, struggles to breathe and loses consciousness. Some deputies are captured laughing at several points throughout the footage.
Contrary to the county's account of the incident, the video shows that Holland wasn’t “found unconscious and unresponsive” and was not “under the continual care of a physician” at the time.
In an email Thursday, County Administrative Officer Wade Horton called the video "extremely painful to watch."
"What happened to Andrew Holland was a tragedy that impacts our entire community," Horton wrote. "Although we can't bring Andrew back, our county has made and continues to make changes in response to this terrible event."
Such reforms Horton listed include banning the restraint chair, hiring a independent contractor to audit county procedures, and adopted the Stepping Up initiative, a sweeping plan that reduces the number of mental ill in the jail.
In July, Holland’s family was awarded a $5 million settlement from the county, which it is using to form a nonprofit to advocate for the mentally ill caught in the criminal justice system.
The family declined to comment for this article.
Since January 2012, 12 inmates have died while in custody at the jail, nearly three times the latest national average.
In August, San Luis Obispo County denied The Tribune and other media outlets’ public records requests for the Sheriff’s Office’s video of Holland’s time in the restraint chair. The requests were rejected due to medical and personnel confidentiality as well as jail security issues.
Sheriff Ian Parkinson in August acknowledged that the county bears some responsibility for Holland’s death, but Horton would not answer Thursday whether any county employee has faced discipline over Holland's death.
How Andrew Holland died
Holland, 36, had suffered from schizophrenia since his early 20s and had been in and out of County Jail on low-level offenses.
He was last booked into the jail Sept. 30, 2015, for battery, resisting an officer and probation violations.
According to court records and his family, much of his next 15 months was spent inside a cramped isolation cell with just enough room for a thin mattress, toilet and sink as his court cases progressed and he continued to have scuffles with jail staff.
Jail video shows Holland striking himself in the face while sitting on his bed in the isolation cell around 6 p.m. on Jan. 20. Blood can be seen pooling on his mattress.
At about 6:30 p.m., a group of riot-armor-clad deputies and what appears to be jail medical staff transport a naked Holland face-down on a gurney to the jail’s main intake area and into a glass-door cell used to house intoxicated inmates.
Five minutes later, Holland is strapped into a plastic restraint chair.
He is left there for nearly two full days, with deputies and medical staff entering the cell every 1 1/2 to 2 1/2 hours to rotate his arms and legs and offer him a cup of water and food.
It is not clear from the video whether they offered him food and water every visit, but Holland is never allowed out of the chair to use the toilet.
According to county policy, staff is required to rotate an inmate’s extremities to prevent blood clots from forming. Blood clots have the potential to form an embolism, which can be fatal. They can be caused by extended sitting or lying down.
After spending 46 hours in the chair, at about 4:30 p.m. on Jan. 22, Holland is transported by jail staff into a neighboring cell, where he is released and left lying naked and alone on the floor with a thin blanket beside him.
After a few minutes, Holland begins to roll around on the floor as he struggles to breathe. At about 5:09 p.m., as many as six deputies gather outside the cell door and watch as he rolls onto his back and his arm falls limp — his eyes open and lifeless.
Deputies then enter, take Holland’s pulse, and call for help before beginning CPR.
Deputies take turns at CPR as medical staff arrives, and finally, at about 5:21 p.m., a Cal Fire crew enters to take over lifesaving efforts.
After about 12 minutes of unsuccessful treatment, they leave Holland’s body behind in the cell at about 5:34 p.m., according to the timestamps on the footage.
Video contradicts sheriff's account
Despite video evidence to the contrary, the Sheriff’s Office released a press release at the time saying that Holland “was found unconscious and unresponsive” in the cell and that “at the time of his death, Holland was under the care of a physician.”
The release repeated: “Holland had been under the continual care of a physician.”
Holland was visited by jail medical staff sporadically during his time in the restraint chair.
Sheriff Ian Parkinson and other county officials have refused to answer questions about why Holland was left in the chair so long, without even breaks to relieve himself.
Holland's parents have maintained the county covered up incompetence and mismanagement that caused their son's death, and have donated $50,000 to the campaigns of two candidates running in June against Parkinson and District Attorney Dan Dow, who declined to investigate Holland's death.
The county has since destroyed the restraint chair and permanently banned their use, though as recently as late July it rewrote policies that would have allowed officials to keep using them.
Horton did not respond to questions about discrepancies in the Sheriff's Office press release.
He also didn't answer questions about the level of professionalism displayed by some county staff in the video.
In several instances — including as Cal Fire medics performed CPR on Holland — deputies are seen laughing.
Asked his opinion on that, Horton only would say that there have been "staffing changes" in the last year.
Matt Fountain: 805-781-7909, @mattfountain1