San Luis Obispo County has agreed to a $5 million settlement for the family of Andrew Holland, who died in County Jail after 46 hours in a “restraint chair.”
Among other reforms, it also has permanently banned use of the device—sometimes referred to as a “torture chair” by inmates—at the jail.
That’s a start, but it will take much more than that to erase the black mark on our county’s reputation.
If San Luis Obispo County is serious about ensuring that inmates, especially mentally ill inmates, receive proper treatment, it should bring in an independent investigator to examine what happened and to recommend any additional changes that may be needed, particularly since 11 inmates have died in custody since 2012.
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It shouldn’t have to be up to parents like Carty and Sharon Holland to serve as advocates, but thank goodness they are. The Hollands intend to use the $5 million settlement to establish a foundation that will support mentally ill people who, like their son, get caught up in the criminal justice system.
It takes strong and selfless parents to look beyond their own grief and focus on helping others avoid a similar loss. We commend the Hollands for taking on this role; we’ve spoken with other parents of incarcerated, mentally ill adult children who are terrified about what their loved ones may be going through.
Is it any wonder, after what happened to Holland?
Forty-six hours strapped to a plastic chair. It can be excruciating to spend even eight or nine hours in an airplane seat. Can you imagine 46 hours in that seat? Now think about being strapped in, naked, unable to get up and use the restroom, unable to shift to try to find a more comfortable position, unable to even scratch your nose.
We wouldn’t treat an animal in such a manner, let alone a human being. Yet that’s what Holland, 36, suffered through at the county jail.
Holland, who had been diagnosed with schizophrenia at 22, was reportedly strapped in the chair for his own protection; the county says he had been “inflicting injury on himself.” While he was in the chair, he was monitored “approximately every 15 minutes by jail staff under the guidance of medical and mental health professionals,” according to a county news release.
Does that mean that “medical and mental health professionals” were aware that Holland was restrained 46 hours?
Was Sheriff Ian Parkinson aware?
Here’s the response County Counsel Rita Neal provided on Friday:
“Although collectively mental health and medical staff at the jail and at the PHF (Psychiatric Health Facility) knew Mr. Holland had been in the chair for some time, individually the exact duration may not have been known. Sheriff Parkinson was aware that Mr. Holland was in the restraint chair but was unaware of the exact duration of time.”
If no one knew how much time Holland had been in the chair, that’s an egregious breakdown in communications. It’s been well documented that extended periods in a restraint chair can cause injury and death—tracking how long someone has been in a chair is truly a matter of life and death.
Consider this statement from the website of a risk management attorney, based on warnings from manufacturers of the chairs:
“Detainees should not be left in the Safety Restraint Chair for more than two hours. This time limit was established to allow for the detainee to (calm) down or sober up, and if needed it allows for the handlers to seek medical or psychological help for the detainee. This two-hour time limit may be extended, but only under direct medical supervision (Doctor/Nurse). This extended time period must not exceed eight hours and range of motion exercises must be performed regularly. Therefore we do not recommend anyone be left in the Safety Restraint Chair for more than ten hours total.”
It goes on to detail half-a-dozen cases in which damages were awarded over deaths or injuries to inmates.
In the case of San Luis Obispo County, medical malpractice insurance will cover the $5 million settlement; the county will pay only a $10,000 deductible.
But that can’t be the end of it.
Again, it’s not enough to ban use of the restraint chair, though it is a relief to know the county now has a written policy prohibiting its use at the county jail.
The county also says it has “changed protocols to ensure that the facility can now promptly accept mentally ill inmates who are a danger to themselves or others.” (Twelve days before Holland’s death, a judge had ordered that he be transferred to the county’s in-patient psychiatric facility. That never happened.)
“Under the new protocol, if the PHF is at census (full capacity), one or more patients would be transferred to out-of-county facilities to accommodate jail inmate admissions in a timely fashion. All patients will be ensured the appropriate level of care,” County Health Agency Director Jeff Hamm told The Editorial Board via email.
The county also has restricted the amount of time an inmate can spend in the jail’s safety cell, and it has increased supervision of medically and mentally ill inmates at the jail.
These are steps in the right direction, but as Tribune reporter Matt Fountain has pointed out, it is unclear what will happen if the county fails to carry out these reforms.
It’s also not clear whether these reforms are adequate.
And what about holding someone responsible for this horror? Have any disciplinary actions been taken?
Given that 11 County Jail inmates have died in custody since 2012, we should all be concerned about the level of medical and mental health care inmates are receiving.
As we now know, the FBI is investigating whether civil rights violations played a role in the series of deaths. We strongly support that; it’s time an outside agency with resources and experience in civil rights investigations examined what happened.
But we also believe the county would greatly benefit from hiring an independent, outside investigator to examine operations at the County Jail and the Psychiatric Health Facility.
As Assistant County Administrative Officer Guy Savage said in a prepared statement, Holland’s death “is a tragedy that should never have happened.”
The best way to prevent this from ever happening again is to find out exactly what occurred and what additional steps may be needed to ensure all inmates receive adequate and humane care.