The video of the torture and subsequent death of Andrew Holland — and let's be clear, it was 46 hours of torture — is a shocking revelation of what can happen when mentally ill individuals are warehoused in county jails, under the care of people who lack the proper training, skills and compassion to handle them.
It's also a shocking indictment of the Sheriff's Office leadership, from the immediate supervisors who were in charge throughout those two days all the way up to Sheriff Ian Parkinson.
The video is extremely hard to watch, but we can't imagine a more powerful way to demonstrate why we absolutely must reform the way we care for mentally ill individuals.
Parkinson, who is running for a third consecutive term, must give the public a complete account of how and why this occurred — instead of deflecting to other county administrators and carefully worded news releases that have proven to be inaccurate.
As Tribune writer Matt Fountain reported, two of the official statements offered by the county have been contradicted by the video.
The county said that Holland was “found unconscious and unresponsive” and that he was “under the continual care of a physician” at the time. The video shows this was clearly not the case.
The sheriff owes the voters — indeed, all members of the public — an explanation of how much he knew about Holland's treatment at the hands of the jail staff.
For instance, Parkinson approved placing Holland in the restraint chair, but did the sheriff know he was held there for 46 hours? If so, did he condone that? Why was no one disciplined or held accountable for Holland's death? And how does the sheriff explain the callous behavior of the deputies surrounding Holland?
The video clearly shows one deputy turn to another and smile as Holland lay dying after finally being released from the restraint chair where he had been strapped, naked except for a helmet, for nearly two full days.
At other points in the more than 100 hours of video footage viewed by The Tribune, officers are seen joking. One makes arm and neck motions in an apparent attempt to mock Holland's movements.
Yet as far as we know, there were no terminations or even suspensions of those involved.
Is that how we would want our sons or daughters treated, should they have the misfortune of suffering from severe mental illness?
Of course not.
Holland suffered from schizophrenia; he was not some freak to be stared at and mocked.
But let's back up; the mistreatment of Andrew Holland started much earlier. He was in the custody of the County Jail for 15 months prior to his death on Jan. 22, 2017.
Much of that time was spent in a cramped, solitary cell, which can exacerbate mental illness, according to a report by the U.S. Department of Justice.
How many more mentally ill inmates are locked up in jails for months at a time, because we don't want to properly deal with the problem?
Again, this isn’t just happening in San Luis Obispo County. Consider this example from the Yuba County Jail, as reported by the Sacramento Bee: Last year, a 34-year-old UC Berkeley student diagnosed with bipolar disorder killed himself by choking on his own urine and feces. This was after previous suicide attempts and psychotic episodes at the jail — along with a court order to transfer him to a psychiatric hospital.
In the aftermath of Holland’s death, San Luis Obispo County is taking corrective action; it’s hired a chief medical officer for the jail and plans to create a new mental health wing, among other reforms. It also has destroyed its restraint chair.
But why are seriously mentally ill men and women being held for extended periods in county jails in the first place? A system that would lock up people with mental illness in county jails that are often ill-equipped — or not equipped at all — to handle them is cruel and inhumane.
In Holland’s case, it was obvious that he needed professional care for his mental illness from an appropriate facility.
A judge had ordered him transferred to the county’s Psychiatric Health Facility in early January, but that didn’t happen because the facility reportedly did not have a bed available for him.
Some argue that it’s actually the county’s mental health system that’s to blame — not the sheriff and the jail staff.
We agree the Psychiatric Health Facility failed in its duty, but remember, it was the correctional staff that maintained custody of Holland, as the video shows.
It was the correctional staff that looked on as Holland was kept restrained in a chair for 46 hours, even though multiple sources say that under no circumstances should an inmate be restrained in a chair longer than 10 hours, and then only when the inmate is under the direct supervision of medical personnel.
And finally, it was the correctional staff that stood watching as Holland lay writhing on the floor of his cell, struggling to breathe.
Surely something else could have been done.
If the Psychiatric Health Facility did not have space, what about a hospital emergency room, where Holland could have been administered drugs to sedate him?
And please don’t tell us there wasn’t enough staff available to safely transport him. No fewer than 11 people — including five deputies in riot gear — were on hand when he was transported, naked and face down on a gurney, to the restraint chair.
If they weren’t available, call in others.
But to leave a mentally ill man strapped to a plastic chair for 46 hours?
If that’s not a crime, it's time to make it one.