Attorneys for the family of an inmate who died in San Luis Obispo County Jail in January are challenging the county’s ruling that the death was “natural,” after they learned the state medical board filed disciplinary proceedings against the pathologist who performed the autopsy.
Andrew Chaylon Holland was held in the jail’s “drunk tank” in a restraint chair for nearly two days, then died about 20 minutes after being released from the restraints Jan. 22.
Records obtained by The Tribune show that County Jail staff had been told four months before, in September 2016, not to restrain inmates inside the sobering cell, which is designated only for unrestrained inebriated inmates.
Records also show that a judge had issued an order Jan. 10 for Holland to be transported to the county’s inpatient mental health facility and administered antipsychotic drugs. Holland was never taken to the mental health facility, although there was room available, and there was no evidence in the coroner’s toxicology report that Holland had antipsychotic drugs in his system at the time of his death.
The coroner’s report listed Holland’s cause of death as an intrapulmonary embolism, which the National Institutes of Health says usually begins as a blood clot in a leg vein and can be caused by extended time sitting or lying down.
County officials said in a statement Friday that they are reviewing all restraint policies and Sheriff Ian Parkinson has suspended all use of restraint chairs in the jail.
In an April 10 filing, the State Medical Board accused Dr. Gary Walter, a Coroner’s Office-contracted medical examiner who performed the autopsy on Holland, of endangering the public after a misdemeanor DUI conviction in May 2016.
According to court records, Walter was arrested March 9 after officers pulled him over and he blew a 0.155 BAC. Walter allegedly told the responding police officer that he was a medical examiner on his way to work. He pleaded no contest in May to misdemeanor driving under the influence and received three years of probation, a fine and a three-month DUI class, according to court records.
Walter performed autopsies on at least five of the 11 inmates who have died in the jail since 2012, according to records collected by The Tribune.
For several years, Walter has been the primary forensic pathology expert for the county District Attorney’s Office in the prosecution of murder and other criminal cases.
In November, Walter contradicted his own autopsy report in testimony given at the murder trial of James Lypps, and the accuracy of his testimony has been previously questioned by several defense attorneys in San Luis Obispo Superior Court.
On Thursday, at a news conference following the death of another inmate at the jail, Parkinson stated that he asked the Santa Cruz County Sheriff’s Office to perform the autopsy on the 60-year-old man, who has yet to be identified pending family notification.
In December, the county Board of Supervisors approved a request from the Sheriff’s Office to hire a full-time staff medical examiner for the Coroner’s Office when Walter’s contract expires June 30. Walter was contracted at a fixed rate of $200,000 every two years.
Emails provided in a records request show the Sheriff’s Office offered Walter a last-chance agreement on March 29 to finish his contract.
Walter performed the autopsy on Holland on Jan. 25.
Holland family attorney Paula Canny alleges that, contrary to Walter’s finding in his report, Holland did not die of “natural” causes.
In a statement to The Tribune, Parkinson said Walter told him Holland’s “prolonged seated position is ‘possibly contributory’ to clot formation,” but that “the chair itself does not cause clots to form.” Parkinson wrote that Walter could rule the manner of death as natural, homicide, accidental, suicide or “unknown.”
“Drew died because of what humans did to his body, that is not natural,” Canny said. “I think (Walter) does have a bias if his employer who’s given him this (second chance) is responsible for the death of the inmate.”
Canny noted that Walter was on his way to work to do an autopsy when he was stopped for a DUI.
“If he couldn’t drive a car safely, what makes him think he can use a scalpel?” she said. “His reports can’t be trusted.”
In its April 10 filing, the State Medical Board’s deputy attorney general accused Walter of professional misconduct based on his arrest and is seeking a hearing to revoke or suspend Walter’s medical license.
‘The only remedy ... is a lawsuit’
Other records obtained by The Tribune show that in September 2016, the Board of State and Community Corrections, the state agency that regulates and inspects county jails, found the San Luis Obispo County Jail in violation of seven sections of Title 15.
In a Sept. 21 biennial inspection, the field representative reported that jail staff was using the sobering cell to house restrained inmates, a violation of state law.
In response to questions Friday, county officials stated that Holland was in the cell because it allows “maximum visibility and offers direct observation” from staff working in that pod.
On Monday, a spokeswoman for the state corrections agency said the agency has received no proof of corrective action from the jail on any of the seven listed violations. In an attached email, an agency inspector wrote that it’s “not uncommon” for jails to not correct violations found in state inspections because compliance with adult Title 15 is “voluntary,” unlike juvenile facilities.
Asked what regulatory teeth the agency has, BSCC spokeswoman Tracie Cone wrote: “You have asked the perplexing question of our existence.”
Cone cited a state Attorney General’s Office opinion that said because the state agency does not fund jails to come into compliance, so it can’t force them to do so.
“The only remedy ... is a lawsuit,” she wrote.
It’s unclear why Holland was never transferred to the county Behavioral Health Department’s inpatient Psychiatric Health Facility. Observation logs from the facility show that during each of the 12 days Holland was at the jail, at least one room was available at the facility.
In a response to questions Friday, the county administrative office wrote: “Holland was not transferred because Mental Health determined they did not have the capacity to take him.”
Jeff Hamm, the health agency director, clarified that it was for safety reasons: “There can be situations in which we appear to have a bed or two available on the PHF (licensed for 16 beds) but, because of the specific characteristics of the patients present, primarily related to the acuity of their illness, our medical director might announce that the facility is at its operational capacity, and impose extraordinary measures on additional admissions.
“That was the case on the weekend of Mr. Holland’s death.”
In-custody deaths, 2011-2017
The following people died while in custody of the San Luis Obispo County Sheriff’s Office since January 2012.
- Jan. 5, 2012: Kevin Lee Strahl, 53. Cause: Hepatic failure, liver fatty change
- Nov. 12, 2012: Joseph Morillo, 43. Cause: Cardiac arrest due to thickening of heart muscle and morbid obesity
- Jan. 27, 2014: Rudy Silva. Died in hospital care. Cause: Acute hypoxic respiratory failure, septic shock, Influenza A and Staphylococcus Aureus Bacteremia
- March 12, 2014: Josey Richard Meche, 28. Cause: Cardiac dysrhythmia with acute methamphetamine toxicity
- May 30, 2014: Timothy Richard Jancowicz, 29. Cause: respiratory arrest due to heroin toxicity
- Jan. 11, 2015: David Thomas Osborn Sr, 63, Cause: Acute myocardial infection, Atherosclerotic coronary artery disease, hyperglycemia
- March 24, 2015: Sean Michael Alexander, 33. Cause: Microscopic encephalitis, marked pulmonary edema
- Sept. 20, 2016: Jordan Benjamin Turner, 36. Cause: Suicide with razor blade
- July 16, 2016: Nicole Honait Luxor, 62. Died in hospital care. Cause: Complications from gallbladder cancer
- Jan. 22, 2017: Andrew Chaylon Holland, 36. Intrapulmonary embolism
- April 13, 2017: (Identity withheld pending family notification), 60. Cause not yet determined
Note: Unless otherwise stated, place of death was San Luis Obispo County Jail.