Grand Jury report on County Jail inmate safety has serious concerns, but no solutions

San Luis Obispo County Jail.
San Luis Obispo County Jail. jjohnston@thetribunenews.com

Despite finding a lack of oversight and responsibility for the well-being of County Jail inmates following a series of in-custody deaths, the San Luis Obispo County Grand Jury suggests only that sheriff and the county health officials do a “joint review” of their management structure and policies.

The civil Grand Jury — whose recommendations aren’t binding — said in a report released Thursday that the agencies should also issue a report of their review by the end of the year.

Since 2011, 11 inmates have died while in custody either inside the jail or at a nearby hospital. The report’s findings are serious and confirm troubling issues raised following the death of two inmates this year: that the jail population is changing due to recent state laws, that management structure is complex, and that ongoing violations of state-regulated minimum standards are not being fixed.

They further found that jail rehabilitation programs are poorly managed, lack space to operate, and face “resistance from custody staff.”

Sheriff Ian Parkinson issued a statement Thursday saying “we generally don’t have a disagreement with (the report’s) findings” and that his office plans to issue “a more comprehensive, formal response to the Grand Jury at an appropriate time and as prescribed by law.”

Each civil Grand Jury, which operates with one team of volunteers per year, is required to inspect correctional facilities in its county, said Grand Jury Foreman Pro Tem Dennis Frahmann.

This year’s jurors toured the County Jail in October, he said, prior to the deaths of 36-year-old Atascadero resident Andrew Holland on Jan. 22 and 60-year-old San Luis Obispo resident Kevin McLaughlin on April 13.

Holland died of a blood clot after being strapped to a restraint chair for 46 hours inside a glass sobering cell, in a violation of state law. McLaughlin died of a heart attack, according to a preliminary autopsy report, soon after complaining of shoulder pain, one symptom of impending cardiac emergency.

Frahmann said public interest in the men’s deaths led the Grand Jury to visit local facilities and review jail inspection reports, sheriff’s investigation reports, and local media coverage.

Jurors also attempted to investigate the death of 26-year-old Jordan Turner, who committed suicide in his cell with a safety razor on Sept. 20.

While the Sheriff’s Office provided some records, the jury “determined it could not conduct a more in-depth look at this time into the circumstances of these three cases” due to ongoing county investigations and possible litigation.

Jurors found that the jail’s “complex medical management structure” made obtaining data more challenging, if it was received at all.

“... (As) a result of seeking this data, the Grand Jury came to understand the overall custodial head of the County Jail does not have management control over the medical elements,” the report reads. The head custodial officer is Undersheriff Tim Olivas, and jail medical treatment is under the direction of the county Health Agency.”

The Public Health Agency, which reports to the County Administrative Office, administers services through Drug and Alcohol Services, Mental Health Services (also called Behavioral Health), and Public Health Services. The jail itself, however, is managed by the Sheriff’s Office, which does not report to the Administrative Office.

“Such a structure raises a concern about how well various aspects of inmate care are coordinated, especially when health issues cross multiple boundaries such as drug abuse, psychiatric care and ongoing medical health issues,” the report says.

Lastly, the report found that the jail is in violation of several Title 15 requirements, including that staff are prohibited from restraining inmates — like Holland — inside sobering cells, among several other violations related to medication, medical confidentiality and policy review.

The jury did not, however, recommend that jail staff fix those violations, which are voluntarily enforced in adult facilities, according to the Board of State and Community Corrections. Frahmann said jurors are prohibited from commenting on things not contained in the report.

“Grand Jury reports only have the ability to raise into the public view our findings and recommendations. There’s no requirements for (officials) to change the findings,” he said.

The Sheriff’s Office and county Health Agency are, however, required to respond to the report to the Board of Supervisors within 90 days.


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 infarction, 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: Kevin Lee McLaughlin, 60. Heart attack (preliminary)

Note: Unless otherwise stated, place of death was San Luis Obispo County Jail.

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