Amid fallout from the death of a schizophrenic jail inmate who was held in a restraint chair for nearly two days, San Luis Obispo County says it has made “sweeping” changes in how it deals with mentally ill inmates, including banning the chair and instituting other reforms to protect inmates and streamline their psychiatric treatment.
But despite public outrage in the months following Andrew Holland’s death in January and assurances from Sheriff Ian Parkinson that restraint chairs are no longer used in the jail, records show that the Sheriff’s Office signed off on policies that included continued use of the chair in March — before the county released its official report on Holland’s final hours — and county health officials reaffirmed the chair’s use in mid-July, with limitations, according to records provided in a public records request.
In response to questions from The Tribune, the county provided emails from a correctional supervisor to jail staff announcing restrictions on the use of the chair in February, and another suspending the chair’s use altogether in April. Formal restraint policies banning the chair weren’t approved until three days after the county announced a $5 million pre-claim settlement with Holland’s family on July 27, records show.
Restraint chairs, used to keep inmates and patients from hurting themselves and others, have been referred to as the “torture chair” and officials have warned of their dangers, including a risk that the restrained person can develop blood clots. The Coroner’s Office found that Holland died of an embolism caused by a blood clot in his leg, though it ruled his death “natural.”
Despite several requests for comment, Sheriff’s Office spokesman Tony Cipolla would not say why the chair was re-approved on March 27. However, he wrote in an email that the county has not used the chair since Holland’s death.
Cipolla and County Health Agency Director Jeff Hamm said the county’s policies allowing continued use of the chair were “under review” from February to July and that procedures “take time to update and finalize.”
The FBI formally launched an investigation into alleged civil rights abuses at the jail in May. On Aug. 22, Parkinson told the County Board of Supervisors that the chair that had restrained Holland was destroyed by county officials. A spokeswoman for the FBI on Thursday declined to comment on the destruction of the chair or whether it had any evidentiary value to their investigation.
‘Not authorized for use’
Holland died Jan. 22 after being let out of the plastic chair he had been strapped to for 46 hours in a cell that was only authorized by state Title 15 standards to house intoxicated inmates. Holland had no alcohol or drugs in his system at time of death, the county coroner said.
The county acknowledged that a restraint chair was used on Holland only after the Coroner’s Office released on April 10 its public report detailing his final hours.
However, emails provided to The Tribune show that on Feb. 9, then-correctional Lt. Denise Armstrong sent a mass email to jail staff saying she was updating the Sheriff’s Office’s restraint policies and until further notice, inmates restrained in the chair were to be let out at least once every two hours.
The Sheriff’s Office approved an updated list of restraint policies on March 27, which were nearly identical to policies last updated in December 2016, records show. It’s unclear whether this update was a result of Armstrong’s review.
On April 14, Armstrong wrote another email to jail staff saying “Effective immediately, the restraint chair is not authorized for use.” According to Cipolla, that email served as an official announcement to staff that the chair would never be used again at the jail.
However, in response to questions from The Tribune on April 14, the Sheriff’s Office was not so definitive, writing in a statement that “the sheriff has suspended all use of the chair until further notice.”
On July 15, the county Behavioral Health Department approved its new restraint policies that reaffirmed that the chair would continue to be used. Hamm said in an email Wednesday that the Sheriff’s Office, not health officials, determines what type of restraint is appropriate to use, and since the Sheriff’s Office re-approved use of the chair in March, Behavioral Health’s policies were “updated to be in alignment with recent changes made to (Sheriff’s Office) custody policies.”
Two weeks later, on the day of the settlement, July 27, the Sheriff’s Office policy manual was updated to end use of the chair.
Finally, on July 31, Behavioral Health updated its policies, also banning the chair.
Cipolla wrote in an email that in lieu of the chair, jail staff now primarily uses a four-point polyurethane soft restraint known as a “WRAP” on inmates in need of restraint. The WRAP contains a “locking shoulder harness, leg restraint, ankle strap and tactical bag,” Cipolla said.
A Tribune review of written county policies shows that the Sheriff’s Office and County Health Agency have officially put into writing reforms they promised when the Holland settlement was announced. These include:
- The restraint chair is no longer mentioned in county policy. Sheriff’s spokesman Cipolla said the chair Holland was restrained to was “cut into pieces and properly disposed of on July 28.”
- Prior to Holland’s death, the county allowed for clinical restraints, such as chairs and beds, as well as “therapeutic seclusion,” or the isolation of mentally ill inmates “for preventative therapeutic purposes.” Neither are allowed under new county policies.
- New county policies say that approval from a sheriff’s supervisor and medical and mental health staff is required to restrain an inmate for more than two hours. If restrained for longer, medical and mental health staff are required to involuntarily admit the inmate to the county’s 16-bed inpatient psychiatric health facility (PHF) or have the inmate taken to a hospital.
- Inmates are now placed in or released from restraints with the approval of a correctional sergeant or designee in conjunction with medical and mental health staff.
- The former policy allowed staff to restrain an inmate for up to eight hours before a mental health assessment was required. The new policies state that mental health assessments are to be done within one hour.
- The new policies state that jail medical staff may at any time request that an inmate be released from restraints if there is a safety issue; that request “shall take precedence over the custodial evaluation.”
- New policies state that placement of inmates into safety cells — isolation cells with no bed and just a hole in the floor for waste — requires approval from a correctional sergeant, nurse supervisor, nurse, psychiatrist or licensed therapist. The former policy required approval from “the responsible physician.”
- Visual checks of inmates in safety cells are to be logged every 15 minutes, and supervisors are now directed to inspect the logs every four hours. The old rules stated every eight hours.
- Jail supervisors are now to review whether an inmate should stay in a safety cell every four hours, whereas it used to be every eight hours.
- A complete medical check and mental health assessments on safety cell inmates are now to be done every 12 hours. They used to be required every 24 hours.
- Now, if an inmate remains in a safety cell for more than 48 hours, the inmate must be transferred to the PHF or hospital for treatment, or cleared for normal jail housing.
Restraint chair policy since Andrew Holland’s death
The following is a timeline of events following the aftermath of former inmate Andrew Holland’s death at the San Luis Obispo County Jail.
Jan. 22: Holland, 36, dies in a sobering cell of a pulmonary embolism caused by a blood clot in his leg, after spending 46 consecutive hours strapped to a restraint chair.
Feb. 9: In an email to jail correctional staff, a correctional supervisor writes that she is updating the department’s restraint policies, and that inmates in restraint chairs are to be released at least every two hours until updated policies are in place.
March 27: Sheriff’s Office approves an updated set of restraint policies that continues the use of restraint chairs and is nearly identical to the previous set of policies adopted in December 2016.
April 10: The Coroner’s Office releases its final autopsy report on Holland, ruling his death “natural,” leading to questions about his death.
April 13: Another County Jail inmate, Kevin Lee McLaughlin, 60, dies of a heart attack after he asked to go to a hospital. In response, Sheriff Parkinson holds a news conference saying he welcomed outside agencies, including the District Attorney’s Office and the FBI, to investigate “any jail death that’s occurred that they felt was worthy of their own investigation.”
April 14: In response to questions from The Tribune, the Sheriff’s Office writes in an email that it “suspended all use of the (restraint) chair until further notice.” In an email to jail staff, Armstrong (then a correctional captain) writes: “Effective immediately, the restraint chair is not authorized for use.”
July 15: County Health Agency officials approve updated restraint policies that allow for continued use of restraint chairs, with stricter provisions and more staff oversight.
July 27: In a news release, the county announces its intention to pay Holland’s family a pre-claim settlement of $5 million and promises a list of reforms “to prevent this type of event from ever happening again.” The Holland family, in its own press briefing, calls for Parkinson’s resignation. The same day, the Sheriff’s Office approves a new restraint policy that removes all reference to restraint chairs, and a new safety cell policy limiting inmates’ time there.
July 31: The County Health Agency adopts a new restraint policy removing all reference to restraint chairs.
Aug. 4: The Health Agency adopts new policies restricting the amount of time inmates can be housed in safety cells.
Aug. 22: In a presentation to the county Board of Supervisors, Parkinson says the county implemented changes at the jail and that the chair Holland was restrained to has been destroyed.