It’s become a heartbreaking routine for Sam Goldeen.
He has watched his brother, 33-year-old Los Osos resident Chris Anderson, who was diagnosed with schizophrenia and bipolar disorder at age 19, go in and out of jail for years. It was always for minor offenses like public intoxication or carrying a knife, which his family says is related to his mental illness and homelessness.
Anderson would sit in jail, usually in a solitary cell, until a judge sent him to a state hospital for treatment and medication to restore his mental state long enough to enter a plea.
This year, he waited five months in San Luis Obispo County Jail — much of that in isolation, his family says — before he received treatment, getting into more trouble along the way by destroying property and tussling with custody staff who aren’t trained to handle those with mental illness.
“Watching my big brother just be locked away changed me,” Goldeen said. “It made me harder, and it made me sad.”
Late last month, Anderson was sent back to the County Jail after spending 39 days at Atascadero State Hospital and pleaded guilty in San Luis Obispo Superior Court to misdemeanor vandalism, a charge he picked up in jail in February.
As of Friday afternoon, he was still in jail awaiting a Nov. 30 sentencing for the vandalism charge. He still has other charges pending, and his family says they don’t know when he might get out of jail.
Since the death of San Luis Obispo County Jail inmate Andrew Holland in January, several local families and former inmates like Anderson have told The Tribune similar stories of how they or their loved ones wound up in jail without mental health treatment or proper medication. Parents described struggling with apathetic jail staff who kept them in the dark about their adult children’s well-being.
Holland, 36, of Atascadero, died of an embolism from a blood clot after being tethered to a restraint chair for nearly two straight days, even though a judge had ordered him transferred to the county’s sole psychiatric health facility for treatment of his schizophrenia 10 days earlier. Holland had been in jail for 16 months by then for misdemeanor charges.
Calling his death “a tragedy that should never have happened,” San Luis Obispo County officials in July announced a $5 million settlement with Holland’s family.
The FBI is investigating whether civil rights violations played a role in his death or other inmate deaths. Since 2011, 11 inmates have died in San Luis Obispo County Jail custody for a variety of causes — a rate that’s at least double the most recent national average.
County officials say the jail is overburdened by inmates with medical issues and mental health needs. About 40 percent are on psychotropic medication, they say.
But family members of current and former inmates say their loved ones’ situations share similarities with Holland’s case, and they argue that law enforcement and health officials need to find a way to keep the mentally ill from going to jail in the first place.
San Luis Obispo County officials can’t discuss their accounts due to medical privacy laws, but The Tribune has verified key aspects of their stories through public records as well as jail and medical records provided by the families.
Some allegations of mistreatment corroborate findings in a June civil grand jury report on inmate safety, as well as past jail inspection reports and a list of reforms the county has pledged to implement following the Holland settlement.
Waiting for treatment
The issue of wait times for jail inmates deemed incompetent to stand trial is the subject of at least eight county, state and federal civil rights lawsuits against the California Department of State Hospitals. A spokesman for the agency wouldn’t discuss the issue of wait times because of the pending litigation.
In San Luis Obispo County, incompetent-to-stand-trial inmates held on misdemeanors waited between three and 98 days for transfer to the county’s sole, 16-bed psychiatric health facility in the year that ended Oct. 31, according to the Sheriff’s Office.
Inmates facing felonies waited 18 to 133 days for transfer to a state hospital during the same period.
Patients at Atascadero State Hospital — where most local male inmates facing felonies are sent — were treated an average of 167 days before they were transferred back to a jail to face charges, according to a Department of State Hospitals spokesman.
Those cases aren’t rare in San Luis Obispo County. According to court records, doubts of competency were declared in 58 felony and 99 local misdemeanor cases between January and October.
If a person is an immediate danger because of a mental health crisis, in or out of the jail, they can also be taken to the county’s mental health facility on a 5150 hold. For up to 72 hours, the patient can be stabilized with medication for either release or booking into the County Jail while criminal charges are pending.
If the psychiatric facility is full or unable to take a patient, the person usually waits in County Jail until a bed opens up. A Sheriff’s Office spokesman said the department does not track how long jail inmates wait on average for an emergency 5150 transfer, though the county has pledged to speed up that process since Holland’s death.
Left in isolation
While awaiting psychiatrists’ reports that would eventually find him incompetent to stand trial in February, Chris Anderson ripped a metal bench from his concrete County Jail cell floor and tried to smash open the cell window. Dawn Marie Anderson, his mother, said she didn’t see him for three weeks after that, and court records show he was placed in a padded safety cell with no bed and only a hole in the floor for waste.
At 5 foot 11 inches and 190 lbs, he’s not especially large but becomes increasingly dangerous when he refuses medication and is left in isolation for lengthy periods, Dawn Marie Anderson said.
“Things got worse and worse because of how they treated him — how they treat all mentally ill in there,” she said.
In July, the Sheriff’s Office and County Health Agency changed policies to no longer allow what they called “therapeutic seclusion,” or the isolation of mentally ill inmates “for preventative therapeutic purposes.” The amount of time inmates are confined to safety cells has also been limited to no more than 72 hours.
Dawn Marie Anderson said she doesn’t know if these changes have helped her son.
She recalls several times in the past year being denied visitation by correctional deputies in the jail lobby because they said Anderson was too dangerous to transport or because he otherwise lost his privileges.
“I asked (the deputy), ‘Where is my son? Is he in that (restraint) chair?’ And she starts screaming at me, ‘Are you insulting me?’ ” Dawn Marie recalled. “Everyone in line just looked at each other like, ‘If they’re talking to us like that, how are they treating our family members?’ ”
She added: “Is it unreasonable to be worried about my son?”
No beds at County Mental Health
Historically, people detained by police during a mental health crisis were taken to County Jail if the county’s psychiatric facility was full.
Among its promised reforms, the county 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,” according to a county news release.
If that policy existed last year, it might have helped Los Osos resident Coral Martin.
Martin was 18 years old when she was arrested for DUI and hit-and-run in March 2016. Though her arrest report shows she was in mental crisis, she was taken to County Jail because there were other inmates waiting for a psychiatric facility bed. She walked out of jail five days later with a concussion, a broken front tooth and post-traumatic stress after a stay in a safety cell that she says still haunts her.
Diagnosed with depression, borderline personality disorder and bipolar disorder, Martin has a history of dissociative episodes — a disconnection between thoughts, consciousness and memory that she describes as a “blackout.” For those conditions, she’s prescribed three psychiatric medications and regularly takes a body hormone.
On March 20, 2016, she and some friends got into an altercation with another group in the McDonald’s parking lot in Morro Bay. During the incident, Martin had a dissociative episode and drove off in her car with her friends, struck a parked vehicle, and was stopped by police. She admits she had smoked some marijuana that day.
Martin said she recalls little of what happened next, but a police report shows that she was confused and combative and experiencing a mental health emergency.
Her mother, Linda Martin, a trauma nurse, told The Tribune that she went to the jail the night of her daughter’s arrest and delivered her four medications to the deputy at the lobby window.
“I would show up and tell the deputy, ‘These are her medications. I hope you understand how important it is that she gets these.’ And they just blew me off,” Linda Martin said. “The whole experience with them is a big blow-off.”
Martin said she received no medication her first night at the jail, and was moved to a cell with other inmates the next day, when she was given just two of her medications. The jail physician decided that her anti-anxiety medication was not appropriate and denied her hormone medication, according to jail records, causing her to menstruate and altering her homeostasis.
“I just kept getting worse in there,” Coral Martin said.
After her arraignment was postponed on her fourth day in custody, and Martin became delusional and was placed in a WRAP jacket restraint inside a safety cell, she said.
“After that, it was all hallucinations, all having to do with being stuck, being trapped,” she said.
Martin recalls defecating on the floor, hitting her head repeatedly on a metal grate and busting her tooth during her night in isolation.
She was taken to a hospital, where she received a CAT scan and was re-hydrated with IV fluids, according to medical records, and released to her family.
Martin later pleaded no contest to misdemeanor DUI (for marijuana) and assault, and charges of hit and run and child endangerment (her passengers were under 18) were dismissed. She lost her job while in jail and had to drop out of classes at Cuesta College to receive treatment at a private facility outside the county.
“I had a great job. I lost everything,” Coral said. “But I’m ready to start working again.”
The Martins filed a formal complaint with the Sheriff’s Office over her treatment at the jail, but never received a response. They’re considering legal action, they said.
“If they had taken her for treatment to begin with, none of this would have happened,” her mother said.
Caught in the system
Even people involuntarily admitted to SLO County’s mental health facility during a crisis find themselves stuck in County Jail.
That’s happened twice in three years to Lisa Kania’s 32-year-old son, Joseph, who was most recently booked into the San Luis Obispo County Jail on Nov. 16 for allegedly assaulting a psychiatric facility staff member while there on a 72-hour involuntary hold, where he was supposed to be given medication and stabilized.
Joseph — diagnosed with schizophrenia at age 19 — does not share the same last name as Kania and does not want to be publicly identified due to stigma surrounding mental illness.
Kania and her husband criticized San Luis Obispo County’s lack of psychiatric facilities in a 2015 Tribune article, describing how they drove Joseph to hospitals or private mental health centers in Ventura, Pasadena, Sacramento and Los Angeles for treatment — even if Joseph was in crisis the entire ride — to keep him out of the local facility.
When Joseph was booked into jail in 2013 after allegedly assaulting a psychiatric facility employee, two weeks passed before Kania was allowed to see her son, she said. Kania also wasn’t allowed into his closed mental health court hearing, either.
“I had no communication with him. It’s like he’s overseas in some foreign prison,” she said. “The stress, the anxiety, the worry — I just want to know, is my son OK?”
A judge ultimately dismissed that charge against Joseph, but the same situation is now playing out again.
Last week, the San Luis Obispo County District Attorney’s Office filed a felony assault charge against Joseph for again assaulting a psychiatric technician. This time he was released to the care of his family after being held in jail for less than 24 hours.
If he’s convicted, Joseph will lose his disability and health insurance, Kania said, and he won’t be accepted in other psychiatric facilities except for the county psychiatric facility, which is the only local facility to take Medi-Cal insurance. But he may not be able to go back to the county facility if he experiences another crisis — an employee there was granted a restraining order, according to court records.
Joseph has averaged at least one major schizophrenic episode every few months, his mother said.
“It is incomprehensible to me how they can charge him with a crime when he’s in (the county psychiatric facility) and he needs help,” Kania said. “They’re setting him up for failure.”
New county mental health policies
A Tribune review of written county policies shows that the Sheriff’s Office and County Health Agency have changed policies for dealing with mentally ill inmates at the County Jail since the Holland settlement was announced in July. These include:
- Use of restraint chairs is no longer allowed. The Sheriff’s Office says the chair Holland was restrained to was “cut into pieces and properly disposed of on July 28.”
- Before 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 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.
In-Custody Deaths, 2012-17
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. Cause: Cardiac arrhythmia due to acute chronic ischemic heart disease
Note: Unless otherwise stated, place of death was San Luis Obispo County Jail.