Timeline: What led to SLO County Jail inmate’s death, and the aftermath
County Health Agency staff logs and other records from the weekend Andrew Holland died in San Luis Obispo County Jail appear to conflict with the version of events as told by Sheriff Ian Parkinson in recent interviews, town halls and campaign events.
Specifically, the schizophrenic inmate's medical and mental health records from Jan. 20 through Jan. 22, 2017 — provided to The Tribune by his family — show that he accepted sedative medication and that jail medical staff noted him as "calm" and showing "minimal signs of aggression" as early as about three hours after he was placed in a full-body restraint chair.
Holland, 36, of Atascadero was left in the chair for nearly 46 hours and died of an embolism caused by a blood clot that formed in his leg roughly an hour after he was released from the chair on Jan. 22.
Parkinson has repeatedly said that Holland, who was put in the chair to prevent him from punching himself, could not be let out of the chair because he was combative and refused his medication, and that he was only let out when jail staff saw a change in his behavior and he accepted medication.
Parkinson, who is seeking a third term in the June 5 Primary Election, did not respond to email and phone requests for comment Thursday. Instead, San Luis Obispo County Administrative Officer Wade Horton responded by email, calling Holland's death "an election issue" and declining to comment further.
"Rather than engage in the election, the focus is on making changes to prevent a similar tragedy from happening again," Horton said. "We can’t address details about Andrew’s medical care, because we are legally bound by HIPAA (medical privacy laws) to keep that information private."
Horton added: "We understand that there is significant media interest in this matter and have already provided comment. Please refer to our previous statements."
While Parkinson has accepted responsibility for his department's role in Holland's death, he has also made public statements defending his staff's decisions and blamed County Behavioral Health, who he said "refused to accept" Holland in the county's psychiatric facility even though records show at least one of the facility's 16 beds was available.
“Our responsibilities, our policies were followed," Parkinson said in an April 7 interview.
County Health Agency officials have not commented in recent months about Parkinson's claims nor answered questions in relation to Holland's treatment and death.
It's not clear if medical or Behavioral Health staff have the authority to release an inmate from restraints without agreement from correctional staff. Anne Robin, the county's Behavioral Health director, and Public Health Director Penny Borenstein did not respond to a request for clarification on that question Thursday.
What the documents show
Documents provided to the family by the county in the wake of Holland's death and subsequently provided to The Tribune state that Holland began to calm down on the night of Friday, Jan. 20, 2017, and was noted as calm and responding to questions several times through that Sunday before he was released.
More than 100 hours of raw jail footage obtained by The Tribune showing Holland's time in restraints also do not clearly show him being outwardly combative with staff.
According to a log filled out by medical doctors at the jail, Holland was removed from his safety cell after he was found punching himself at about 5:30 p.m.; he was placed in the restraint chair in a sobering cell. The log states that he "remained calm and agreed to take medication" at about 6 p.m. and lists him as receiving 2 milligrams of Lorazepam, an anti-anxiety medication, and 20 milligrams of Olanzapine, an anti-psychotic drug.
The medications were crushed up and put in water, which Holland swallowed. The log states he spit out "some" of the medication after taking more water. At 7:56 p.m., another 2 milligrams of Lorazepam was administered in an intramuscular shot, according to the log.
Though Holland was noted as "spitting" around 10 p.m. on Jan. 20, a nurse noted that he "responds appropriately when asked questions" at 12:45 a.m. on Jan. 21, "responds to questions" at 4:40 a.m., and by 8:30 a.m., was "sitting in chair, calm."
Though the medical log notes that Holland was refusing water and spitting at times, it was noted through Saturday afternoon and Sunday that he was "calm, quiet;" "cooperative, minimal signs of aggression, minimal spitting," and that he drank water and ate some lunch.
A similar log from jail Behavioral Health staff noted that Holland was spitting and calling staff names on the morning of Jan. 21, and noted that his case was discussed with Dr. Daisy Ilano, the chief medical officer, who said that "due to capacity issues," admission to the psychiatric facility was "denied." The log notes that admission would be "revisited" if beds opened up at the facility.
Another mental health worker noted Jan. 21 that Holland requested medication but later refused it. On Jan. 22, the mental health staffer noted that he suddenly agreed to accept a dose of the anti-psychotic drug Zyprexa in a Boost drink. The staffer later returned and told Holland that he would need to commit to not harming himself before he could be released.
According to the log, his response was a "simple yes."
Questions for Parkinson
In a candidate debate Wednesday night, Parkinson's challenger, private investigator Greg Clayton, said he had reviewed the medical records Tuesday and asked Parkinson why Holland was left in the chair if he was noted as medicated and calm that Friday.
In his response, Parkinson said Clayton was not privy to all information because he had not read the Sheriff's Office's investigative reports containing interviews with jail staff.
The Tribune has previously been denied various reports about Holland's treatment and death in records requests to the county, though it has not specifically requested "investigative reports," which are usually exempt from disclosure.
The county did not acknowledge a request for the referenced reports Thursday.
Together, the medical and Behavioral Health reports contradict several statements Parkinson has made about the issue since March.
“Because he was having a psychotic episode and he would not take medication and his behavior was not changing,” Parkinson replied.
Corral paraphrased another Parkinson response that Holland was let out of the chair because "deputies saw, quote, a change in his behavior.”
On March 8, immediately following a town hall forum in Oceano, Parkinson fielded questions from four members of SLO County Progressives, a political activist group that supports Clayton in the sheriff's race.
"My beef is, like, how did he end up there for 46 straight hours?" asked Nick Andre, co-chair of the organization and co-owner of Kumani Inc., a media company that has provided campaign services to Clayton's campaign, according to a recording of the exchange. "Why couldn't you have released him earlier?"
“Because he took medication that he wouldn’t take before. And they (medical staff) wouldn’t give it to him involuntarily," Parkinson said.
Parkinson told the group that it was the County Health Agency's call to put Holland in the restraint chair.
“The chief medical officer for the county and the chief psychiatrist for the county consult immediately when anybody (goes in the chair). That was the Friday conversation," Parkinson said. "It’s a medical decision to protect him, and it’s a mental health decision to protect him.”
But according to an incident report drafted Jan. 20 by a correctional deputy who removed Holland from his safety cell, a team of riot gear-clad correctional deputies placed Holland in the chair "with authorization" from a correctional lieutenant, whom The Tribune is not naming due to death threats to custodial staff since Holland's death.
Asked by Andre at the town hall about time limits for people in restraints, Parkinson replied: “You know, you realize people sit in wheelchairs their entire lives?”
Tave Holland, Andrew's cousin and an attorney who's representing the family, said the records and video show that jail nurses "did their job."
"Custody was punishing Andrew for being mentally ill, pure and simple," Tave Holland said. "There's nothing Andrew could have done to be released. He wasn't human to them. He was just some animal to be tied up and left to die."
Since The Tribune published jail surveillance video of Holland's death on March 16, SLO Progressives and the Holland Family Alliance have circulated a petition calling on Parkinson to drop out of the race.
According to a statement posted on its Facebook page Wednesday, local elected officials to join the petition include SLO Mayor Heidi Harmon and council members Aaron Gomez and Dan Rivoire, Grover Beach City Council Member Mariam Shah and County Planning Commissioner Dawn Ortiz-Legg.