Never again can an inmate be allowed to die like Andrew Holland

Andrew Chaylon Holland, pictured here in a 2015 family photograph, died Jan. 22 after a blood clot formed after he was restrained in a chair for nearly two days in San Luis Obispo County Jail.
Andrew Chaylon Holland, pictured here in a 2015 family photograph, died Jan. 22 after a blood clot formed after he was restrained in a chair for nearly two days in San Luis Obispo County Jail.

By any reckoning, San Luis Obispo County Jail inmate Andrew Holland, 36, died an awful death. While there have been other inmate fatalities at the County Jail — a 60-year-old man died Thursday after complaining of shoulder pain — the circumstances surrounding Holland’s death are especially disturbing.

He was strapped naked to a plastic restraint chair for 46 hours and died in a cell just 20 minutes after he was freed from the chair — a device sometimes referred to as “the devil’s chair” or “the torture chair” by inmates and their advocates.

The Tribune learned Friday that the San Luis Obispo Sheriff’s Office has “suspended all use of the chair until further notice” and is reviewing its “restraint policies and procedures.”

That’s the right course of action.

Ideally, the restraint chair will be permanently banned, or at the very least, its use severely restricted to limited periods of time, because no one should have to go through what Andrew Holland experienced.

Authorities say Holland — who was diagnosed with schizophrenia and had been in and out of custody for several years — was restrained for his own safety after he was seen “striking and inflicting injury upon himself.”

He was not allowed to leave the chair, but his limbs were exercised approximately every two hours, according to county officials.

If Holland was such a danger to himself and/or others that he had to be restrained for such an agonizingly long time, he did not belong in the County Jail.

Superior Court Judge Jacquelyn Duffy said as much; 12 days before Holland’s death, she ordered that he be confined and treated at the county’s mental health inpatient facility.

The judge had also ordered that he be administered antipsychotic drugs, which wasn’t done.

Documents obtained by The Tribune show there was at least one bed available in the Psychiatric Health Facility in the days leading up to Holland’s death.

But according to Jeff Hamm, the county health agency director, that doesn’t necessarily mean the facility can accommodate a specific patient.

“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,” he wrote in response to questions from The Tribune.

County Mental Health Services is working on increasing capacity; a four-bed crisis unit is expected to open next year for patients who can’t be accommodated at the Psychiatric Health Facility.

That’s a far more humane approach than strapping a disturbed inmate in a restraint chair that’s widely known to cause serious health issues — though the county has so far not attributed Holland’s death to his long confinement in the chair.

An autopsy concluded that he died of natural causes, specifically, an intrapulmonary embolism — a blood clot in the lungs. Generally, an intrapulmonary embolism begins as a blood clot in the leg that then travels to the lungs.

Sheriff Ian Parkinson said the restraint chair did not cause a blood clot to form, yet it’s been acknowledged that restraint chairs make inmates susceptible to blood clots.

The manufacturer of the Safety Restraint Chair recommends limiting time in the device to two hours:

“This two-hour time limit may be extended, but only under medical supervision … This extended time period must not exceed eight hours and range of motion exercises must be performed regularly. Therefore we do not recommend anyone be left in the Safety Restraint Chair for more than 10 hours total.”

(The type of chair used at the County Jail, a Pro-Straint Restraint Chair, does not include such warnings with its online promotional materials.)

Multiple deaths and injuries in U.S. jails have been linked to restraint chairs, and both legal and health professionals have advised using extreme caution when restraining inmates.

In 1999, a judge ordered Ventura County jailers to stop using the chairs after four former inmates claimed they were kept in restraints for long periods of time for only minor offenses. The county later agreed to limit time in the restraint chairs to four hours.

Even Maricopa County, Arizona — with its reputation as a hard-nosed, law-and-order county — got rid of its restraint chairs after they were linked to up to three deaths — including one death that led to an $8.5 million lawsuit settlement. (The county did, however, replace them with restraint beds.)

Legal and medical professionals advise using the chairs only as a last resort, and under strictly controlled circumstances.

San Luis Obispo County’s policy in effect when Holland died was vague as to how long the restraint chair could be used; it stated that restraints should be used “no longer than is reasonably necessary.”

A new state standard that took effect April 1 requires that an inmate be transferred to a medical facility for evaluation after eight hours in restraints.

Unfortunately, that standard came too late to help Andrew Holland.

Holland’s family is pressing for changes in the way mentally ill inmates are treated, and depending on the county’s response to the family’s initial claim, may file a lawsuit.

But it should not require a lawsuit or the threat of a lawsuit to get the county to do the right thing. Nor should the community have to wait the years that it typically takes for a civil case to wend its way through the courts.

Sheriff Parkinson did invite the FBI to investigate “any jail death that’s occurred that they feel was worthy of their own investigation.”

However, we believe an investigation must go beyond any single incident to examine how inmates — particularly inmates with mental illness — are handled both at the County Jail and County Mental Health Services. If nothing else, it will shine a light on what additional funding or staffing may be required.

If the county doesn’t have the ability to administer treatment humanely, promptly and professionally at existing facilities, that must be corrected or we must find a place that is able to provide proper care.

This is not an incident that can be glossed over and forgotten.

As awful as it is, it will be far worse if no effective steps are taken to ensure it doesn’t happen again.