The knock came around midnight.
The officers told Carty Holland that his son, Andrew, had died at the county jail.
“They didn’t tell me how he passed,” Holland said. “The ugliness of it came later on.”
Andrew, a 36-year-old man with schizophrenia, had been found unfit to stand trial and was at San Luis Obispo County Jail awaiting transfer to the county’s psychiatric health facility in 2017 when staff observed him hitting himself in the face and strapped him down to a chair in an observation cell.
He was restrained — naked except for a blanket — for 46 consecutive hours and died from a blood clot 40 minutes after he was released. Holland recalled watching video of the incident: When Andrew was finally let go, he was unable to stand up, so guards “dumped him” onto the ground. He “spent his last minutes writhing on the floor … while deputies watched,” federal investigators found.
“It was a gruesome way to die,” Holland said.
Following Andrew’s death, his family settled with the county and spoke out about the incident, prompting local reforms, Justice Department intervention, a statewide report from a disability rights group and updates to California’s state regulations concerning use of restraints.
Eight years later, federal officials say the jail has made “significant strides,” and facilities across the state have codified the updated regulations in local policies. But many point to ongoing gaps in community mental healthcare services and the challenges jails face in properly caring for people who are mentally ill.
“There have been some changes here that have helped,” Holland said. “And I’ll tell you what, it’s like pulling teeth.”
‘Significant’ but ‘inadequate’ changes
Holland said his family initially received little information about what happened to his son. A sheriff’s office press release the next day said “an inmate was found unconscious and unresponsive in a glass observation cell” with “no outward signs of trauma.” It failed to mention the restraint chair.
An initial autopsy from the coroner’s division of the sheriff’s office ruled the death as “natural,” caused by a blood clot. But the family pushed for a second opinion, and a private autopsy found the clot was caused by prolonged immobility.
Weeks later, Holland and his wife, Sharon, spoke out in a local news story that revealed Andrew had been restrained for two days and found with “bruises on his arms and legs, a swollen nose and dried blood and feces on his body.”
That April, another detainee died in the jail, and the FBI officially began looking into the facility the next month, according to local reports. Come July, the county announced it would pay Holland’s family $5 million. The family held a press conference that day, saying the money would be used to start a foundation in Andrew’s name and calling on the sheriff to resign.
The county, meanwhile, pointed to “sweeping changes” made in the prior months. In a statement at the time, Sheriff-Coroner Ian Parkinson said his office “recognizes the tragedy of this situation” and was committed to working with the county’s health agency “to ensure something like this does not happen again.”
The county said it had discontinued restraint chair use, updated restraint policies and restricted the amount of time someone can spend in an isolation cell. The county’s health agency also changed its protocols to ensure the county’s psychiatric facility could “promptly” accept mentally ill inmates who are a danger to themselves or others, the county said.
The sheriff’s office and health agency increased communication between staff, provided training, and added “dedicated supervision” of medically and mentally ill inmates, the county said. The jail also hired a chief medical officer, moved to an electronic medical records system, expanded its medical clinic and commissioned an outside evaluation of jail health services.
The facility was holding approximately 540 people — both sentenced and pretrial detainees — at any given time, many with a mental illness or substance use disorder.
Stephanie Landgraf, a correctional captain at the jail, said the sheriff launched a mental health task force of community organizations to assess county needs and identify gaps in services. She said the task force later morphed into a work group through the Stepping Up Initiative, a national initiative to reduce the number of people with mental illnesses in jails.
In 2018, the DOJ’s Civil Rights Division and the U.S. Attorney’s Office for the Central District of California launched an investigation into the jail. Investigators noted additional changes at the facility during their probe: The jail created more mental health housing and a behavioral health area, opened a unit to restore to competency people deemed to be unfit to stand trial, and switched to a private contractor, Wellpath, the nation’s largest provider of correctional healthcare.
Even with those “significant changes,” in 2021, the DOJ concluded that the jail violated the Eighth and Fourteenth Amendments and the Americans with Disabilities Act by failing to provide adequate medical and mental health care, placing people with serious mental illness in isolation for prolonged periods and subjecting detainees to excessive uses of force, among other issues.
Even as the jail stopped using restraint chairs, staff were restraining people in another device: the WRAP, a full-body system that restrains someone in a seated position. Officers were using the device as early as 2016 and, by 2021, the jail was using it more than a dozen times monthly, often invoking “vague and uncertain grounds” to justify use, the report found.
The report found the jail lacked adequate accountability, data collection, analysis and corrective action. It outlined more than 60 remedial measures, calling on the jail to revise and comply with policies, increase and retrain staff, and report and review data, among dozens of other items.
“In listing these remedies, we note that over the course of our investigation the Jail has made changes to its personnel, policies, and procedures,” the report said. “We have taken those changes into account, but find they are inadequate.”
A push for statewide regulations
Even as they grieved, the Hollands continued to advocate for change and share Andrew’s story in the media. The family led annual marches and candlelight vigils at the jail and donated to the campaigns of candidates running against the sheriff and district attorney. “We raised a lot of ruckus,” Holland said.
The case drew the attention of Disability Rights California, the agency designated under federal law to advocate for people with disabilities in the state. The agency launched a survey of restraint chair use in jails and reviewed state regulations and policies from all 58 counties. The Hollands also met with investigators.
The resulting report, published in 2020, said Holland’s death demonstrated “the need for clear, enforceable restraint standards” and concluded that existing state regulations were “insufficient to protect incarcerated individuals from the dangers posed by the restraint chair.”
The report recommended changes to state regulations, including requiring medical assessment prior to or at the beginning of restraint, direct observation during restraint, and time limits on the duration, as well as accountability measures, such as videotaping, documenting, and reporting to the state.
Some counties were already taking these steps, the report noted. Nine were not using the chairs at all, and others had policies in place that go far beyond the minimum standards, such as limiting chair use to two hours within a 24-hour period. But changes to state rules were still necessary, the report said.
Regulations for local detention facilities, including minimum standards, are created by the Board of State and Community Corrections, an independent statutory agency, and reviewed every two years. The Disability Rights California report recommended the BSCC create a separate set of regulations specifically for the use of restraint chairs, including a requirement for jails to track incidents and durations and report them to the BSCC monthly.
How three states are addressing the use and abuse of restraint chairs in jails.
Pennsylvania: How public data led to a ban on restraint chairs in Allegheny.
Iowa: How a watchdog investigation spurred reform in two jails.
California: After a mentally ill man died his family’s advocacy led to statewide changes.
In 2019, the BSCC established a committee — including Disability Rights California staffers — to revise the regulations. In 2021, the BSCC implemented changes requiring jails to do the following in situations where restraint is used: attempt less restrictive alternatives before restraint, maintain direct visual observation until a medical opinion can be obtained, follow the manufacturer’s duration limits and document incidents.
The updates included some but not all of the proposals outlined in DRC’s report. The BSCC did not implement the recommendation to require jails to report incidents to the state monthly. Notably, the regulations then and now also require staff to review restraint at least hourly and to take someone to a medical facility if they cannot be “safely removed” after eight hours.
Asked about how the changes to California regulations have affected the use of restraint chairs across the state, the BSCC said it could not comment. “We do not collect data on the use of restraints,” said spokesperson Jana Sanford-Miller. She said her staff was unaware of any statewide agency that collects data on the use of restraints. Disability Rights California said they haven’t done a follow up survey since the report.
Illinois Answers spoke with sheriff’s department officials in California who said the changes in state regulations prompted them to review their county-level policies. “The only thing we really had to change was we had to go by manufacturer guidelines, so we had to write that in,” said Commander Nate Wilson of the Orange County Sheriff’s Department.
Lt. Dennis Griffin of the Humboldt County Sheriff’s Department said his agency’s policy was already in line with the updates. His agency abides by the rule requiring staff to transport a detainee to a medical facility if restraint exceeds eight hours, he said, and that almost happened in 2023. His staff were preparing transport when they were able to safely release the person.
While the BSCC does not have specific enforcement powers such as fines or compliance mandates, jurisdictions have incentive to maintain compliance to avoid litigation, Sanford-Miller said. “In addition, making inspection reports public and asking sheriffs and facility operators to personally appear before the Board to explain why facilities remain out-of-compliance has also resulted in jurisdictions fixing items of noncompliance,” Sanford-Miller said.
Donald Specter, a senior staff attorney with the Prison Law Office, a nonprofit public interest law firm based in Berkeley, said his organization has investigated at least two jails in California regarding the use of restraint chairs. He said it’s crucial for jails to set duration limits, require supervisor approval for use and involve periodic examinations by medical personnel.
“Those policies and procedures have proven effective in reducing the number of people subject to being in a restraint chair and the durations and the conditions under which they’re in the chair,” Specter said.
Years later, the jail has made ‘significant strides’
In January, the Justice Department announced a settlement agreement with San Luis Obispo County to resolve the department’s findings and recognize “the significant strides the county has made in some areas.” At the same time, the settlement “does not amount to any admission of wrongdoing” by the county, which disputes the findings and denies the allegations.
“We are encouraged by the improvements the San Luis Obispo County Jail has made since we announced our investigation, but there is still more that must be done to achieve constitutional compliance,” Assistant Attorney General Kristen Clarke said in a press release.
In a statement, the sheriff’s office said the settlement “not only highlights the significant advancements we’ve achieved over the years but also underscores the progress we are committed to maintaining.”
The agreement cited “improved” medical and mental healthcare, higher staffing and “progress” in curbing excessive force. It also reiterated and expanded on the measures outlined in 2021 and required the county to implement a quality assurance program to ensure “deficiencies” are identified and corrected in a timely manner, with regular reports to analyze trends.
“No one event is going to completely change everything, but it does have a spotlight on it to change the way we do corrections,” said Landgraf, the correctional captain. “And I think we’ve made a lot of significant improvements.”
Data provided to Illinois Answers through public records requests shows the jail has reported multiple deaths since Holland’s in 2017. The jail continues to report dozens of use of force incidents a year, according to jail data, including over a dozen uses of the WRAP annually in recent years.
Landgraf said staff now restrict use of the WRAP to two hours or less, document it as a use of force and track trends. “If they were not able to be safely removed … we would consider that a medical crisis and transfer them to a hospital,” she said.
Asked about what has contributed to improvements at the jail, Landgraf noted the county in 2018 received a multi-year grant from the DOJ’s Bureau of Justice Administration “Justice and Mental Health Collaboration Program” to address communication and data sharing among county agencies.
She said the jail also saw “significant changes” after moving in 2019 to an incentive-based program for detainees with serious mental illness, which rewards people with points to purchase items in the jail if they practice “good behavior,” such as socializing and maintaining hygiene.
By 2022, the jail had attained accreditation for healthcare services through the National Commission on Correctional Healthcare, recognizing the facility’s compliance with national standards.
Brian Atwell, who previously oversaw crisis services for the county’s psychiatric health facility, said, since 2018, he has helped administer crisis intervention training for the sheriff’s department and other law enforcement agencies in the area. He now serves as president of the local chapter of the National Alliance on Mental Illness (NAMI), which merged with the Andrew Holland Foundation in 2022.
“What I’ve noticed is a huge shift in police response, in the way they interact with individuals on the front end before even getting people to jail,” Atwell said. “Once they are in jail, I’ve noticed the change in the custody staff and interacting with the individuals … to keep people from having to get to the point of restraint and seclusion.”
Tom Buckley, vice president of the NAMI chapter, has focused on bolstering mental health resources in the community and improving communication between providers. A longtime social worker who grew up with Andrew Holland, Buckley started a mental health outpatient program five years ago and collaborates closely with Wellpath and a local mental wellness group.
“It’s easy to demonize law enforcement, but I think that a major change that needs to happen is a better collaboration with law enforcement,” Buckley said.
Paula Canny, an attorney for the Holland family, said she’s frustrated that the district attorney never brought criminal charges and the same sheriff remains in office.
Asked if the situation at the jail is better now than eight years ago, Canny said she’s not so sure. “It’s maybe a little bit different,” she said, adding, “To me, it just comes down to the fact that the people who suffer in jails shouldn’t be in jail in the first place. They’re mentally ill.”
Holland said he’s still grieving his son. It was a “very public death” in a very small community, he said. But, with a lifetime lived in San Luis Obispo and his kids and grandkids nearby, he’s not going anywhere.
Holland said he believes the most significant change at the jail has been switching to a private healthcare provider. If restraint must still be used, he said, it must be limited.
“If your staff can’t get it right, can’t get them straightened out in two or three hours, then you need to call professionals that know how to do that,” Holland said. “Because you’re risking the person’s life otherwise. And they certainly did with my son.”
![[Video] Strapped Down: Investigating Restraint Chairs in Illinois Jails](https://i0.wp.com/illinoisanswers.org/wp-content/uploads/2024/05/B0011836.jpg?fit=1200%2C9999&ssl=1)
