County Jail
County Jail

County Announces $5 Million Settlement Over Jail Inmate Death

Author: Administrative Office
Date: Thursday, July 27, 2017 9:09 AM

County officials have taken a hard look at the circumstances leading up to Mr. Holland’s death and have made sweeping changes in an effort to prevent a tragedy like this from reoccurring.


The County of San Luis Obispo has agreed to pay the family of Andrew Holland a $5 million settlement after his death at County Jail in January.

“Andrew Holland’s death at County Jail was a tragedy that should never have happened,” said Assistant County Administrative Officer Guy Savage. “It’s clear that counties and jails across the nation face systemic problems as the number of inmates with mental illness continues to climb. We are focused on fixing those problems here in San Luis Obispo County.”

County officials have taken a hard look at the circumstances leading up to Mr. Holland’s death. Since January, the County has made sweeping changes in an effort to prevent a tragedy like this from reoccurring. Some of the more significant changes include:

  • There are only 16 beds at the County’s only Psychiatric Health Facility, but there are about 600 County Jail inmates at any given time and a substantial number of these inmates suffer from mental illness. The County Health Agency changed protocols to ensure that the facility can now promptly accept mentally ill inmates who are a danger to themselves or others.
  • The Sheriff’s Office discontinued the use of its restraint chair and has updated its restraint policies. Restraint chairs are commonly used in emergency situations at jails across the state to prevent inmates from harming themselves.
  • The Sheriff’s Office has also restricted the amount of time an inmate can spend in a safety cell to no more than 72 hours. Now, after 48 hours, only a Health Agency psychiatrist can extend the amount of time an inmate can spend in a safety cell, and only by 24 hours after an in-person assessment of the inmate. After 48 hours in a safety cell, an inmate must be either cleared for jail housing, cleared for an extended stay in a safety cell by a psychiatrist, admitted to the County Psychiatric Health Facility, or transported to a hospital.  
  • Both the Sheriff’s Office and the Health Agency have added dedicated supervision of the medically and mentally ill inmates at County Jail and have increased communication between the Sheriff’s staff and Health Agency staff.

The County has also changed important policies and procedures at County Jail and the Psychiatric Health Facility, provided additional staff training, and improved oversight and communications between the Sheriff’s Office and the County Health Agency to address the treatment of the medically and mentally ill inmates at County Jail.

“The Sheriff’s Office recognizes the tragedy of this situation and we are committed to working with the Health Agency to ensure something like this does not happen again,” said Sheriff-Coroner Ian Parkinson.

Mr. Holland, a 36-year-old Atascadero resident who had been struggling with mental illness much of his adult life, was in custody since September 2015 and faced multiple charges, including resisting arrest, battery and a probation violation.

He was later declared by the San Luis Obispo County Superior Court to be incompetent to stand trial. The court ordered him to be transferred to the County’s 16-bed Psychiatric Health Facility, which is operated by the County Health Agency. Unfortunately, the facility was unable to accept him.

On January 20, 2017 while Mr. Holland awaited transfer, correctional deputies observed Mr. Holland striking himself in the face and head repeatedly. Jail staff placed him in a restraint chair to prevent him from harming himself further. Additional efforts were made to transfer him to the Psychiatric Health Facility during this time. He was also under observation and monitored approximately every 15 minutes by jail staff under the guidance of medical and mental health professionals.

After he was released from the chair on January 22, 2017, he was under direct observation and soon became unresponsive. Custody deputies and medical staff tried unsuccessfully to revive him.

"We feel terrible about what happened to Mr. Holland. The County Health Agency is dedicated to making the changes necessary to prevent this type of event from ever happening again," said County Health Agency Director Jeff Hamm.

Mr. Holland’s family and the County agreed to settle out of court rather than engage in lengthy, expensive and stressful litigation. Most of the funds to pay the settlement will come from the County’s medical malpractice insurance, less a $10,000 deductible the County is required to pay.