Carty and Andrew Holland
© calcoastnews.comCarty Holland with his son, Andrew.
A San Luis Obispo County Jail inmate died in January from an intrapulmonary embolism about 20 minutes after he was released from a plastic restraint chair where he had been held for nearly two days, according to a county coroner's report.

The manner of Andrew Chaylon Holland's death was ruled "natural" — a finding disputed by his family.

An intrapulmonary embolism usually begins as a blood clot in a leg vein, according to the National Institutes of Health.

Holland, 36, was found unresponsive Jan. 22 in a glass observation cell normally used for sobering inmates. A Sheriff's Office news release issued a day after his death said Holland had been placed in the cell after he was seen "striking and inflicting injury upon himself." The Sheriff's Office also stated that Holland was "under observation and was monitored and checked approximately every 15 minutes."

When guards noticed he was unconscious, the news release stated, custody and medical staff tried unsuccessfully to revive him.

The Tribune has sought records of Holland's final days in the jail, but the county has denied most of them, citing medical confidentiality. A request for specific custody records, including observational and restraint logs, is pending.

Court records show Holland had been ordered by a judge to be removed from the jail and treated at the county's in-patient psychiatric facility 12 days before his death.

Sheriff Ian Parkinson said Tuesday that jail staff followed all protocols during Holland's two days in restraints and that the restraint chair did not cause the blood clot to form.

Even though Holland's "seated position, dehydration, and self-injury were all possibly contributory to the cause of death, the formation of the intrapulmonary embolism was a natural response in the body," Parkinson wrote in an email response to The Tribune's questions, reiterating the coroner's ruling.

Parkinson also wrote that the Sheriff's Office's investigation into Holland's death is complete.

Paula Canny, the Holland family's attorney, said Tuesday that the family plans to file an administrative claim against the county demanding Parkinson make changes for jail staff dealing with inmates who have mental health issues. Should the county reject that claim, Canny said she plans to file a wrongful death lawsuit.

"Calling Andrew Holland's death 'natural' is like saying drowning is a natural death even though the decedent was held under water by another person," Canny wrote in an email. "That is not natural. That is cruel and callous."

She added: "The manner of death is homicide, not natural causes."

Holland is the eighth person to die in jail custody since 2012, according to Tribune archives. The number of county inmate deaths was higher than the national average in 2014 and 2015.

A spokesman for the California Department of Justice on Monday declined to confirm or deny whether the agency is investigating Holland's death or custody practices inside the San Luis Obispo County Jail.

Coroner's report

According to the coroner's report dated March 14, Holland was booked into the jail in September 2015 and was transferred to County Mental Health several times when his mental competency was questioned but then returned to the jail. He was initially booked on suspicion of assaulting a police officer, according to court records.

The report states that at about 5:40 p.m. Jan. 20, correctional deputies saw Holland punching himself in the face in a solo safety cell. He was restrained "for his safety" and placed in a Pro-Straint Restraint Chair in the glass observation cell, which is within view of the correctional staff manning the pod's center console.

According to the report, Holland was strapped into the seven-point harness chair (restraining an individual's arms, body and legs) at 6:55 p.m. Jan. 20 and was released from the chair at 4:43 p.m. Jan. 22. It does not state why he remained in the chair so long.

The coroner also notes that Holland refused food and water "numerous times" during his restraint.

The coroner wrote in his report that after watching surveillance video of the incident, Holland could be seen lying naked on his stomach in the cell at 4:55 p.m. At 5:02 p.m., Holland "appears to be having respiratory distress," the author notes, and at 5:08 p.m., Holland stopped moving.

Correctional deputies entered the cell at 5:09 p.m. and began CPR. An automatic electronic defibrillator was used before Holland was pronounced dead inside the cell at 5:36 p.m, according to the report.

The coroner noted that Holland had marks on his body consistent with restraint straps and handcuffs, and his hands were swollen with a contusion on his right hand and swelling in his face. There was an abrasion to his shin and dried blood inside his nose.

The Sheriff's Office's Jan. 23 news release stated there were "no outward signs of trauma on Holland's body."

While examining Holland's lungs during the autopsy, the coroner noted a 5-centimeter-long blood clot. No drugs or alcohol were found in his toxicology screening.

Asked why Holland was placed, and kept, in the chair, Parkinson wrote that Holland was causing physical harm to himself and would not respond to staff's attempts to stop him. Parkinson wrote that Holland was classified as a suicide risk, noting Holland's several alleged incidents of assaulting staff in the past.

County policy states that inmates should not be kept in restraints longer than necessary and that keeping an inmate in restraints for an extended period of time requires approval from a facility manager.

"His level of custody classification required him to have multiple correctional deputies present any time he was out of his housing location and placed in restraints," Parkinson wrote.

'This really hit me'

Holland was born in Oregon and grew up in San Luis Obispo County, according to several childhood friends.

He was known as a class clown, his former friends said, but he began to get into trouble in the early 2000s. As he would later tell a probation officer in a 2015 interview, Holland began to manifest schizophrenia in his 20s.

Court records show that between July 2014 and December 2016 nine criminal cases were filed against him, mostly for allegedly assaulting custody staff at the jail in incidents later determined by judges to be directly related to his mental illness.

Holland was found mentally incompetent to stand trial four times during that period, records show, and was taken to the county's in-patient mental health unit on Johnson Avenue in San Luis Obispo or Atascadero State Hospital for treatment, only to be restored to competency within a few months and returned to County Jail while his criminal case played out.

In several of those cases, court records show, judges suspended a prison sentence in favor of mental health treatment. Each time, however, he wound up back at County Jail after allegedly assaulting a staffer.

In an April 2015 interview with his probation officer after an alleged assault on a correctional deputy, Holland apologized and told the officer that he was off his medications at the time and "not thinking straight." According to the report, he told the officer that since restarting his medication, his paranoia waned and he said he wanted to go to ASH to continue treatment, as well as participate in a rehabilitation program.

Holland spoke openly with the officer about his diagnosis of schizophrenia and stated: "At age 25, this really hit me," according to the probation report.

At a competency hearing 12 days before his death, while he was at the jail, Superior Court Judge Jacquelyn Duffy ordered that Holland be confined and treated at the county's mental health inpatient unit, according to court records. She did so on the recommendation of a court-appointed psychiatrist.

She also authorized county mental health staff to administer Holland antipsychotic medications, which Duffy's order stated was "necessary as a part of treatment to assist the individual in regaining competency."

Records do not indicate whether Holland was given the medication before his death.

Canny, the Holland family attorney, alleges that County Jail staff violated state law and used the restraint chair as a "substitute for treatment."

According to state law, if an inmate cannot be safely removed from restraints within eight hours, "the inmate shall be taken to a medical facility for further evaluation."

"To blame this on Andrew Holland is despicable," Canny said. "Andrew Holland suffered from a well-known and well-documented mental illness. Placing a mentally ill person in a restraint chair for 46 hours is dangerous and cruel."