There are nearly ten times as many mentally ill persons in jails and prisons as there are in mental hospitals presently in the U.S., according to a recent Marin County Civil Grand Jury report. And California's county jails have a "particularly severe burden" due to the closing of most of the state's mental hospitals.
We are reexamining the 2017 death of Andrew Holland at the San Luis Obispo County Jail, with a special segment produced by former KCBX News reporter Bree Zender.
“Tyler, Just got your letter. Thanks for writing.”
This is Sharon Holland. She lives on a ranch with her husband in a rural part of Atascadero, California. Mother of four. She’s reading from a letter that one of her sons, Andrew, wrote in 2008 to her older son, Tyler.
“I just got out of isolation. Close to three months down. I’ve got that scraggly beard that you like. Feels good to be out of the dungeon. I’m waiting to go to Atascadero State Hospital. Back to the loony bin. Oh well. I’m not too upset about it. I’m just kind of rolling with the punches at this point. That’s crazy you wrote me. A couple days ago, I was thinking to myself, ‘Why doesn’t my bro write me?’ Then, I stopped myself and I said to myself, ‘How many times have you written him?’ You’re interested in a girl, I hear. That’s cool. But when did you start liking the female gender? Smiley face. No, seriously. I really do miss you. And the family. It’s hard to explain what I’m going through. It’s weird because sometimes when I’m out of jail, I feel like I’m more in prison than when I’m not in jail. I’ll have a dream that I’m in jail, and I can’t get out. Only to wake up there. I don’t really know what to think about God anymore. I don’t know how he would allow someone to suffer as much as I have. I read on the Internet that schizophrenia is not curable. They can numb it a little with medication. But other than that, it’s like a cancer without a cure. Tyler, I’m telling you this because I really want out of this life. I’m not saying that I’m planning on killing myself. I’m just saying, if it were to happen, be happy for me. And know that I really do love you. And I’ll see you in heaven. I know you’re going to be there. Because if you weren’t, God’s got some explaining to do. Anyhow. Tyler, I love you. Thank you for being my brother. You’ll always be in my heart. Keep your head up. Drew.”
Nearly nine years after Andrew Holland wrote that letter, on January 20, 2017, San Luis Obispo County Jail officers took Andrew from his solitary confinement cell, and strapped him naked to a restraint chair. They would not let him stand 46 hours. Not even to use the toilet. Less than 45 minutes after jail staff released him from the chair, Andrew was dead.
According to two different autopsies, he died of an intrapulmonary embolism. A five-centimeter blood clot formed in his leg, and traveled to his lungs. The county’s senior deputy coroner ruled the manner of death as ‘natural.’ According to a second autopsy, the clot formed because he could not stand for nearly two days, and it ended up suffocating him. He was 36 years old.
Over a year has passed since Andrew’s death. The San Luis Obispo County Sheriff’s Office says it’s made changes in how mentally ill inmates are treated in the county jail.
We’re revisiting the events that led to Andrew’s death, and afterwards. The Holland family said had they not insisted on an outside investigation, it’s possible the true details of how and why Andrew died would never have come to light.
The Holland family has set roots in San Luis Obispo County. Carty Holland, and his brother, Ron, owned a family contracting business together. Carty and his wife Sharon raised their four kids alongside his brother’s children.
“My name is James Tavener Holland… Tavener Holland. But I go by Tave. And Andrew Holland is my cousin. My first cousin,” Tave Holland said.
Tave said he, his two siblings, and Andrew… along with Andrew’s brothers and sister - Corban, Tyler and Elena - were close growing up. Tave is about three years older than Andrew.
“We were cousins, but as kids we grew up much more like siblings. You know, one week it seemed like we were with my Uncle Carty and Aunt Sharon, and another week we were with my mom and dad,” Tave Holland said. “Whether it’s playing in the creek, riding bikes, causing trouble… we did everything together.”
Tave said Andrew specifically watched out for him. When Tave was a sophomore in high school, he missed nearly a whole school year after coming down with Valley Fever. It got to a point where he couldn’t rise out of his bed unaided.
“Andrew would come by to see me. And as I got a little stronger, he would encourage me to get out of the house and go take a hike in the creek with him. Go downtown,” Tave Holland said. “And probably more than anyone really constantly showed up.”
Tave said Andrew was around 12 or 13 at the time. Andrew was a gifted athlete, surfing especially. He and his family would travel looking for the best place to surf.
His parents say he started expressing delusions when he was around 18 years old. This is a typical age many people start showing symptoms of schizophrenia. Here’s Andrew’s father, Carty.
“It would vary. It didn’t always look the same, but he would start hearing voices,” Carty Holland said. “He would start being very, very paranoid. Just delusional.”
Carty and Sharon said Andrew began self-medicating around the same time he first developed symptoms of schizophrenia. This became a recurring pattern in his adult life.
“Andrew… often times is he would begin to decompensate off of his medication,” Sharon Holland said. “If the medication wasn’t working quite right, or if he found himself starting to hear voices, a lot of times he would then turn to alcohol. Or whatever he could find. And it would begin to make him feel better for a very short period of time. And then he would really crash, because then he would stop taking his meds altogether.”
His family members said Andrew’s paranoia often centered around authority figures, particularly police officers. They say the only times he was violent with others was if he felt threatened by an authority figure. His family said this symptom of his mental illness got him in a lot of trouble, cycling in and out of the criminal justice system. And when he was in jail… and the right medications often limited, he found himself in more trouble.
“Well, let’s just say if a guard came to his cell door, and asks him to step out of the cell… he’s talked to us about this. ‘I thought they were coming to kill me..’” Carty Holland said. “Well that’s not a rational mind, if your guard comes to your cell and says ‘step out, we want to take you to go shower… we want to do this or do that…’ In his delusion and the voices, they were saying we’re going to kill you.”
For years Andrew revolved in and out of many places - from the jail to the Atascadero State Hospital, to the county’s Psychiatric Health Facility, to his family’s home, and sometimes the streets. The last time, he was in the county jail because of a September 2015 incident. Andrew was arrested and charged by San Luis Obispo police with resisting arrest with force and battery on a police officer, and a parole violation. The Holland family alleges he was kept in solitary confinement at the county jail for nearly 14 months.
According to the American Psychological Association, increasingly laws are being passed making it illegal to place mentally ill inmates in solitary confinement. Numerous studies have found the conditions of solitary confinement can severely exacerbate symptoms of mental illness.
When asked about Andrew’s time in solitary confinement, the San Luis Obispo County Sheriff’s Office would not comment.
The county coroner’s report states that between the time he was arrested in September, 2015, and the day he died, Andrew was transferred once to the county’s psychiatric health facility for five days, then returned to the jail. On January 10, 2017, he was ordered to be committed once again to the psychiatric health facility until quote his mental competency to stand trial was restored. Ten days later, he was still waiting transfer when jail staff allegedly saw him punching himself in the face, and that’s when they moved him to a holding cell and locked him into the restraint chair for the next two days.
After he was released from the chair, he was placed in metal ankle shackles and handcuffed before being examined. He was still wearing the metal ankle shackles when officials started examining his dead body.
"For about a month, I was in real distress because as a mother I knew something was wrong,” Sharon Holland said.
Sharon says the jail had taken away Andrew’s visiting rights, because he had gotten himself into trouble. She and Carty wrote letters to the Sheriff and visited the jail, trying to see him. But the letters were never delivered and the jail staff wouldn’t let them see Andrew. She suspected there must be something wrong with his medication. She didn’t know what was wrong, but she just had a feeling.
“And I had a dream. My son, my middle son, the one just older than Andrew… came to me and said, ‘Mom, Andrew is dead.,’” Sharon Holland said. “And I said, ‘Don’t ever say that to me.’ And he said, ‘No, it’s true. He’s gone.’ And I woke up, I was so real.”
About a week and a half later, at nearly midnight on January 22, Sharon and Carty couldn’t sleep. They usually go to bed around 8 or 9 at night. There was a knock on the door. Sharon stayed in bed, and Carty got up to answer it. It was two police officers. “
Carty came upstairs, and he looked at me and he said in the very same voice… ‘Andrew’s gone,’” Sharon Holland said. “’And I said ‘Don’t say that.’ He said ‘It’s true.’ It was exactly the same scenario. And I knew it was true, but I had been in so much pain. And it was just like… ‘How could this be?’”
Very little was known to the public about Andrew’s death at the beginning. The San Luis Obispo County Sheriff’s Office issued a press release the next afternoon.
The release said Andrew was placed in a glass observation cell in the jail because quote “he had been striking and inflicting injury on himself.” It made no mention Andrew had been placed in a restraint chair.
According to the Sheriff's Office, jail staff checked on and monitored Andrew quote “approximately every 15 minutes,” and that he was under the continual care of a physician when he was in the glass observation cell. It said jail staff found him unconscious in his cell and began providing emergency lifesaving attention to revive him. And it said there were no quote “outward signs of trauma on Holland’s body” and quote “no foul play is suspected.”
This immediately struck Karen Velie as suspicious. Velie runs a website called Cal Coast News, and lost a closely-watched libel lawsuit in 2017. But it was Velie who contacted the Hollands, telling them her sources at the jail said Andrew had been strapped naked to a restraint chair for nearly two days. It was Velie who urged the family to seek a second autopsy.
Tave Holland--Andrew’s cousin--is now an attorney, with an office near downtown San Luis Obispo. He says he had a hard time believing what Velie said happened to his cousin.
“She's a controversial character and I understand why. But whatever controversies surround her and her reporting... pretty much everything that she told me was dead on accurate,” Tave Holland said. “Essentially Karen and I had to develop very quickly some level of trust with each other because I didn't know her well enough to take what she was saying and take that to my and uncle and say I need you guys to do another autopsy. I mean these are all the things that are happening. I need to hear from the sources.”
Velie convinced her sources to talk to Tave.
“They were bothered very deeply by what they saw. Eventually, some of them were willing to talk,” Tave Holland said. “And when you hear the same story from, when you hear a story you can’t believe from one person, it’s one thing. But when you hear that same unbelievable story more or less in the same detail from three, four, five...even six people.”
Tave knew he had to convince his Aunt Sharon and Uncle Carty to get a second autopsy on Andrew’s body. Eventually they agreed.
In the first autopsy, performed by a contract forensic pathologist who is no longer working for the county, the cause of death is right intrapulmonary embolism, essentially a blood clot that formed in his leg, traveled to his right lung, and suffocated him.
In autopsies, the cause is the medical reason for the death. The manner is a characterization of how the medical reason happened- whether it was natural, suicide, homicide, accidental and so forth.
After receiving the final autopsy report, San Luis Obispo County’s senior deputy coroner Jason Caron certified Andrew’s manner of death as ‘natural,’ saying the clot naturally formed in Andrew’s body. The second autopsy found the same cause of death: right intrapulmonary embolism. The key is the autopsy performer’s opinion of the manner of death. Dr. Duc Van Duong said Andrew must have been restrained for a long period of time prior to death, because it was his opinion that the blood clot formed from prolonged immobility.
Tave says the second autopsy was crucial. Because the first autopsy…
“...concluded that this was the natural cause of death and that the most he would give was that possibly the chair and the time in the chair restrained was possibly a contributory factor, but would not in any way acknowledge that it could have been a direct factor in his death,” Tave Holland said. “And that's some next level horseshit.”
On February 25, Velie published an article on the Cal Coast News website reporting Andrew had been strapped naked to a restraint chair and placed in a glass cell for nearly two days, citing accounts from anonymous county employees.
At that point, Tave brought in another lawyer. He said he felt too close to this case to work on it himself. So he found Paula Canny, a lawyer from the Bay Area, through someone he went to law school with who now works for her.
About a month and a half after Andrew’s death, Tave said San Luis Obispo County Sheriff Ian Parkinson requested to meet with him. The reason given, according to Tave, is that the Sheriff felt the Hollands needed to “get the answers that they deserve.”
Tave said just the two of them met in the Sheriff’s office for about four hours, and that the Sheriff didn’t dispute the main details of the Cal Coast News article, except that Andrew wasn’t naked, that he had a blanket on him at all times while he was in the chair.
It’s typical American jail protocol that when inmates are at risk of suicide or injuring themselves at their own volition, they are stripped nude, so they have no material with which to do themselves harm.
Tave also alleges when he asked the Sheriff why Andrew wasn’t allowed to get up to use the bathroom, the Sheriff said it wasn’t possible at the time.
“I said something to the effect of… Ian…. For God’s sake… Why?” Tave Holland said. “Why didn’t they let him up to go to the bathroom? In addition to being the human thing to do, it could have saved his life.”
To prevent blood clots, jail staff is expected to perform range of motion exercises, releasing a limb one at a time and massaging and moving the joint around to promote blood flow.
Tave says the Sheriff told him that when jail staff was performing these exercises on Andrew... “He’s punching, he’s kicking, he’s lashing out at staff in such a violent way,” Tave Holland said. “He described him as a wild animal… acting like a wild animal.”
Sheriff Parkinson’s office declined repeated requests - over the past six months - for an interview with KCBX. Parkinson also declined to comment on the existence of the meeting and what Tave said happened during it.
A little over a month later, Tave said he and the Holland’s lawyer, Paula Canny, met with San Luis Obispo County counsel. Tave was aware that there was security footage at the jail, and in the cell Andrew was in for those two days. He requested that the video be made available to them. What they saw on the footage shocked them.
Tave said the biggest thing that came from viewing the video was that Andrew was not violent in any of the footage. He was peacefully put in the chair. And when jail staff performed range of motion exercises, Andrew hardly moved.
“When I see the actual footage, this is really what floored me and what left me gutted,” Tave Holland said. “What I really wasn’t prepared for was how docile he was. How unaggressive. How compliant he was. And the utter needlessness of the whole thing.”
The surveillance videotape of Andrew’s time in the chair has not been made available to the public, despite public information requests from multiple media organizations, including KCBX News. Yet while reporting for KCBX News, I was given access to portions of this footage, observing nearly two dozen interactions jail staff and nurses had with Andrew while he was in the chair. And in those portions of the footage, Andrew never attacked or gave any sort of indication that he was going to attack nurses or jail staff.
In the video portions I viewed, there were times when Andrew’s blanket, which jail staff had placed on his lap, fell to the ground. Jail staff passed by the glass observation cell, and did not enter to replace the blanket.
The footage provided to KCBX News was a part of a documentary the Holland family made for the mediation process. The Holland family said they don’t want the video to be released to the public for privacy reasons, but they want the public to know exactly what happened to Andrew so that the County and society can address the human root of the problem. Here’s Carty Holland speaking about the county:
“If they really wanted transparency they would want the public to see that the video and and just take it on right up front and then it will help the public to help fund the necessary changes,” Carty Holland said.
Tave says the policies and procedures that were in place last January would have saved Andrew’s life if they had been followed, and that just making the policies stricter won’t fix anything.
Roughly six months after Andrew’s death, San Luis Obispo County made a settlement with the Hollands for $5 million dollars. At the time, the county’s attorney - Rita Neal - said the county opted for the settlement to avoid a lengthy legal battle with the Holland family.
The Hollands said they are using the money to try to help others who are struggling with mentally ill family members who have been caught up in the criminal justice system. They also said they frequently get calls from people who have family members struggling with similar issues that Andrew faced.
I’m Bree Zender. Thanks for listening.
Music by Evgeni Rogozin, Mister Drey, Montplaisir, and Podington Bear. This special segment was edited by KCBX News Director Greta Mart.