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Two years later: Has the county made systemwide changes since Andrew Holland’s death?

Posted at 5:39 PM, Jan 22, 2019

Tuesday, January 22 marks two years since the tragic death of Andrew Holland. The 36-year-old, who suffered from schizophrenia, died at the San Luis Obispo County Jail after spending 46 hours strapped to a restraint chair.

The county settled a lawsuit with Holland’s parents and vowed to change how it treats mentally ill inmates.

Fast forward to the summer of 2017, just six months following Holland’s death, when the county sent out a list of systemwide changes that were made at the jail and the SLO County Health Agency.

Those changes included:

  • Discontinued use of a restraint chair
  • Restricted amount of time in safety cells
  • A new place for inmates who are incompetent to stand trial
  • Changed Psychiatric Health Facility protocol to promptly accept inmates with declining mental health
  • Made medical forms easier for families to submit online
  • Increased observation of medically and mentally ill inmates
  • Increased collaboration between jail, medical and mental health supervisors
  • Increased training for deputies, medical and mental health staff at County jail
  • Formed Sheriff’s Mental Health Task Force

San Luis Obispo County District 3 Supervisor Adam Hill says in the past two years, communication has strengthened between the SLO County Health Agency and the San Luis Obispo County’s Sheriff’s Office.

“I feel like everybody’s on the same page now,” Hill said.

The Stepping Up Initiative is also at the county’s forefront for change. It’s a nationwide effort that aims to keep the mentally ill out of jail, an effort San Luis Obispo County has joined.

Like Hill, Anne Robin, the SLO County Behavioral Health Administrator for SLO County Health Agency says communication between departments in the county has strengthened.

“The level of communication that we have with the decision makers in the court, we meet monthly to really look at the system, and that had happened way in the past but it’s happening now as part of the mission,” Robin said.

Jail transfers to the Psychiatric Health Facility have increased and the process is quicker for inmates, according to Robin.

“At any one time we have between three to five inmates in our 16-bed inpatient unit,” Robin said. “We have embraced the idea that inmates have first cut at a psychiatric health facility bed.”

San Luis Obispo County Psychiatric Health Facility

Since that change, Robin says the PHF no longer accepts children. Instead, juveniles are taken to out of area hospitals for treatment.

Mental health specialists are also staffed at Twin Cities Community Hospital and Sierra Vista Regional Medical Center to provide assessment and treatment to patients upon arrival. Still in the works and through Assembly Bill 1810, a mental health diversion court.

“Where the Court can divert people pretrial into a program if there’s a nexus between their mental health disorder and the crime they committed,” Robin said.

Also at the jail, Dr. Christy Mulkerin is the Chief Medical Officer and was appointed after Holland’s death. She is overseeing the medical, mental and dental healthcare of all inmates.

“My role is to not only make sure they’re getting the very best care while they’re here but try to improve the transition to the community to help them not come back,” Mulkerin said.

Part of the care will soon include a behavioral health unit at the jail. Mulkerin says it will be a facility with at least 12 beds that will offer counseling and medication services to inmates.

The San Luis Obispo County Jail will soon open a behavioral health unit for inmates.


On February 1, Mulkerin says a new private healthcare provider called Wellpath will take over. That contract will include a new five-bed Jail Based Competency Program that will treat mentally ill inmates who’ve been charged with a felony and are incompetent to stand trial.

In addition, the Sheriff’s office requires deputies undergo 40 hours of training to better understand how to handle a mentally ill inmate in their line of work. Plus, the protocol when it comes to safety cells has also changed.

“Now, inmates can only be in the safety cell for 48 hours and they’re under a psychiatrist’s care that whole time,” Mulkerin said.

But is it enough? The Holland family also released proposed changes they wanted to see the County make following their son’s death. Through the grieving process and a desire for change, the family has created the Andrew Holland Foundation. It’s a non-profit with a team working to help mentally ill people in the criminal justice system. A portion of a $5 million settlement the family received from SLO County following Andrew’s death will go toward the foundation.

The Holland family has already helped several families. Andrew’s parents, Carty and Sharon Holland are hearing from families around the country. Two years later, they want to make sure the tragedy that rocked their family has turned into a catalyst for change.

“Ever since Andrew’s death we have had probably once every week and a half, people reaching out from around the United States,” Carty Holland said.

The ultimate goal for the foundation? Carty says it’s to build a facility in northern San Luis Obispo County that could house mentally ill inmates who might otherwise end up in jail.

“We would really like to work with the County or the City of Paso Robles, or the state,” Carty said. “I want to work and Sharon wants to work and the foundation wants to work with whoever is in that position to make a change.”

The United States Department of Justice is conducting an investigation into the medical and mental health care of inmates at the SLO County Jail. The FBI is also investigating a civil rights violation at the jail.

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