Supervisors need to launch investigation into Andrew Holland’s death

Mike F. Brown


The policing and jail business is inherently hazardous. The opportunity for mistakes is ever present. Violent acts and their potential are a constant threat. From time to time split second decisions must be made, such as whether to shoot or otherwise incapacitate a proven or potentially armed assailant.

Sheriff’s deputies, police officers, corrections officers, highway patrol officers, and probation officers can face terrible decisions, often alone and in the dark. They deserve the utmost support and respect.

When an apparent tragic mistake occurs, such as the admitted missteps that resulted in the death of San Luis Obispo County Jail prisoner Andrew Holland and a $5 million taxpayer settlement, it is incumbent upon the elected San Luis Obispo County Board of Supervisors, who constitute the accountable legislative authority, to take control of the situation.

The board should ask for the most complete and exhaustive formal investigation possible. and then issue a full and completely transparent report of what happened, how it happened, why it happened, and which officials and employees failed to follow administrative procedures and more importantly in this case, common sense and care for human life.

After all, a prisoner is already in a constrained environment.

In this regard, county staff has indicated that the county is conducting an “overall investigation” of the situation. The methodology and staffing of the investigation have not been disclosed. Thus it is not known if it is an in-house effort or if there is an independent outside investigator, such as the county engaged in 2009 to investigate its then-county administrator and assistant county administrator with regard to a litany of allegations (subsequently proved) involving improper personal conduct and conflicts of interest.

It seems deficient that the board has not engaged independent outside expert help, given the much more tragic and serious nature of this debacle.

Relatedly, the sheriff had announced previously that he had requested the FBI to investigate the matter. On Aug. 2, the FBI confirmed that it was investigating potential civil rights violations. Currently, accusations are circulating that there are jail videotapes displaying staff behavior in the Holland case that may go beyond inadvertent negligence. These allegations may be considered in the FBI’s investigation.

It has been reported and confirmed that the Los Angeles Times has made a public records release request for these videos. It is also reported that other news outlets have subsequently filed their own requests. The matter may begin to take on national notoriety as a result.

County counsel and staff are considering how to handle the media demands. Has the SLO County Board of Supervisors had an opportunity to review the videos?

The fact that the FBI is conducting an investigation does not relieve the board of supervisors from the responsibility of conducting its own investigation of the structural, management, performance, and communications problems evinced in its own statement of “sweeping changes.” The FBI is not a management consultant and is not responsible for ensuring accountability and discipline within the county bureaucracy.

The board can little afford to appear to be consenting to a cover up in a varnished investigation by their own staff bureaucrats and officials, some of whom are political supporters and many of whom are long term colleagues with strong professional and social ties among themselves.

So far, the county’s official response has been to admit mistakes and to promulgate a list of revised administrative procedures. The substance of the changes suggests serious operational, communication, and management problems. For example the document, in the form of news release posted on the county website, states in part:

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 (PHF), but there are about 600 county jail inmates at any given time and a substantial number of these inmates suffer from mental illness. The SLO 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.

COLAB NOTE: If the PHF is full, why don’t they have a contract with an outside locked mental health facility such as Vista Del Mar in Ventura to receive the overflow? Did anyone in the county refuse to fund such a contract?

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. 

COLAB NOTE: What does the 48-hour clearance do? Holland was already in mortal danger prior to 48 hours. Again, if the PHF is full, why not transport them to a contract hospital sooner? Hill and Gibson are always bragging about the great County Budget. Did they not have the funds? What happened here?

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. 

COLAB NOTE: What does this mean? In the past, if there had been a problem, wouldn’t the jail commander or duty jail shift commander pick up the phone and call the duty Behavioral Health Department manager? If it wasn’t resolved, why didn’t they call the sheriff, behavioral health director, health agency director, and CAO to get action?

In the end, and if the investigation is independent and the results are publicly disclosed, there will be much more citizen support for law enforcement, the justice system, the health agency, and the county leadership.

There are several new separate jail death suits brewing, one of which is predicted to be very high cost.

Mike Brown is the Government Affairs Director of the Coalition of Labor Agriculture and Business (COLAB) of San Luis Obispo County. He had a 42-year career as a city manager and county executive officer in four states including California. He can be reached at