Did misrepresentations lead to SLO County inmates deaths?

Andrew Holland


More than a month before two men died and a third man seriously injured himself while in county custody, a San Luis Obispo County official said the county had corrected inadequacies regarding the treatment of mentally ill inmates. Following a $5 million dollar settlement to the family of one of the deceased men, the county is again claiming it has changed its procedures.

For years, San Luis Obispo County employees have lodged complaints about the mistreatment of mentally ill people in county custody. In addition, mandatory bi-yearly investigations have found the jail’s treatment of the mentally ill in violation of state law.

In 2012, several nurses lodged complaints about jail conditions through the county’s whistleblower hotline. The staffers, who have asked to remain unnamed because of fear of retaliation, said their concerns were dismissed.

In 2015, jail inspectors determined that the county had failed to comply with state requirements regarding adequate staffing, policies and the proper use of restraints and rubber rooms.

In Nov. 2016, SLO County Health Agency Director Jeff Hamm answered 20 questions about medical staffing, restraints and isolation at the jail. In his reply, Hamm wrote that most of the issues had been corrected.

Since then four men have died in county custody and the county is again reporting it is making many of the same changes Hamm said were made in 2016.


Hamm’s Dec. 15, 2016 written response to reporter’s questions:

Velie – Is the county psychiatric facility now accepting all inmates including those charged with felonies?

Jeff Hamm

Hamm – Yes.

Velie – Why was the county psychiatric facility refusing to see inmates charged with a felony?

Hamm – It was an oversight that has been corrected.

Velie – What is the longest amount of time it takes a mentally ill patient to get an evaluation regarding competency for court?

Hamm – Competency evaluations are conducted by Court-contracted psychologists, not the Health Agency.

Velie – Do some inmates stay in jail longer than they would be sentenced because of not getting a mental health evaluation?

Hamm – As stated above, the evaluation of competency is facilitated by the Court, not the Health Agency. The Health Agency’s duties are to attempt to restore the individual’s competency once determined by the Court to be incompetent to stand trial. The length of time that takes depends on the individual’s condition, treatment history, drug use, and a myriad of other factors. I cannot speculate whether a hypothetical individual’s experience in being evaluated by the Court and, if so ordered, restored to competency, would take longer than a potential jail sentence might be, depending on the charges, etc.

Velie – Are mentally ill inmates still placed in safety cells for a week or longer?

Hamm – Inmates placed in a safety cell are reevaluated for readiness for a step down cell every 24 hours. If after 72 hours an inmate still presents as a danger to self or others, or is gravely disabled, a team including a Lieutenant and health and psychiatric staff determine if the inmate may be safely rehoused. If the inmate is still at risk, they are referred to the Psychiatric Health Facility.

Velie – Is mental health staff now evaluating inmates retained in safety cells every eight hours? If yes, when did that policy start?

Hamm – Our policy for psychiatric evaluation in safety cells is a minimum of every 24 hours. Inmates placed in restraints must have a mental health evaluation no later than eight hours from initiation of restraint.

Velie – Is health staff documenting the reasons for restraints? If yes, when did that policy start?

Hamm – The decision to place an inmate in restraints is one made by correctional officials for safety reasons. Health Agency staff do not document the reasons except as they are informed and as they relate to health care issues.

Velie – Is a medical opinion given for placement in restraints no longer than four hours from the time of placement? If yes, when did that start?

Hamm – Yes. An updated policy was implemented on 8/24/16.

Velie – Have all the policy and procedures for medical and mental health been updated?

Hamm – All clinical protocols for medical care have been updated. Eight of 66 have been re-reviewed/updated in the past month and are awaiting final physician signature. All mental health policies were reviewed in 2016 and updates were made as needed.

Velie – Did staff combine mental health and medical policies and procedures in the same file?

Hamm – Not yet. The two sets of policies and procedures at the jail are currently administered separately—the medical care policies and procedures by Public Health staff and the mental health policies and procedures by Behavioral Health staff.

Velie – Did you start having mental health treatment plans for individuals as suggested? If yes, when did this occur?

Hamm – Yes. Medication plans have always been in place. Additional treatment plans for clinical and/or counseling services were started in May 2016.

Velie – Are there now policies and procedures in place for restrained inmates? If yes, when did this begin?

Hamm – Yes. An updated policy was implemented 8/24/2016.

Velie – Is medical staff documenting use of force? If yes, when did this begin?

Hamm – Use of force has always been documented in progress notes kept in an inmate’s medical record. Several months ago a “Use of Force” form was created to capture and standardize the information.

Velie – Is there now Narcan for overdoses in stock at the jail?

Hamm – Yes.

Velie – Is an MD available three times a day seven days a week for sick call?

Hamm – A physician sees inmates for acute and chronic health care conditions six mornings a week and is available immediately by phone 24/7 for questions from on-site nurses.

Velie – Is a nurse available 24/7 for screening incoming inmates?

Hamm – Yes.

Velie – Is staffing currently inadequate? If not, when did staffing numbers become adequate?

Hamm – Health Agency staffing levels at the jail are adequate. Incremental increases have been made in each of the last few budget cycles. The last increase in staffing occurred as part of the Fiscal Year 2016-17 budget process, which took effect late summer 2016.

Velie – Please respond to the audit’s findings that staffing levels were prohibitive to the proper dispensing of medications.

Hamm – Staffing levels have been increased, and are constantly being evaluated.

Velie – Has the county enacted monitoring of self-medications as suggested?

Hamm – Yes.

Velie – What is being done to keep mentally ill inmates from being kept in safety cells, which the state said could be seen as a form of punishment, rather than sent to a hospital?

Hamm – Flow through to the PHF (mental health facility) when indicated has increased. There are still times when transfers are delayed due to PHF census (unavailability of beds). Additional clinical staff has been added to the jail treatment teams to work with inmates. Emergency medication protocols have been updated and are being used.

Velie – What have you done to improve mental health policies?

Hamm – The Health Agency has a quality improvement process that involves periodic review of all policies and procedures and updates as needed. All jail behavioral health policies and procedures were reviewed over the last year and revisions were made as needed.


Two die and another injured in county custody in Jan. 2017

The San Luis Obispo County Jail is run by Sheriff Ian Parkinson and houses about 550 inmates per day. The county health department, under Hamm, is charged with the medical and mental health care of the inmates.

In June 2016, police arrested 56-year-old Anthony Vazquez on a misdemeanor charge and booked him into the San Luis Obispo County Jail. However, a judge dropped the charges and ordered Vazquez transferred to the county mental health facility.

During that time, inmates court ordered to the county mental health facility would often languish in jail while the county mental health facility staff would claim the unit was at capacity.

As a result, Vazquez was not transferred to the county mental health facility until Oct. 5.

In 2016, the county mental health facility was never at capacity and at times housed only two or three patients, according to the facility’s daily log sheets acquired by CalCoastNews through a public records request.

Several months later, Vazquez said he was feeling bad and began pleading to see a doctor other than the one at the county facility, telling staff and others that he thought he was dying, sources said. His requests were denied.

On Jan. 14, Vazquez was rushed to French Hospital Medical Center where he died as the result of a gastrointestinal bleed, sources said. In the mental health facility’s daily log, his death is refereed to as a discharge, according to the log.

While county staffers question the treatment of patients at the county mental health facility, the mentally ill may fair worse at the SLO County Jail, county employees say.

Jeremiah Mobley’s booking photo transferred to grey scale

On Jan. 20, deputies strapped Andrew Holland naked in a restraint chair where he remained until shortly before his death, two days later, according to jail records. During that time, deputies failed to provide Holland with adequate food and water or allow him to use a restroom.

While in the chair, a blood clot formed in Holland’s leg. Upon Holland’s release from the chair, the blood clot traveled to his right lung causing a pulmonary embolism and his death.

On Jan. 21, Jeremiah Mobley called 9-1-1 asking for help for mental health issues. After officers were told no beds were available at the county mental health facility, officers transported Mobley to the SLO County Jail.

While in the jail, deputies kept Mobley hogtied for several hours in a cell before they striped him and moved him naked into a small concrete cell, with no bedding and a hole in the floor for his waste. Mobley was in county custody for about a week.

Last month, after voicing fears that he would be forced to return to the SLO County Jail, Mobley shot and killed himself.



For years, the mentally ill have languished in the jail even though the court has ordered the county to either transfer the inmates to ASH or the county’s psychiatric facility in San Luis Obispo.

Under Hamm’s leadership, the county mental health facility on Johnson Avenue has refused to admit more than a few mentally ill transfers from the jail at a time claiming the mental health facility is at or above its 16-bed capacity.

In his Dec. 15, 2016 response, Hamm said the policy of not transferring inmates was an oversight that had been corrected. But in the cases of Holland and Vazquez, both men languished in jail while county mental health facility staff claimed all the beds were full.

In 2016, the mental health facility was never at capacity.

In his Dec. 15, 2016 response, Hamm said that inmates were no longer kept in safety cells for more than 72 hours.

On Dec. 30, 2016, guards took Holland from his isolation cell, stripped him down and threw him naked into a small concrete cell with rubber padding, no bedding and a hole in the floor for his waste, according to jail records.

Fifteen days later, deputies moved Holland out of the rubber room and back to an isolation cell, according to jail records.

In his Dec. 2016 response, Hamm said a medical opinion is given within four hours of an inmate being placed in restraints.

SLO County Sheriff’s Office procedures and policies and Title 15 require that a qualified medical professional physically check on an inmate held in a restraint chair within four hours. However, according to Holland’s chart, while a county physician spoke with jail staff over the phone, she did not personally examine Holland. It was not until more than 18 hours later, that a doctor examined Holland, according to jail logs.

In his Dec. 2016 response, Hamm said that medical staffing at the jail is adequate.

In the 2015 inspection report and in minutes of a 2016 health department meetings, it is noted that the jail is not fully staffed. Both inmates and staff have suffered, the state audit found.

On Jan. 22, the jail was seriously understaffed. While the only nurse on staff was attending to Mobley, Holland collapsed and went into respiratory arrest at the other end of the jail complex, sources said.

In July, the San Luis Obispo County Board of Supervisors agreed to pay $5 million to Holland’s family and to make “sweeping changes,” that include many of the changes Hamm said had already been made by Dec. 15, 2016.

The sweeping changes the county has promised include a policy that inmates can be kept no more than 72 hours in a rubber room, plans to increase staffing and a protocol of promptly responding to court ordered county mental health transfers.

The county has started promptly responding to court orders to send inmates to the county mental health facility, sources said. However, staffing remains inadequate as does health care for inmates, sources said.

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2 Comments about “Did misrepresentations lead to SLO County inmates deaths?”

  1. Shenanigan says:

    That sound you hear is Jeff Hamm looking over his shoulder as he dusts off his resume. He will be fired within the next six months. They’re only waiting to bring the new CEO for the county on board and then they will do the dirty deed. Someone has to take the fall for the debacle at the county jail and it sure won’t be Ian–he’s too loved by the “right people.”

  2. T-Bone says:

    The Narcan can also be used to revive medical staff that steal any opiates and overdose such as the cake nurse that you reported about a year or so ago.
    San Luis jail is so dysfunctional it should be under federal oversight.
    I really don’t know why the FBI isn’t investigating this bunch of Barney Fife fools.

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