The San Luis Obispo County Jail lacks oversight in ensuring the well-being of jail inmates, both the Sheriff’s Office and County Health Agency said Tuesday in agreeing with most of a recent Grand Jury report. They will address the jail’s medical management structure in a report by year-end.
But the jail will continue to hold “at-risk” inmates inside glass sobering cells for observation if necessary until they discuss alternatives with state regulators next month, the Sheriff’s Office said. That’s despite the grand jury finding that the practice violates state standards, which say the cells can only hold inmates who are a danger because of their inebriation.
One local non-intoxicated inmate suffering from mental illness died in a sobering cell in January.
In June, San Luis Obispo County’s civil Grand Jury found a “complex medical management structure” at the jail, namely a disconnect between correctional deputies and health staff due to medical confidentiality requirements.
There is “no single official at the County Jail level that has true oversight and responsibility over all aspects of an inmate’s well-being,” the Grand Jury said. Other jurisdictions overcome that hurdle by contracting correctional health services to an outside provider, allowing custodial “direct responsibility” over the inmate, the report found.
The Grand Jury recommended the Sheriff’s Office and Health Agency jointly review jail policies and management structure and present a public report by the end of the year. Its recommendations are non-binding.
We conducted a review of (inmate Andrew Holland’s death) and realized that there are some things we need to change.
The release of the Grand Jury report followed three deaths in the jail over a seven-month period, including that of Andrew Holland, who died in January of an embolism after spending 46 hours strapped to a restraint chair inside a sobering cell.
As of Tuesday, use of the restraint chair has been “permanently eliminated,” the Sheriff’s Office said in a statement. The practice had been suspended following Holland’s death. Even though other counties use the chairs, the statement reads, “the Sheriff’s Office will no longer take the chance of using a system of restraint that could cause or contribute to a serious medical issue or death.”
Both agencies reported Tuesday that their joint review is underway.
Regarding Holland’s death, “We conducted a review of the bad patient outcome and realized that there are some things we need to change,” said Health Agency Director Jeff Hamm. He declined to provide specifics. “So far, I think we’ve made significant changes.”
On July 11, the agencies entered into a memo of understanding establishing three committees with correctional and health staff reviewing policy, operations and quality management, according to the Sheriff’s Office. Each committee meets at least once a month.
IN-CUSTODY DEATHS, 2012-17
The following people died while in custody of the San Luis Obispo County Sheriff’s Office since January 2012.
  • Jan. 5, 2012: Kevin Lee Strahl, 53. Cause: Hepatic failure, liver fatty change
  • Nov. 12, 2012: Joseph Morillo, 43. Cause: Cardiac arrest due to thickening of heart muscle and morbid obesity
  • Jan. 27, 2014: Rudy Silva. Died in hospital care. Cause: Acute hypoxic respiratory failure, septic shock, Influenza A and Staphylococcus Aureus Bacteremia
  • March 12, 2014: Josey Richard Meche, 28. Cause: Cardiac dysrhythmia with acute methamphetamine toxicity
  • May 30, 2014: Timothy Richard Jancowicz, 29. Cause: Respiratory arrest due to heroin toxicity
  • Jan. 11, 2015: David Thomas Osborn Sr., 63, Cause: Acute myocardial infarction, Atherosclerotic coronary artery disease, hyperglycemia
  • March 24, 2015: Sean Michael Alexander, 33. Cause: Microscopic encephalitis, marked pulmonary edema
  • Sept. 20, 2016: Jordan Benjamin Turner, 36. Cause: Suicide with razor blade
  • July 16, 2016: Nicole Honait Luxor, 62. Died in hospital care. Cause: Complications from gallbladder cancer
  • Jan. 22, 2017: Andrew Chaylon Holland, 36. Intrapulmonary embolism
  • April 13, 2017: Kevin Lee McLaughlin, 60. Cardiac arrest
Note: Unless otherwise stated, place of death was San Luis Obispo County Jail.
July 25, 2017
The Tribune
By Matt Fountain