It was 5:36 p.m. on Jan. 22, 2017, and Andrew Chaylon Holland was dead.

An official report details the bleak tableau that greeted a coroner’s office investigator at the scene of the 36-year-old Atascadero resident’s death: Holland was naked and his legs were in shackles. His body lay supine on the floor of an observation cell at the SLO County Jail. Adhesive pads from a portable defibrillator—evidence of the jail staff’s efforts to revive him—were still on his chest.

Holland died less than an hour after spending nearly two days in a restraint chair, where he’d been placed for his own safety after the jail’s correctional deputies saw him attempting to harm himself. According to the coroner’s report, Holland was in the chair from 6:55 p.m. on Jan. 20 until 4:43 p.m. on Jan. 22. During that time, he’d refused food and water. Soon after he was released from the chair, a video feed from the observation cell showed Holland lying on his back. By 5:02 p.m., he appeared to have trouble breathing. By 5:08 p.m., Holland appeared to have stopped moving, the report states.

An autopsy later determined that Holland’s death was caused by a blood clot in one of his lungs. According to the National Institute of Health, sitting or lying down for long periods of time without moving can sometimes cause circulation to slow and blood to pool in extremities such as legs, which can cause a clot to form. Those clots can often travel from the legs to the lungs, causing a potentially fatal embolism.

But at the time of Holland’s death, he wasn’t supposed to be in the jail at all. He was supposed to be under the care of mental health professionals.

Holland, who had been struggling with schizophrenia since his 20s, had been found mentally incompetent to stand trial. On Jan. 10, a SLO County Superior Court judge ordered him to be transported to the county’s lone mental health facility. Allegedly, there wasn’t any room for Holland at the time. So he was forced to wait at the jail until a bed at the facility was available. At the time of his death, Holland had been waiting 12 days for that transfer.

Holland isn’t the only mentally ill inmate to find himself in such a situation. According to court documents obtained by New Times, multiple inmates deemed mentally incompetent to stand trial have faced lengthy waits in SLO County Jail for transfer to county or state psychiatric facilities. While they are on hold for weeks, and sometimes even months, those inmates remain in a jail that, by its officials’ own admission, is ill equipped to provide the resources to treat them.

“The jail is the last stop, and we are the only stop that cannot refuse them,” SLO County Sheriff Ian Parkinson said during an April press conference. “And at the end of the day, we are forced to deal with a situation where they don’t belong in the facility, and we don’t have the capabilities to treat them the way they should be treated.” 

The problem

The road to declaring a criminal defendant incompetent to stand trial can be a long and involved process. It begins when someone, usually the defendant’s attorney, raises a question as to whether their client is mentally capable of understanding the charges against them, can understand what is going on in court, or capable of rationally participating in their defense.

“There are a variety of things that can trigger these proceedings,” said Matthew Guerrero, a local defense attorney who has represented several clients declared incompetent to stand trial. “Sometimes it can be because [the defendant] has a developmental disability, or it can be a drug-induced psychosis. But commonly, it’s mental illness.”

After undergoing a court-ordered psychiatric evaluation, the court can determine that a defendant is incompetent to stand trial (IST), and order the proceeding in the criminal case halted until they can be treated and brought back to competency. Many defendants declared IST are referred to either a local psychiatric facility, such as the SLO County Mental Health facility in misdemeanor cases, or to a facility in the state hospital system like Atascadero State Hospital for violent or felony-level crimes.

At these inpatient facilities, IST defendants suffering from mental illness can get treatment and medication until they are well enough to once again be deemed competent. Then, their criminal cases can resume in court.

It appears to work well on paper, but SLO County defense attorneys like Guerrero know that in reality, it’s far from a perfect system. The SLO County Mental Health Services facility has just 16 beds available for patients, but only some of those beds are available for IST defendants.

Space in the state’s psychiatric hospitals is similarly limited. Until that space opens up, SLO County IST defendants are forced to wait in the county jail.

“We would show up for hearings assuming they’d already gone to a [facility], but what we started to find was that they hadn’t even been picked up,” Guerrero said.

The length of those waits in the jail varies widely. A sampling of SLO County’s IST cases filed between 2014 and 2016 showed that waits for IST defendants could be as short as four days or as long as 122 days. That’s not counting the time it takes to actually get them declared incompetent.

One of Guerrero’s clients, a 28-year-old man arrested on a burglary charge in September 2016, was declared IST and ordered to be transferred to Atascadero State Hospital on Oct. 27 of that same year. He wasn’t transferred until Feb. 6, 2017, leaving him waiting in jail for 104 days.

Over the last few years, defense lawyers like Guerrero have tried to force the facilities, particularly those run by the California Department of State Hospitals, to take their IST clients sooner by filing orders to show cause. Those orders essentially require state hospital representatives to come to court and explain why they were unable to take in the defendant.

“You are basically seeking a contempt finding against them for not picking up your client,” he said.

While filing such motions sometimes helps force a facility’s hand in taking an IST inmate, Guerrero said it remains difficult to get them placed. Long waits in the jail make it harder for attorneys to work their clients’ cases and possibly puts those inmates and others in danger.

“The biggest concern is for their personal safety and the safety of those around them,” Guerrero said. 

Danger of isolation

While they wait, IST inmates are left in a jail that is less equipped to handle their mental health needs than a proper county or state treatment facility. SLO County’s Behavioral Health Department provides some resources, including a part-time psychiatrist and other mental health staff, but, unlike a true psychiatric facility, the jail cannot forcibly medicate inmates.

“It’s a very difficult population to manage,” said SLO Sheriff’s Office Correctional Lt. Stephanie Landgraf.

A lack of proper treatment and medication could worsen the symptoms of an inmate with mental illness, causing their condition to further deteriorate, a problem often referred to as “decompensating.”

Within the jail, that deterioration can result in untreated mentally ill inmates acting out, attempting to hurt themselves or others. Holland, who had been declared IST at least three times before, was facing a misdemeanor charge for allegedly assaulting a correctional deputy at the jail. He was placed in the restraint chair after a correctional deputy observed Holland punching himself in the face.

Even if an inmate isn’t placed in the restraint chair (the sheriff suspended its use in the wake of Holland’s death), they can still be segregated and placed in the jail’s isolation or safety cells if they pose a danger to themselves or others.

“[The cells] are one of our only tools to deal with someone who is assaultive or self-assaultive,” Landgraf said.

Several human rights and mental health organizations, including the American Psychiatric Association, have raised concerns about placing mentally ill inmates in isolation for prolonged periods of time.

“Placement of inmates with serious mental illness in these settings can be contraindicated because of the potential for the psychiatric conditions to clinically deteriorate or not improve,” the American Psychiatric Association declared in a 2012 official statement on the issue. “Inmates with a serious mental illness who are a high suicide risk or demonstrating active psychotic symptoms should not be placed in segregation housing as previously defined and instead should be transferred to an acute psychiatric setting for stabilization.”

  Guerrero said he witnessed such deterioration firsthand while defending Andrew Wesley Downs, a 20-year-old schizophrenic man who shot and killed two women on Christmas Day of 2010. Downs was found by the court to be not guilty by reason of insanity and was eventually committed to a state hospital. After the verdict, Downs still waited three months for a transfer to Atascadero State Hospital. According to an order to show cause filed by Guerrero, Downs was placed in a single-person cell during that time, and his mental state continued to deteriorate.

“His mental state has decompensated further during that period,” the order reads. “He is refusing to shower and is exhibiting odd behavior, including drinking from the toilet.”

Landgraf and the jail’s other officers deal with the consequences of severely decompensated inmates on a daily basis. It’s not uncommon for them, she said, to smear the walls or themselves with their urine or feces.

“You see this kind of cyclically downward spiral in a place where all we really have for them is a concrete box,” Landgraf said.

Such inmates can become highly unpredictable and even aggressive, putting the jail’s correctional deputies and other staff at risk, according to Landgraf.

“It poses a huge security issue,” she said. 

‘Am I going to be here for life?’

The long waits for transfers aren’t just a strain on the inmates, their attorneys, and the sheriff’s correctional deputies. That between time also poses a challenge to the families tasked with caring for them.

“It’s extraordinarily difficult, because you feel so helpless,” a local mother, whose son spent more than two months in SLO County Jail after being declared incompetent to stand trial, told New Times.

The woman asked that she and her son, who suffers from bipolar disorder, not be named. She said she feared that going public with their story might impact her employment and her son’s future treatment should he end up in custody again.

Court records show that the woman’s son was arrested and charged with a non-violent misdemeanor. He spent 67 days waiting for a transfer to the county mental health facility. Much of that time was spent alone in an isolated cell, she said.

During her son’s stay at the jail, obtaining information about the status of her son’s condition and what—if any—treatment he was getting was difficult, the woman said. That was in part due to medical information privacy laws and to a lack of available rooms for visitations between such inmates and their families at the jail. When she was able to visit her son, the stresses of jail and isolation on his mental condition were clear and alarming. He refused his medication and began to become frightened, paranoid, and even angry, the woman told New Times.

“I was scared he’d do something to cause him to stay [in the jail] for a really long time,” she said.

At times, she even feared that her son’s own safety might be endangered if he continued his downward spiral while waiting in the jail.

“It was horrible. He would always ask me, ‘Am I going to be here for life?’” she said. “That’s why I was scared that he’d become suicidal.”

Things began to turn around after a chance meeting with a representative from the nonprofit Transitions Mental Health Association. Soon after meeting the representative, the woman said she was able to get more regular updates about her son, and he was eventually transferred to the county mental health facility, as the court had ordered. There, she said her son was able to get the treatment he needed, including therapy and medication.

“They gave him hope,” she said.

Her son was eventually restored to competency and sentenced to probation. To this day, the woman said she still doesn’t know exactly what triggered the transfer of her son from the jail. Even after the experience, she said she didn’t blame the jail or its staff for what happened to him, stating that she believed they were simply not as equipped to deal with mental illness as an actual psychiatric facility.

“A jail isn’t a hospital,” she said. “They are not set up for people with [mental illness]. They’re just not, so it’s not their fault.”

Today, with her son recovering, the impact of his time in the jail has left a mark. The woman said her son has occasional nightmares about being back in custody and has become nervous about contact with law enforcement, opting to get rides to work rather than walk and risk bumping into police officers.

“So, now somebody picks him up because he’s afraid to walk,” she said. 

Not just SLO

The challenge of getting IST inmates transferred to the proper treatment facilities isn’t unique to SLO County. The issue is something that California and many other states have been wrestling with for decades.

In the 1970s and 1980s, the country began to push for releasing mentally ill and developmentally disabled individuals from long-stay hospitals, instead opting to provide them with support and treatment within the community, commonly referred to as deinstitutionalization. While the goal of the effort was to reduce the population in overcrowded mental hospitals, some of which kept patients in near-inhumane conditions, the well-intentioned program may have had unintended repercussions, according to the California Council on Mentally Ill Offenders.

“While the deinstitutionalization of state hospitals in the 1970s and 1980s was the appropriate and humane approach to serving and supporting those suffering from mental illness, serious underfunding of the community-based system that was to replace it, has had substantial consequences,” the council’s 2016 annual report stated.

As the number of mentally ill individuals coming into contact with law enforcement and the criminal justice system increased, so did the number of criminal defendants declared incompetent to stand trial. Those accused of felonies or violent crimes are sent for treatment at one of the nine psychiatric facilities operated by the Department of State Hospitals. But in state hospitals, such as the Atascadero State Hospital, IST inmates are only a fraction of the patients in treatment, making lack of beds an issue that could stymie efforts to get inmates transferred in a timely manner. In addition, state hospitals like Atascadero take IST inmates from across the state, leaving only so much room for counties like SLO or Santa Barbara. According to Department of State Hospitals data, IST patients accounted for about 25 percent of the total state hospital population. As of May of this year, a total of 814 patients were awaiting admission to the state hospital system, 539 of whom were designated as incompetent to stand trial. Locally, of the 244 IST patients placed in Atascadero in May, just four of them were from SLO County.

“Atascadero [State Hospital] admits patients based on the availability of beds and staff,” State Hospitals spokesman Ken Paglia wrote in an email response to questions from New Times.

The problem of long waits for IST placement in state hospitals was acute enough to attract the attention of the Northern California Branch of the ACLU, which filed a lawsuit against the Department of State Hospitals in July 2015 on behalf of several IST inmates and their families. The case remains ongoing.

The lawsuit is a window into the plight of IST inmates statewide, some of whom faced waits as long as a year or more. During those waits, a few of the inmates became the victims of prison violence. One inmate included in the lawsuit was raped multiple times while in custody and awaiting a transfer. Another committed suicide.

Michael Risher, a senior attorney for the Northern California ACLU, said keeping IST inmates waiting in jail for transfers was both dangerous and a violation of their civil rights.

“As a fundamental matter, jail is not the place for people who suffer from these mental illnesses and developmental disabilities,” Risher said. “These people are presumed innocent and have due process rights and the right to a speedy trial.” 

Solutions

While the lawsuit makes its way through the gauntlet that is the state’s legal system, IST inmates in county jails across California continue to wait, and the search for programs, policies, and other solutions to address the issue continue at both the local and state levels.

“Everyone wants to get them to a place where they can get treatment,” said SLO County Correctional Lt. Landgraf.

One possible solution can be found in the records of the SLO County Superior Court’s more recent IST cases. Court records show that some IST inmates who’d normally be recommended for placement in ASH or another state hospital were instead being recommended for treatment to regain their competency inside other California jails.

They’re called jail-based competency treatment programs. Funded and run in partnership between State Hospitals and the private Liberty Healthcare company, the program provides resources for a select group of county jails to provide psychiatric treatment to IST patients, essentially expanding the number of beds available to them. The program appears to be a direct reaction to the outcry over the issue. While in a jail-based competency treatment program, inmates not only get access to psychiatric resources, but practitioners can also require them to take their medication, as they would at any state hospital.

“[The] Jail-Based Competency Treatment programs expand the department’s ability to treat incompetent to stand trial patients in response to increased IST referrals in recent years,” Paglia wrote.

Four California jails currently offer the program: the West Valley Detention Center in San Bernardino County, the Robert Presley Detention Center in Riverside, the Rio Cosumnes Correctional Center in Sacramento, and the San Diego Central Jail.

As of May 5, there were 147 IST patients in jail-based competency programs. This year, the program continued to expand. There are plans to open another jail-based competency program in Sonoma County in June. Paglia said that the department is also exploring expanding the program in Northern and Central California, but did not specify which counties were up for consideration.

Landgraf said that inmates recommended to the program by the court would be sent to West Valley, and cut down on the wait times for IST inmates who would otherwise remain in jail for anywhere between 11 and 16 weeks to get into a state hospital like ASH.

“We can probably reduce that down to two or three if we have that bed space,” she said.

While it’s too early to tell if allowing some of SLO’s IST defendants to go into the program will be effective, SLO defense attorney Guerrero was cautiously optimistic.

“It remains to be seen if it’s going to be as well structured as the Department of State Hospitals treatment program,” said Guerrero, who added that some of his more recent clients had already been referred to the program. “But it’s better than having our clients sitting in a place where they aren’t getting any treatment.”

Locally, it appears that the county is also looking for ways to better serve the needs of its IST population, and the mentally ill inmates, generally. The 2017-18 proposed SLO County budget includes funding to hire an additional licensed vocational nurse/licensed psychiatric technician to provide services at the jail, as well as a health information technician and a correctional nurse.

“The recommended positions and contracted services will provide extended psychiatric care coverage at the county jail, including additional monitoring of inmates needing emergency medication in the evening and overnight hours, as well as administrative support for data entry of inmate behavioral health and psychiatric care in the electronic health record to ensure continuity of care, particularly upon release from the county jail,” the county’s proposed budget states.

Both the Sheriff’s Office and county are also implementing programs to address mentally ill individuals outside the jail, with the hopes of getting them support and services before they end up in the jail or facing criminal charges. Those include the creation of a county Crisis Stabilization Unit, which will provide emergency services and support to individuals experiencing a mental health crisis. The program is expected to be operational by February 2018. In April, SLO County Sheriff Parkinson debuted the department’s newly formed community action team. The two-deputy team will focus on homelessness issues in unincorporated SLO County, including working with Transitions Mental Health Association and the SLO County Behavioral Health Services division to provide resources and other services to mentally ill individuals living on the streets.

In addition, there are plans to build an on-site suite for inmate medical and mental health services as part of the second phase of the jail’s expansion project. Construction is expected to take about one year, according to Landgraf.

In the meantime, Parkinson has asked both the SLO County District Attorney’s Office and the Los Angeles branch of the FBI to independently investigate deaths at the jail, including Holland’s.

At his April press conference, Parkinson indicated that it would take a dedicated effort by the community to address the systemic problems that have left the state’s county jails to function as the “de-facto mental health facility for the county,” housing not only IST inmates but a growing number of other mentally ill inmates in need of treatment and care.

“We will not give up our fight to try to change the system,” he said. “But the reality is if people don’t pay attention, if people don’t get involved, and people are not willing to take action, then it’s never going to change.”

Staff Writer Chris McGuinness can be reached at [email protected].