A mentally-ill inmate whose March death sparked community protest was ignored for more than three hours before he was found dead inside his Rockdale County cell, even though deputies were required to check his condition every 15 minutes, documents reviewed by The Atlanta Journal-Constitution show.
The shift was slow and there was little to do, but rather than look inside Shali Tilson’s cell, a supervisor falsely logged that he performed the checks. Tilson, 22, tried to summon deputies shortly before his March 12 death by pressing a call button, but a supervisor said it had long been broken, according to an internal Rockdale sheriff’s investigation, which the AJC and Channel 2 Action News recently obtained.
Tilson’s body had begun to grow stiff by the time they found him naked and surrounded by trash, a supervisor told internal affairs investigators, the report states.
Rockdale District Attorney Alisha Johnson said she is reviewing a recently completed GBI investigation into Tilson’s death and has sent out additional investigators to gather more information.
“We’re trying to turn over every stone we can,” said Johnson, who did not comment on the internal investigation. “If that leads to a criminal prosecution, so be it.”
Supervisors recommended one deputy be fired and four suspended without pay, according to written reprimands from the sheriff’s office, which runs the jail.
The findings of the jail’s internal investigation outraged Tilson’s family, who said that the deputies involved deserve harsher punishment.
“We want to see all involved held accountable for my son’s death,” his mother Tynesha Tilson, 45, said. “They all basically got slaps on the wrist. My son got a death sentence.”
A Rockdale County sheriff’s spokeswoman declined comment because the investigation is still open.
A candlelight vigil in honor of Tilson is planned outside Rockdale County Jail for Sept. 15.
Controversy and protests
More than 500 inmates and detainees have died in Georgia's local jails in the past decade. An investigation earlier this year by The Atlanta Journal-Constitution, Channel 2 Action News and the Georgia News Lab found that mental illness played a role in a large share of those deaths, that many were preventable and that deaths routinely occurred after jail staff failed to recognize or act on warning signs until it was too late.
The internal investigation’s findings into Tilson’s death fuel his family’s concerns that he was severely neglected or worse before his death. Tynesha Tilson accused deputies of brutality in a video posted by the Hip Hop Enquirer, an online publication, and complained that it took a month before they received his body. A coalition of activists who are part of the Black Lives Matter movement held protests decrying Tilson’s death and the treatment of mentally ill inmates.
Sheriff Eric Levett replied to Tilson's mother with a March 27 Facebook message urging the public against jumping to conclusions. He angered Tilson's family and activists further by asking "those who seem to not want to understand the process" to "humble themselves" and wait patiently for the results of the investigation.
Internal investigators interviewed the deputies involved on March 26 and 27 and released their findings April 12.
Tilson died from blood clots in his lungs caused by dehydration, a May 14 autopsy report found. A medical examiner found two injuries in his skull with bleeding on the brain, contusions on his ankle and foot, and red marks on his abdomen.
Deputies reported they used force on Tilson six times during his nine day stay at the jail, it said. The sheriff’s office has not released details of those incidents.
Signs of mental illness
Tilson was 8 when doctors diagnosed him with bipolar disorder and schizophrenia, his mother Tynesha Tilson said. The Rhode Island native kept his symptoms under control for years with medication, but decided in high school the side effects were too dangerous and turned to stringent diet and exercise instead. Last September, against his parents’ advice, he took a break from his paralegal studies at the Community College of Rhode Island to move to Rockdale County to care for his father, who had a stroke.
Tilson’s parents worried he was on the verge of a mental breakdown. He would either sleep all day or barely sleep at all and paced around their home. It looked as if he was trying to catch hold of his racing thoughts, his mother said.
“Shali was trying to take too much on his little shoulders,” Tynesha Tilson said. “It was just too much.”
His parents failed to convince Tilson to seek treatment.
On March 3, the day of his arrest, he appeared untethered from reality, according to police videos obtained by the AJC through a public records request.
Witnesses told police he was trying to kick in the door of a stranger’s apartment, the arrest report states. Tilson and his family had moved out of the building about four months before, Tynesha Tilson said.
Tilson claimed to know a woman at the scene who denied they had ever met. He shouted obscene phrases that made no sense. At times, he bursts into song or chants. At one point, he asked the officer driving him to jail to drop him off at his sister’s place.
“Give me some time, give me some effort,” he repeated to that officer. The officer said he thought Tilson was on drugs.
‘I think he’s gone’
Tilson typically spent his time in jail banging on his cell door, but nine days after his arrest, he was unusually quiet, the internal report said. Video showed that he spent the hours before his death pushing trash around his cell, reaching for the broken call button, and trying to climb up the door. Just after 5 p.m., he laid down in a corner of his cell. His head dropped, and he never moved again.
Deputies said they thought he was sleeping, but they and medical personnel failed repeatedly to look into his cell when they passed it, according to a video reviewed by an internal investigator. Deputies checked the weather report on the internet, sat at their desks, or helped with a power outage that interrupted their video feeds, according to statements to investigators and video.
Falsely logging that a suicide watch check had been performed “happens all the time,” said Sgt. Dan Lang, who was on duty that evening, the internal report states. “Sergeant Lang stated he knows this is not policy but this is what they do in the jail,” it said.Lang looked into the inmate’s cell at 8:35 p.m. Tilson looked like he stopped breathing.
At 8:35 p.m., Sgt. Dan Lang looked inside Tilson’s cell. The inmate appeared as if he had stopped breathing.
Deputies opened a flap on Tilson’s cell door. Cpl. Christian Klein told investigators that he aimed his stun gun away from the inmate and fired it, the report said.
“I just did it close to the flap so he’d be able to hear it, because you know that would get my attention if I was asleep and wasn’t waking up, you know that would wake me up,” Klein told an investigator.
Tilson didn’t move. They opened the cell door and Klein felt his arm, which was cold to the touch.
“Sarge, I think he’s gone,” Klein told Lang. They left to call for help.
Data reporter Jennifer Peebles contributed to this report.
