A special grand jury found that the death of a 22-year-old inmate at the Rockdale County jail last year was “preventable” and was caused by staff complacency and lack of procedure.
But it did not find evidence that “any person, criminally or intentionally, caused the death.”
The grand jury was assembled by Rockdale District Attorney Alisha Johnson to look into the death of Shali Tilson, whose body was discovered in his cell March 12, 2018, after nine days in custody. An autopsy by the GBI found Tilson died of blood clots in his lungs caused by dehydration.
The grand jury said over the course of four months it toured the jail, reviewed “hundreds of pages of documents; watched hours of available video recordings of Shali Tilson’s incarceration” and questioned more than 60 witnesses, according to an 84-page presentment completed Sept. 19.
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“The Grand Jury found that medical, mental health and jail staff, through complacency, reluctance, assumptions and lack of procedures, training, leadership and adherence to policy, failed to recognize and adequately address the mental state and physical decline of Shali Tilson,” the presentment said.
“The Grand Jury did not find evidence that any person, criminally or intentionally, caused the death of Shali Tilson. Nor did it find evidence that any person or persons intentionally withheld water from Shali Tilson or consciously ignored signs that he was suffering from physical distress and/or dehydration.”
The special grand jury had no authority to criminally indict those it investigated, Johnson said. However, it did recommend that her office consider criminal prosecution against Sgt. Dan Lang, a jail supervisor on the night Tilson died, for providing a false statement. His report said he made checks on Tilson every 15 minutes when he and his staff did not.
Johnson plans to have a grand jury consider an indictment by November, she said. Under Georgia law, prosecutors must follow special procedures before indicting a law enforcement officer.
“This community wants an investigation to be thorough, and upon reading the presentment they will be able to see this was a thorough investigation,” Johnson said.
An attorney for the family said they are “devastated that no one will be held criminally liable for Shali’s death.”
“However, the struggle for Justice for Shali is far from over,” Mawuli Davis said in a statement.
Tilson was arrested March 3, 2018, AJC.com previously reported. His parents said he suffered from bipolar disorder and schizophrenia and was on the verge of a “psychotic break” when he was taken into custody.
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Witnesses told police he was trying to kick in the door of a stranger’s apartment, an arrest report states. Tilson and his family had moved out of the building about four months before, according to his mother, Tynesha Tilson.
Tilson claimed to know a woman at the scene who denied they had ever met. He shouted obscene phrases that made no sense. At one point, he asked the officer driving him to jail to drop him off at his sister’s place.
The officer said he thought Tilson was on drugs.
According to the presentment, a urine sample was collected from Tilson and was sealed, labeled and placed in a refrigerated storage facility, but was later thrown out without being tested.
When he arrived at the jail, Tilson refused to get out of the back of the police car and physically resisted when a deputy tried to remove him, family attorney Mawuli Davis said.
On March 4, Tilson was put on “suicide watch,” according to the presentment. The grand jury said that was not at the suggestion of the mental health staff at the jail, and no one can explain why he was placed on the watch.
“Had the Administrative Segregation Order form been filled out as required by Post Orders, then, maybe, the Grand Jury would not be left to guess and question why Tilson was placed on suicide watch,” the presentment said.
Tilson was moved to holding Cell 11, a solitary cell located in the booking area of the jail, according to a civil action filed by his family. The cell was about 9 feet long and 5 feet wide, according to the presentment. There was no furniture or bed, and there was a small grated toilet. The door had a single, rectangular window for viewing in and out of the cell and a flap for passing items in and out.
It had no water source.
“The only source of water available to an inmate incarcerated in Cell 11 is water that is provided to the inmate by jail staff,” the civil action states.
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The presentment said Tilson spent an “excessive” amount of time in the cell.
“(It) is a very stark and limited housing location,” it said. “For seven days, Tilson was confined in this cell with no bed or blanket, constant light and little resources to care for his own needs.”
During his time in the cell, he never said he was suicidal, the presentment said.
The cell had an intercom system that an inmate could use to call for help in case of emergencies, according to the presentment.
“Testimony before the Grand Jury established that the ability to speak through the intercom system has not worked for several years,” the presentment said. “Additionally, the Grand Jury learned that the intercom systems in the jail have continued to deteriorate and often do not function at all.”
In a video of his last day in custody, Tilson can be seen pressing the button to the intercom, seemingly trying to call for help.
Tilson typically spent his time in jail banging on his cell door, but nine days after his arrest, he was unusually quiet, an internal report said.
Jail policy states that inmates on suicide watch must be checked every 15 minutes to ensure they are responsive. The grand jury presentment said those checks were not performed between 4 p.m. and 7:30 p.m. the day of Tilson’s death.
Lang, the deputy who was supposed to be monitoring Tilson, falsified the suicide watch log where he was supposed to verify that the checks had been formed, the presentment said.
Deputies said they thought Tilson 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.
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At 8:35 p.m., 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 tried to wake Tilson by firing his stun gun, the presentment 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.
The jail staff members testified before the grand jury that they didn’t know Tilson was in distress, the presentment said. The staff had not received any kind of training regarding dehydration or its symptoms, it said.
The “best evidence” of Tilson’s distress came from a fellow detainee, who testified he heard the man yelling “help me,” “why you doing me like this,” and “I don’t want to die like this,” the presentment said.
“However, there is no evidence that the jailers in the booking area heard these statements,” it said. “Moreover, (the detainee) stated that even he wasn’t concerned about Tilson or his statements because Tilson had been yelling the same or similar statements for several days.”
The grand jury said there’s no evidence that Tilson was denied water intentionally. Several members of the jail staff testified that they had provided Tilson with water, even on the day that he died.
However, the jail staff was not required to monitor hydration and was not sure if Tilson actually consumed the water provided to him. A nurse testified that when jail staff tried to give Tilson water, he threw it back through the flap in the door.
Four jail staff members were placed on administrative leave after Tilson’s death.
Lang was fired from the sheriff’s department, according to the presentment. The grand jury suggested the district attorney look into Lang’s actions.
“The Grand Jury recommends that the District Attorney review the action of Dan Lang on March 12, 2018 in the ‘catching up the log’ for possible criminal prosecution for giving, making or providing a false statement,” the presentment said.
The grand jury also listed recommendations for the jail to prevent future deaths, including creating a written policy to ensure that detainees showing erratic behavior be drug tested, having a “water on request” policy for inmates, having licensed mental health staff readily available, and revamping systems put into place to monitor inmates.
The grand jury expressed concerns over jail policies, communication practices and facility characteristics.
“While the Grand Jury does not find evidence that any person criminally or intentionally caused the death of Shali Tilson,” the presentment said, “the Grand Jury does believe that this tragic death was preventable.”
In a statement, the sheriff’s office said it “has already begun implementation of substantial measures designed to prevent the recurrence of a similar incident.”
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