On Feb. 7, 2023, 19-year-old Anthony Stringfellow Jr. died by suicide at a state mental health facility in Hines, Illinois west of Chicago.

"Anthony was awesome. He loved his family," Athena Webster said of her son. "He loved life."

Webster is now demanding answers to many questions about the four days her son spent inside the facility that was supposed to save his life.



Athena Webster and her son Anthony Stringfellow, Jr.

## The call for help

A few days earlier, Anthony had attempted to jump out of a second-floor window. His family called 911.

"We didn't know what to do. He was just so depressed and he couldn't see any way around it," a tearful Webster said.

Her son was taken to a hospital emergency room first and then transferred to Madden Mental Health Center. Initially over the weekend, he was not allowed to see his family, which is often the case for someone admitted to Madden who had just attempted suicide.

## Inside Madden

Rodily Cadichon, a mental health technician trainee, was working on some of Anthony's first days inside Madden.

Cadichon described the first time he met Anthony.

"He was just walking around. I said, 'Is there anything I can help you with?'" Cadichon said. "And he said: 'Well, you wouldn't understand. He said no one understands me. No one can help me.'"



Madden Mental Health Center

The Madden admissions report obtained by CBS News Chicago described Anthony's mental status as "paranoid" and "depressed" and noted he was "irritable being here."

Anthony was assigned a room in Pavilion 6. Madden records show boxes checked describe him as a "moderate risk" for suicide, and because of that, he was supposed to be under "frequent observation".

Another checked box indicates that observation was to happen every 15 minutes. The report indicated Anthony would only need to be in Madden for "7 to 14 days".

## February 7, 2023

On Anthony's fourth and final day inside Madden – February 7 -- Cadichon was not supposed to be working.

"I was called in by my manager, a nursing manager, to come in because they were short-staffed again," Cadichon said.

Anthony was one of those patients in the short-staffed Pavilion 6, where Cadichon and another mental health technician, Candace Burbridge, were working.

"It was me and Candace with I can't remember how many patients. I believe we had 11 or 12 apiece," Cadichon said. "Candace was assigned to Anthony."

At dinner time, Anthony was a no-show.

"Candace went to find Anthony. She said, 'Rod, help.' She screamed it several times," Cadichon said. "She was just sobbing and crying."

Anthony was in his bathroom. Cadichon and Burbridge found him in a corner near the bathroom door.

"Anthony is sitting with a rope, well, string around his neck. And the middle door hinge, he tied it and he hung himself," Cadichon said.

While someone called 911, Cadichon tried to save Anthony's life.

"I'm doing chest compressions, I'm counting to 30, and I'm thinking to myself, 'If this was my son, I wouldn't quit,'" Cadichon said, "and, I told Anthony, 'I'm not going to quit.'"

Broadview Ambulance 7 responded to the 911 call within minutes. Anthony was taken to Loyola University Medical Center nearby in Maywood, where records show he no longer had a pulse. The time of his death was noted on hospital records as 5:59 p.m.

That day, Anthony was finally supposed to see his family. He and his mother spoke for the final time at around 3:30 p.m.

"He said: 'Y'all coming up here right? You said today, you're coming, right?' , 'Yes, baby. Our appointment is at 7:30 p.m.,'" Webster said.

At 4:18 p.m., Anthony called his mother back and left a final message saying: "Hey Ma, I love you. I love you. I love you."

## What happened to Anthony Stringfellow, Jr?

Cadichon and the state have photos of that middle door hinge that show the bolt up. That was where Anthony was able to tie a shoelace around and then hang himself.

CBS News Chicago reviewed Illinois State Police and Illinois Department of Human Services Office of Inspector General investigative reports, which show Burbridge initially told investigators she had checked on Anthony and noted it in logs.

Someone also told EMTs who arrived on the scene that Anthony was last seen at dinnertime, less than 15 minutes before he was found in the bathroom.

Cadichon says that was not true.

His food tray was actually on the table.

State investigators wrote Burbridge told them:  "… from 4:30 to 5:00, Burbridge conducted three 15-minute suicide checks. At 5:00 Burbridge documented … the patient was in his room. At 5:13 patient was … unresponsive."

Investigators reviewed surveillance video from the facility which showed "Burbridge failed to conduct the last two 15-minute checks." When they followed up with Burbridge, she told them a supervisor "instructed" her to "fasify" the records. She told investigators she did not conduct all the checks on Anthony because she "lost track of time" doing other work-related tasks.

"It's heartbreaking. It's hearbreaking. If those 15-minute checks, at least every 15 minutes, were performed the way that they were supposed to, Anthony would either still be here, or they would have caught the act soon enough where his life would have been spared," said Trish Hudson, Webster's attorney.

The investigative findings are only one issue Hudson is raising in the civil court and court of claims lawsuits against Madden staff and the state.

"The string that he used, that's a prohibited item," Hudson said. "How did that get there?"

Hudson also has questions about the door hinge. Why was it not removed or altered according to anti-ligature efforts that began statewide several years before Anthony's death?

In addition to the investigative reports, CBS News Chicago obtained more than 400 pages of internal emails and documents detailing the state's suicide prevention plan and the status of that project at Madden around the time of Anthony's suicide.

On Jan. 23, 2023, two weeks before Anthony's death, emails exchanged between state directors and the woman in charge of Madden ask for a checkup on the progress of the anti-ligature work. Unsure, she responds she will "gather the requested data."

Two weeks later, Anthony died. A flurry of emails followed his death.

A state director followed up two days after Anthony's suicide on Feb. 9 with an email saying, "Circling back. I don't think I ever received the requested data."

Webster's attorney wants answers.

"How did that implementation fail? Why were the ligatures still there?" Hudson said.

The Illinois Department of Human Services (IDHS), which oversees mental health facilities, says Pavilion 6 at Madden, where Anthony died, is now closed and under anti-ligature renovation. That includes removing and replacing door hinges to make them ligature-resistant.

Cadichon lost his job soon after Anthony's death.

The state is still in the process of trying to terminate Burbridge for her role in the incident. She was placed on paid administrative leave after the investigation findings were released.

Neither IDHS nor the Illinois Attorney General would comment on the pending litigation. The office of the AG is representing a nurse in the civil case.

**IDHS statement:**

> "The IDHS Division of Mental Health continues to prioritize the safety of all state-operated facilities, and Madden Mental Health Center (MHC) remains committed to providing inpatient mental health treatment in a safe and supportive environment. Suicide prevention is a critical provision of mental health care that involves early diagnosis, clinical intervention, and promoting awareness to reduce the risk of self-harm. Regulatory safety standards are instrumental in this process, establishing guidelines that mitigate risks and ensure safety and security for all patients. These standards are strictly adhered to in all state-operated facilities.
> 
> Following a patient suicide at Madden MHC in 2023, the Illinois State Police conducted an investigation, as did the IDHS Office of Inspector General (OIG). During that time, one of the employees was placed on paid administrative leave.  As a result of the OIG finding this employee at fault for failing to monitor the patient adequately, the facility is following the process to terminate this worker's employment."

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