Emails reveal missing materials, staff shortages, renovation delays at mental health facility contributed to patient's death

Anthony Stringfellow Jr., 19, tied a shoelace to the raised bolt of a hinge on his bathroom door at Madden Mental Health Center in Chicago's western suburbs on Feb. 7, 2023. 

A recently hired mental health technician who was only working that day to cover a staffing shortage found Anthony and tried to save his life. But by the time Anthony was taken to the emergency room at Loyola University Medical Center in Maywood by EMTs, he could not be saved.

According to a Dec. 10, 2019, email, more than three years before Anthony's death, the facility was cited by the CMS/Joint Commission for issues involving "fixtures/equipment" that could be used by patients to die by suicide. Madden was put under a "mandate to correct immediately."

Internal emails exclusively obtained by CBS News Chicago show extensive delays due to nearly $1 million of missing materials, staff investigations, staff shortages, and mismanagement over a several-year period that contributed to Anthony's death.

Anthony's life and death

"He had a gift for words, like he rapped," said Anthony's mother, Athena Webster.

She remembers her son as an artistic wordsmith.

"The way he would put certain things together, it was exciting," Webster said.

Webster described her son as a caring sibling and son. In her words, Anthony was "awesome. He loved life."

That was until life became overwhelming.

On Feb. 2, 2023, police records show the family called 911 because Anthony was "attempting to jump out the window from the second floor."

"He was just so depressed," Webster said, "He couldn't see any way around it."

Anthony was taken to the UChicago Medicine emergency department, where he was evaluated. It was determined he met the minimum requirements for "involuntary hospitalization."

The next day, Anthony was transferred to Madden in Hines, Illinois.

"Saturday morning, in the wee hours of the morning, they transferred him to Madden," said Webster. 

That was Feb. 4, 2023. Three days later, mental health technician Rod Cadichon found Anthony in his bathroom. 

"Anthony is sitting with a rope, well, string around his neck," Cadichon said. "He hung himself."

The bolt of a door hinge was higher than normal. According to an autopsy and records, Anthony wrapped a shoelace around that bolt.

"This is the longest that I've been without seeing my son all his life," said Webster. "I've seen him almost every day of his 19 years."

Webster is now suing certain Madden doctors and nurses working the day Anthony died, as well as the Illinois Department of Human Services (IDHS) — alleging neglect in the care of her son.

Admission records indicate Anthony was a "moderate risk" for suicide and should be checked on every 15 minutes.

An Illinois State Police investigation determined that the observation order was not followed.

"I hate that I relied on them to help our family, to help our son," said Webster.

Madden's anti-ligature project

CBS News Chicago, through the Freedom of Information Act, requested internal emails between IDHS directors and Madden administrators to find out what was going on around the time of Anthony's death.

Over two months, we had to narrow our request from the original 3,600 responsive records to just 260 that IDHS ultimately provided. The emails cover a time period ranging from January 2023 to May 2024.  

Those emails paint a picture of a facility under pressure to complete a state and federal anti-ligature project and falling behind in meeting goals and deadlines.

The state effort to make its facilities safer for patients by removing or replacing fixtures such as door hinges, and other equipment that a patient could use to hang themselves, began in 2017-2018. This is according to Madden's own historical timeline provided in one of those emails.

In January 2023, one month before Anthony's death, IDHS was asking for regular updates on the anti-ligature work.

But after Feb. 7 — the day Anthony died — those requests became more urgent under scrutiny of Illinois State Police investigators, IDHS Office of Inspector General, and inspections by the Joint Commission.

As CBS News Chicago originally reported, the investigations both internal and external noted that the 15-minute checks had not been done as ordered, the patient was not "properly monitored," and paperwork was "falsified."

By the end of that February, Patricia Hudson, who was interim deputy director of hospital operations at the time, asked former chief engineer David Earnisse about piano hinges to change out on patient bedroom doors.

The next day, Earnisse replied: "We have no piano hinges…. They were never ordered before and never discussed with me."

Piano hinges are solid metal from top to bottom, and have no places where anything can be tied around a hinge or bracket.

"I was confused," said Earnisse. "I felt like they were trying to pin this suicide on me."

Nearly two months after Anthony's death an April 13, 2023, email shows a total cost for anti-ligature locks and ligature-resistant piano hinges for Madden that came to  $280,730. To the question, "Should we proceed?" Hudson answers: "Yes. We need this to proceed."

Project delays and confusion

But other executives remained confused by the status of the project, and how much it would cost to get it back on track.

Then, on April 19, IDHS interim director of licensing and quality management Laura Godinez sent this email to Hudson: 

• "Madden's tab was too confusing… and there were no estimated cost figures put in there."
• She indicated someone else "would try to get money figures for the items… but  she was still waiting for a finalized list and count of items from Madden that needed to be purchased."
• "David [Earnisse] said that he and Grainger were getting frustrated because items and plans kept changing."
• "Why are they changing? Make a decision and go with it."
• "Honestly… I am not sure what the issues are, but I don't think we are moving along very well with Madden's list — or at least I don't understand it."

Two days later, a business associate sent a spreadsheet outlining anti-ligature items Madden needed to purchase. The total cost was $1,012,148.

Over the course of the spring and summer of 2023, many of those items or products were found.

"When I was chief engineer, they wanted to know how much stuff we had left. So I had to go and count up everything that we had and I had turned that in to let them know all the stuff that was still left over," Earnisse said.

Earnisse said the previous Chief Engineer had ordered a lot of things that were never installed. He said all of those things were stored on Pavilion 7.

Earnisse said the main reason many items remain uninstalled was the lack of adequate staff. "One carpenter, one plumber. I mean with an 8-hour shift besides doing all the other work orders that are going on, they don't have enough staff to install everything. I mean, it takes months and months and months of work."

By fall 2023, after the new inventory of the stored products, the request for needed items was lowered to $165,000.

"No one was accountable for what they were spending," said Earnisse. "The only thing I was told to order was the piano hinges."

By spring 2024, now a year after Anthony's death, according to an historical timeline of the anti-ligature project, "nothing originally requested is needed."

An attempted suicide and more scrutiny

On May 8, 2024, now a full 15 months after the death of Anthony Stringfellow Jr., an administrative alert is emailed to IDHS about an attempted suicide that was interrupted. It happened in a different pavilion — one that had had much of the anti-ligature work finished.

Still, the director of the division of mental health, Dave Albert, wanted "a detailed (written) update on the anti-lig efforts at MMHC?" from Hudson. 

Hudson, who is now the chief executive officer of Madden Mental Health Center, promised the report by that Monday.

Albert acknowledged that, and asked her to "include past deadlines/target dates that may not have been met."

Here is the timeline Hudson provided Albert:

• 2018: Identified major ligature risks in patient bedrooms and bathrooms, as well as in common rooms. All materials purchased and received in 2018. The plan was to complete one vacant unit at a time.
• 2019: Joint Commission identified same ligature risks facility found year before and approved plan for removal/reduction. In August, Pavilion 5 was finished and work began on Pavilion 4.
• 2020-2022: Chief Engineer resigned. Work on P4 slowed. Larger projects were abandoned by Trades staff. Investigation initiated and time theft uncovered. Disciplinary action initiated while Trades staff continued to abandon work assignments.
• 2023: Successful patient suicide. Began current Division of Mental Health anti-lig project and intense oversight of local anti-ligature efforts.
• Spring 2023: $915,000 of product requested and approved
• Fall 2023: Amount of product requested lowered to $165,000 after product purchased in 2018 and 2019 was found.
• Feb 2024: Facility reassessed – nothing originally requested needed to be purchased.
• April 2024: Engineering and trade staff was fired and contractual staff hired as well as a Regional Engineer. The Joint Commission conducted a follow-up survey on the status of anti-ligature efforts and approved a new plan for removal and mitigations.

But delays and setbacks continued.

The new estimated date for Pavilion 4 to be finished was pushed back to June 2024. Pavilions 3, 6, and 8 still had intensive plumbing work to be done. Pavilion 6 was where Anthony died by suicide in February 2023. 

The estimated date for completion of the remaining work on all of the Pavilions was now set for the end of 2025.

Albert's Chief of Staff replies, "What can we do to accelerate this?... it seems like 19 months is an excessivevy long timeline."

"They identified the harm. They identified the fix. They just didn't follow through in actually fixing the issue," said Lisa Dailey, executive director of the Treatment Advocacy Center (TAC).

Dailey is concerned not only about the delays in ligature mitigation work but also the lack of sufficient patient monitoring, which played a role in both Anthony's death and the May 2024 attempted suicide.

"If you're not going to do that, and then you also don't ligature-proof the rooms, then it's just double negligence in my opinion."

Dailey does not want to see troubled mental facilities like Madden close.

"I think oversight is the solution, and funding is the solution, and holding people accountable for making these kinds of mistakes is the solution," she said.

Webster agrees.

"It's time for a whole lot to change," she said, "Can't keep doing this to people. These are human beings and families and lives that you are destroying."

Current project status

According to a statement provided by IDHS to CBS News Chicago, the agency said it has "prioritized environmental safety efforts, including ligature resistance, at all its facilities, including Madden Mental Health Center (MHC)."

As of the end of April 2025, two of six pavilions that house patients "have completed extensive retrofitting to eliminate known ligature risks, with two more actively under construction."

IDHS indicated its goal to have all patient pavilions completed by the end of 2025 remains the same.

Pavilion 6, where Anthony died, was closed for renovation on Dec. 4, 2024 — but had to reopen briefly. Anti-ligature renovations got fully underway on Jan. 15, 2025 nearly two years after Anthony's death.