Anthony Stringfellow Jr. was 19 when he entered Madden Mental Health Center. He needed protection from himself—from the depression that had driven him to attempt jumping from a second-floor window days earlier. His mother, Athena Webster, made the hardest call a parent can make: trusting strangers to watch over her son when his life was hanging in the balance.
Four days later, Anthony was dead. A shoelace around his neck, tied to a door hinge that should have been removed years earlier. The mental health technician assigned to check on him every 15 minutes hadn't seen him in over an hour. When confronted, she admitted to falsifying the logs, claiming a supervisor told her to do it.
This is how the system works: A child dies. A facility lies. And the machine keeps running.
"I'm not going to quit"
On February 7, 2023, mental health technician Rodily Cadichon wasn't supposed to be working. Madden was short-staffed—again—so management called him in. He and another technician, Candace Burbridge, were watching 11 or 12 patients each in Pavilion 6. Anthony was one of Burbridge's.
At dinner, Anthony didn't show. When Burbridge went to find him, she started screaming for help.
They found Anthony in his bathroom, a shoelace tied to the middle door hinge. Cadichon did chest compressions, counting to 30, thinking about his own son. "I told Anthony, 'I'm not going to quit,'" he said. But it was too late. Anthony was pronounced dead at 5:59 p.m. at Loyola University Medical Center.
At 3:30 that afternoon, Anthony had spoken to his mother for the last time. "Y'all coming up here right?" he'd asked. "You said today, you're coming, right?" She promised they'd be there at 7:30 p.m. At 4:18, he called back and left a voicemail: "Hey Ma, I love you. I love you. I love you."
The lies begin before the body is cold
State investigators would later uncover what happened between that final call and Anthony's death. Burbridge told them she'd conducted three 15-minute suicide checks between 4:30 and 5:00 p.m., documenting that Anthony was in his room at 5:00. Surveillance footage told a different story: She hadn't done the last two checks at all.
When confronted, Burbridge revealed the likely truth. A supervisor, she said, had "instructed" her to "falsify" the records. She'd lost track of time doing other tasks. Anthony's food tray sat untouched on the table—he'd never made it to dinner, despite what staff told arriving paramedics.
The falsification of records isn't a bug in the system—it's a feature. When staffing is cut to boost margins, when one technician watches a dozen suicidal patients, the math doesn't work. Something has to give. Usually, it's the truth. Sometimes, it's a life.
The door hinge that killed him shouldn't have existed
Here's what makes Anthony's death especially damning: The door hinge he used to hang himself was a known hazard. Illinois had begun anti-ligature efforts years before Anthony arrived at Madden—removing or modifying fixtures that could be used for self-harm.
Two weeks before Anthony died, state directors emailed Madden's leadership asking for updates on anti-ligature progress. The response was telling: "I will gather the requested data." They were still gathering when Anthony found that hinge.
Two days after his death, a state director followed up: "Circling back. I don't think I ever received the requested data."
The data arrived in the form of a dead teenager.
The accountability that never comes
Madden's response to Anthony's death is a case study in institutional self-protection. Cadichon, who tried to save Anthony's life, lost his job soon after. Burbridge, who falsified the checks that might have saved him, was placed on paid administrative leave. The state is "following the process" to terminate her, allegedly.
Pavilion 6 was subsequently closed to undergo the anti-ligature renovations that should have happened before Anthony arrived. The door hinges are hopefully replaced or being replaced. The Illinois Department of Human Services released a statement thick with bureaucratic prose about "regulatory safety standards" and "clinical intervention." They mention Anthony's death exactly once, calling it "a patient suicide at Madden MHC in 2023."
Not a preventable death. Not a system failure. Just another incident.
The price of broken promises
Anthony's mother is suing, represented by attorney Trish Hudson. "If those 15-minute checks were performed the way 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," Hudson said.
But the lawsuit isn't just about missed checks. It's about the shoelace that never should have been there. The door hinge that should have been removed. The staffing levels that made proper monitoring impossible. The higher-ups who allegedly told staff to lie about it.
It's about a system where falsifying records is standard practice, where known hazards remain in place until someone dies, where accountability means putting the whistleblower out of work while the person who falsified documents collects a salary.
The machine keeps running
Anthony Stringfellow Jr. trusted the system with his life. His mother trusted it with her son. They got back falsified logs, an unmodified door hinge and a voicemail that said "I love you" three times.
This is how the psychiatric industry works in America, whether the facility is owned by the state, private equity or a publicly traded corporation. The names change, the geography shifts, but the pattern holds: Staff shortages justified by budget constraints. Safety measures deferred to save money. Records falsified to cover the gaps. Deaths rebranded as incidents.
And when someone dies—when a 19-year-old hangs himself from a door hinge that should have been removed years ago—the machine doesn't stop. It sends emails asking for data. It places people on paid leave. It issues statements about "regulatory safety standards."
Then it calls in another short-staffed technician to watch another dozen suicidal patients, in another facility with hazards waiting to kill, with another supervisor ready to suggest which boxes to check when the next tragedy becomes inevitable.
Anthony Stringfellow Jr. entered Madden Mental Health Center because he wanted to die. The facility's job was to keep him alive for seven to fourteen days—long enough to stabilize, to see his family, to remember why life was worth living.
They couldn't even give him four.