A state social services agency that has been under fire on several fronts, most recently in an internal audit that found shortcomings in how the agency responded to complaints, is accused of negligence in a pair of lawsuits filed by the family of a man who died by suicide in a west suburban mental health center. Anthony Stringfellow Jr., 19, died by hanging on Feb. 7, 2023, at the Madden Mental Health Center near Maywood, according to two lawsuits that between them list the Illinois Department of Human Services, the state, the facility and individual care providers as defendants. His death occurred despite guidelines intended to make hospitals treating patients with mental illness safer for those who would attempt to harm themselves. The negligence allegations are in a November 2023 complaint filed with the Illinois Court of Claims that names IDHS as a defendant and in an amended complaint filed in Cook County in June 2024 that names three doctors and a nurse as defendants. An Illinois Auditor General’s Office report released in December detailed other issues at Madden, with investigators finding that while the center reported fewer allegations of mistreatment compared to other IDHS facilities, it had the lowest completion rate of employee training in the prevention and reporting of mental abuse, physical abuse, sexual abuse, neglect, egregious neglect or financial exploitation. In Stringfellow’s case, the complaints allege that despite his history of “active suicidal ideation,” he was able to obtain the means to take his own life inside the mental health center, where he had been for only three days. Stringfellow’s mother, Athena Webster, said her son had attempted suicide less than a week before he died, just a couple of days before arriving at Madden, according to court documents. A previous suicide attempt is corroborated in statements made by a Loyola University Medical Center nurse that were included in a Cook County medical examiner’s office document on Stringfellow’s death. Stringfellow’s autopsy report also indicates he was prescribed Ambien after being admitted to Madden and that anger management counseling sessions had been planned for him. Stringfellow also had a known medical history of schizophrenia and paranoid tendencies, according to the autopsy report. A doctor who consulted with Webster’s lawyer said the case had merit, in part, because a “reasonably careful psychiatrist under the circumstances of this case providing care and treatment to Anthony knew or should have known to keep his environment free of hazardous objects which he could use to commit suicide and/or injure himself and/or others,” according to a court document. Under standards set by The Joint Commission, a health care accreditation agency, mental health hospitals must conduct environmental risk assessments for suicide prevention and take action to minimize risks, including removing ligature points. According to the standards, patients at high risk of suicide should be monitored. The Joint Commission has defined ligature points as places where fabric or material can be looped to cause harm or loss of life. The Joint Commission’s 2022 accreditation report of Madden, obtained by the Tribune, said the hospital was in “the process of correcting identified ligature risks with supply shortages and funding approval as the main challenges.” While the report indicates at least one unit had completed renovations for those risks, several others still had “many ligature risks.” It’s not clear from the lawsuits where Stringfellow was housed at Madden, and IDHS declined to disclose that, but the complaints allege there was infrastructure in the room that indicate it was not ligature-resistant. Mental health hospitals must conduct environmental risk assessments that identify “features in the physical environment that could be used to commit suicide” and take “necessary action to minimize the risk(s),” the same Joint Commission document said. The Illinois Suicide Prevention Plan 2020, the latest available online through the state’s Department of Public Health, says state surveyors should work with The Joint Commission and other accrediting bodies to evaluate ligature risk. “Ligature resistant environmental settings and determinations made by surveyors from IDPH should prioritize patient safety, but also maintain an environment that fosters patient recovery,” the document says. In its response to questions about Stringfellow’s death, IDHS said investigations were conducted by the Illinois State Police and the IDHS inspector general. The inspector general’s investigation found an employee at fault for failing to monitor Stringfellow adequately. IDHS said the employee is on administrative leave and in the process of being fired. “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,” IDHS said in its statement. The agency did not provide specific information on conditions at Madden but said “regulatory safety standards” are key to suicide prevention and that “these standards are strictly adhered to in all state-operated facilities.” IDHS also said it has prioritized identifying and removing ligature risks under guidance from The Joint Commission. The agency said its division of mental health’s central office maintains a list of all remaining risks across the state-operated mental health hospitals and works to eliminate barriers to fixing them. IDHS said that because many of those projects require significant construction, including electrical or plumbing work, patients must sometimes be temporarily housed on a different unit to accommodate the work. The agency said “Madden has successfully removed nearly all ligature risks in patient spaces.” On Wednesday, a small group connected with Madden rallied outside the mental health center in Hines, an unincorporated community in Cook County near Maywood, to bring attention to their complaints that management has allowed an unsafe work environment, according to rally organizer and retired Madden employee Sharon White. IDHS and its facilities have been the frequent target of criticism in recent years. A 2022 investigation by ProPublica, Capitol News Illinois and Lee Enterprises found that state police had started dozens of criminal probes into alleged employee misconduct in the preceding decade at the Choate Mental Health and Developmental Center in downstate Anna. An IDHS inspector general investigation in 2023 also found “fundamental problems,” including instances of staff members deliberately covering up misconduct. Gov. JB Pritzker that same year launched a plan to improve conditions at Choate while also aiming to expand opportunities to move elsewhere. A recent watchdog report found “concerning barriers” in reaching the goals of that three-year plan, including long waits for Choate residents to transition to more home-like settings or be moved to other state-run facilities. Last month, the Illinois Auditor General’s office released a report covering fiscal years 2021 through 2023 that found that IDHS employees throughout the state worked excessive overtime during that period, with possible detrimental effects that come with working long hours. The report also said misconduct allegations within the agency increased in that period and that its inspector general’s office was slower to investigate complaints. The audit showed that Madden reported fewer allegations of mistreatment compared to other IDHS facilities. But it also said that of the seven IDHS mental health centers, Madden had the lowest completion rate of employees who underwent so-called “Rule 50” training, which requires the IDHS inspector general to conduct periodic training for those workers in the areas of prevention and reporting of mental abuse, physical abuse, sexual abuse, neglect, egregious neglect or financial exploitation. While most of the mental health centers for 2022 and 2023 had either 100% compliance rates or were within two percentage points of that, Madden’s rate was 94% in 2023, the audit shows. In court documents, defendants named in the Cook County lawsuit deny an allegation that they “should have ordered one-to-one observation and/or constant supervision” for Stringfellow before he took his own life at Madden. They also deny that they should have known Stringfellow had a high risk for suicide or self harm, according to filings in the case. Dr. Ronald J. Lotesto and nurse Grace Mangio were employed by IDHS at the time of Stringfellow’s death, according to court documents. The two other defendants, Drs. Anandbhai Patel and Wei Hu, in court documents also said they at some point administered care to Stringfellow but did not say they were employees of Madden. IDHS would say only that three of the defendants were full-time IDHS employees; it would not specify who. Patel’s lawyer, Michael Trucco, as well as Illinois Attorney General Kwame Raoul’s office, which is representing Lotesto, Mangio, Madden and IDHS, declined to comment on the lawsuits. Hu’s attorney could not be reached for comment. Webster, Stringfellow’s mother, and her lawyer Patricia A. Hudson declined to comment.