QuickTake:

Oregon Health Authority leaders want to know how a journalist got the analysis of a Lane County patient’s death. The report found the patient lived in squalid conditions and did not receive adequate care.

State officials are investigating the disclosure to Lookout Eugene-Springfield of an Oregon State Hospital analysis into the death of a 25-year-old patient at the Salem facility March 18, 2025.

That document, called a “root cause analysis,” offered insights into the care and death of Kenneth Hass, who was homeless in Eugene before he entered the hospital. 

The report shows Hass spent his final months in a feces-filled seclusion room before dying after falling three times in a single night. Staffers waited more than 4 minutes after he fell the final time and was motionless before they entered his room to check his vitals, that analysis and other state records show.

The hospital’s 61-page analysis called out a “culture of complacency” at the psychiatric hospital, which has experienced five unexpected patient deaths since 2023. The hospital has previously refused to answer questions about the analysis and its findings.

“Oregon Health Authority’s Information Security and Privacy Office is conducting an independent investigation,” said the hospital’s Jan. 30 note to staffers, which multiple employees provided to Lookout Eugene-Springfield.

The investigation marks another effort by the hospital and state to clamp down on the flow of information about the facility and how it cares for patients. The hospital cares for more than 1,500 Oregonians annually, usually people who are in the criminal justice system.

In a separate case, the hospital and the health authority took the unusual step of redacting findings by federal inspectors that the hospital’s failures potentially contributed to the patient’s “harm and death.” An unredacted version previously obtained by Lookout found the state also redacted details unrelated to the patient’s medical file, such as a lack of training and staff protocols.

In another instance, a communications aide for Gov. Tina Kotek asked the hospital to not send out a routine press release disclosing that the hospital was in immediate jeopardy with federal regulators due to the patient’s death. 

In the Jan. 30 note that revealed the investigation, hospital officials provided staffers information in a question-and-answer format. The disclosure of the investigation was in the answer to this question: “How does OSH leadership plan to address that the root cause analysis (RCA) of a patient death was leaked to the media? The RCA results are not even shared with staff, and this further erodes trust.”

Besides the investigation, the note said, the hospital has “changed its procedures” to reduce the risk of information being shared again, calling the record subject to attorney-client privilege and “intended to allow for frank discussion.”

Spokespeople for the health authority and Oregon State Hospital were unable to answer questions about the parameters of the investigation, whether it is ongoing and whether the probe is considered confidential after its wide disclosure to rank-and-file hospital staffers.

The authority’s Information Security and Privacy Office provides services that include privacy consultations, support on compliance issues and security work such as “system vulnerability assessments, computer forensic investigations and analysis, and information security incident management,” the health authority’s website states. The office also says it “protects the organization by identifying, assessing, and reducing or eliminating risk.”

The root cause analysis did not identify Hass by name, which Lookout Eugene-Springfield has confirmed through his family and public court records that show he was a patient at the hospital.

Efforts by government agencies to identify whistleblowers and how they provide information to the press are misguided, said Adam Rose, deputy director of advocacy for the Freedom of the Press Foundation, a national nonprofit that supports press freedom and whistleblowers.

The organization was co-founded by the late Daniel Ellsberg, a famous whistleblower who provided the Pentagon Papers to The New York Times in 1971. Those documents showed the public that the Vietnam War was not going as well as the federal government publicly stated at the time.

“The hunting of whistleblowers is wrong because it is failing to address the actual problem, which is the reason they blow the whistle in the first place,” Rose said in an interview with Lookout.

Rose added that whistleblowers serve an important service for the public.

“As for any energies that might be spent in trying to root them out or prevent future leaks, I think any administrator or any taxpayer or any stakeholder should be asking: ‘Why would we expend any effort on anything other than fixing the problem?’” he said.

Ben Botkin covers politics and policy in Lane County. He has worked as a journalist since 2003, most recently at the Oregon Capital Chronicle, where he covered justice, health and human services and documented regional efforts to fentanyl addiction. Botkin has worked in statehouses in Idaho, Nevada, Oklahoma and, of course, Oregon. When he's not working, you'll find him road tripping across the West, hiking or surfing along the Oregon Coast.