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What does accountability look like when the person who needs it most is no longer here?
For more than six months, Lookout Eugene-Springfield has chronicled the safety concerns and missteps that preceded Lane County resident Kenneth Hass’ death at Oregon State Hospital in March, as well as attempts by state health officials and Gov. Tina Kotek’s office to keep details of his death and a federal investigation into the matter hidden from the public.
No more.
It is past time to give Hass’ death the scrutiny it deserves. No closed-door hearings. No reports released quietly months down the road. It’s time for public hearings that put state lawmakers, Oregon Health Authority Director Sejal Hathi and other agency leaders in the same room to go over everything that went wrong and the changes being made so nothing like it happens again.
During the past few months, Lookout has had conversations with several legislative leaders about the need for hearings to understand these compounding failures. Failures that resulted in staff watching Hass lie motionless on the floor of a seclusion room in the psychiatric hospital for more than four minutes before anyone went in to check on him.
Recently, we’ve heard the Oregon Senate Judiciary Committee may hold a hearing on Hass’ death at its upcoming Legislative Committee Days, Nov. 17-19, a three-day period meant to update lawmakers on past legislation and preview potential items for the next legislative session in February. We applaud that effort and would like to see it officially scheduled soon.
While we would have liked to see lawmakers take action sooner, the upcoming committee days provide an opportunity to get all of the stakeholders — Oregon State Hospital staff and administrators, Oregon Health Authority leaders, patient advocates and legislators — in the same room, and for a public accounting.
That’s the first step. Next is for lawmakers and the public to get candid answers to the following questions:
- Why has Oregon State Hospital failed to develop policies and procedures to ensure patient safety and security, as a federal investigation found, especially in light of another patient death in a seclusion room in 2023, and two other deaths last year?
- Why did state hospital officials attempt to conceal the findings of that federal investigation from the public?
- What actual steps has Hathi, the Oregon Health Authority director, taken to improve conditions at the hospital since hearing from staff seven months before Hass’ death that Oregon State Hospital suffered from a culture of retaliation and a lack of accountability?
While they’re at it, they could answer specific questions about Hass’ death. Oregon Health Authority officials have cited patient confidentiality and attorney-client privilege in redacting the federal investigation’s findings and some emails by staff from the health authority, the state hospital and Kotek’s office. Lookout obtained unredacted emails only after successfully petitioning the Oregon Department of Justice to dispute the health agency’s redactions.
The details of Hass’ case are egregious. So despite any privacy concerns, the public needs answers to these questions:
- Why was Hass repeatedly placed in seclusion rooms for months leading up to his death, without a clear plan in place at the state hospital for ensuring patient safety while in seclusion?
- Why did hospital staff on multiple occasions place Hass in restraints for up to 11 hours at a time, without clear justification for their use?
- Why didn’t hospital staff provide a timely emergency response to Hass when he fell on March 18, despite them seeing the fall, gathering outside his room and watching him lay motionless for four minutes?
- Did that culture of retaliation Hathi had heard from staffers contribute to his death?
The state made some changes since Hass died. After learning details of the incident, Kotek replaced the hospital’s interim superintendent Dr. Sara Walker. The Oregon Health Authority also released a 30-day plan to improve patient care and safety at the hospital.
But a three-page report — issued in April — and assurances from the health authority that things will get better are far from satisfactory. We’ve heard this from the health authority before, after all. Responding to the two patient deaths last year, Walker in August 2024 said the hospital would investigate and figure out “what can we do differently to prevent that sort of thing from happening again.” Hass died seven months later.
Public hearings are just the first of several steps owed to Hass’ family, the families of other Oregon State Hospital patients and the patients themselves, in order to restore public faith in the state-run psychiatric hospital. Accountability from those who failed Hass, and the establishment of concrete policy changes at the hospital, should follow. Such accountability can be achieved by the governor, legislative action or both.
Sierra Hass, Kenneth’s sister and legal guardian, wasn’t allowed to hug him when she visited him at the state hospital. She told Lookout recently that she would tell him, “I love you. I’m here for you. I’m trying to make this better for you.”
Oregon health officials can no longer make things better for Kenneth Hass. But maybe they can for the next Kenneth Hass. That should start this month with public hearings.
