Walker resigns as superintendent of Oregon State Hospital after patient death 

Dr. Sara Walker resigned as interim superintendent of Oregon State Hospital after Gov. Tina Kotek learned more details about the death of a patient from Lane County at the state-run psychiatric hospital. 

Oregon State Hospital employees received word of the development shortly before 9 p.m. Friday, in a message from Kris Kautz, interim director of the Oregon Health Authority, which runs the hospital. Lookout Eugene-Springfield obtained copies of the email from multiple employees of the hospital.   

“Tonight, Gov. Tina Kotek will announce a new acting superintendent at Oregon State Hospital after learning more details about the recent fatality,” Kautz wrote in the message. “Gov. Tina Kotek directed me in my role as acting director at OHA to immediately install new leadership at OSH after OHA executive leadership shared information with the Governor’s Office less than 24-hours ago regarding the fatality. Interim Superintendent and Chief Medical Officer Dr. Sara Walker has resigned.”

The development comes after Lookout Eugene-Springfield reported about the death and an August 2024 meeting in which Oregon State Hospital managers spoke candidly about problems that included a lax attitude toward rules and a culture of retaliation when people try to make improvements. The audio of the nearly one-hour meeting, recorded surreptitiously, was shared with Lookout Eugene-Springfield.

Federal inspectors and surveyors with a national accrediting organization found the hospital was unable to follow rules and emergency protocols on March 18, when 25-year-old Kenneth Hass died. They found Hass, who is from Lane County, was in a locked seclusion room with an unlocked bathroom. The one staffer assigned for constant observation was insufficient to respond to his multiple falls.

“The hospital’s medical emergency response to the patient’s loss of consciousness was not timely or effective,” an inspector wrote in a preliminary report for the federal Centers for Medicare & Medicaid Services, released April 2 to Lookout Eugene-Springfield.

The state health authority runs the hospital, which provides mental health services from a main campus in Salem with capacity for up to 558 patients as well as a satellite campus in Junction City that houses up to 145 patients. The majority of the hospital’s patients go there for court-ordered mental health care so they can assist their attorneys with their defense against pending court charges from throughout Oregon, including Lane County. The hospital stays are limited to three months to a year, depending on the severity of the charges. 

The message to employees included a statement from the governor, promising to offer increased oversight at the hospital.

“I have also directed the agency to make a 30 day plan to address issues related to patient care and safety as well as other staff concerns that have been reported,” Kotek said. “Families and patients trust the state hospital and we must meet the highest possible standard.”

Violations related to patient deaths have repeatedly surfaced at the state hospital. In November 2023, a patient died in a seclusion room, where staff placed him after he complained of breathing difficulties. In April 2024, another patient died the same day he arrived from the Douglas County Jail. Medical staff forgot to check that patient’s vitals when he arrived, inspectors found. In May 2024, another patient died of a suspected fentanyl overdose. 

Dave Baden, deputy director at the health authority, will fill in as interim superintendent, the governor’s message said. Baden has worked at the health authority since 2019, serving in roles such as chief financial officer and, previously, interim director of the Oregon Health Authority. 

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