Oregon lawmaker pushing for more oversight of Oregon State Hospital 

State Rep. Hai Pham wants more accountability and transparency at Oregon State Hospital — with the goal of keeping patients safe and receiving appropriate, quality care. 

Pham, D-Hillsboro, is chair of the House Interim Committee on Behavioral Health, which puts him in a position to lead the Legislature’s efforts to keep Oregon State Hospital accountable. The psychiatric hospital cares for hundreds of patients at its main facility in Salem and at a satellite campus in Junction City. Most patients enter through the criminal justice system.

“I want to make sure that at the end of the day that the patient is centered at the middle of the conversation there,” Pham said in an interview with Lookout Eugene-Springfield. “Because the state hospital needs to really focus on making sure that patients are safe and that they get the appropriate care that they deserve.”

Since November 2023, the hospital in Salem has seen five unexpected patient deaths, sparking regulatory actions from the federal Centers for Medicare & Medicaid Services. The most recent of those was Lane County patient Kenneth Hass, who died March 18, 2025, in a seclusion room.

In a joint hearing June 17 of the House and Senate behavioral health committees, Oregon Health Authority bosses updated lawmakers, including Pham, on steps they are taking to make improvements. Those include staff huddles, team evaluations of cases for solutions when patients remain in seclusion rooms, and a stronger emphasis on safety.

Pham is glad to see those steps, and he wants to see the progress continue.

“We are making those changes now,” Pham said. “But how do we ensure that we continue to have this oversight, so that there’s not another sentinel event or bad adverse outcome happening?”

In the months ahead, he plans to have a workgroup that will look for potential solutions — and a bill for the 2027 legislative session — that would put more accountability measures in place to help patients. The details of any legislative proposal will come forward after the workgroup’s discussions.

A key part of that is legislative oversight, Pham said, pointing to the recent joint hearing. 

“That shows the public and people in the hospital and administrators that, ‘Hey, we mean business, and we are paying attention.’”

Asked about the push for accountability, a hospital spokesperson pointed to Oregon Health Authority Director Sejal Hathi’s June 17 testimony to lawmakers. 

“The state hospital must become consistently safe, transparent, accountable, disciplined, and high-functioning,” Hathi said at the hearing.

Disability Rights Oregon, an advocacy group with a federal charter that allows it access to Oregon State Hospital, welcomed Pham’s efforts. 

“Lack of stable leadership and accountability, chronic staffing issues, and deaths in custody mean lives are at stake at the state hospital right now,” Dave Boyer, managing attorney of Disability Rights Oregon’s Mental Health Rights Project, said in a statement to Lookout. “People with mental illness deserve to be treated with dignity, and their right to safe, timely, quality care must be protected. We appreciate the Legislature’s attention to this crisis, and we commend Representative Pham for his leadership and genuine outreach to impacted stakeholders, including Disability Rights Oregon.”

For Pham, increased oversight means more than a singular hearing and moving on.

“I don’t want to have to wait for another bad outcome before we have another review of systems,” Pham said. “I want to make sure we have further check-ins with the state hospital, further check-ins with leadership, and say, ‘Hey, what’s going on?’”

Hospital’s advisory board languishes

Historically, Oregon lawmakers have looked for ways to improve patient conditions. In 2009, the Legislature passed a bill creating the state hospital advisory board.

Under the law, the advisory board shall periodically provide comprehensive reviews of laws and policies at the hospital related to “safety, security and care of patients.”

The advisory board had its most recent meeting July 17, 2025. That was nearly a year ago and four months after the last patient death.

Two other meetings, scheduled for September 2025 and November 2025, were canceled. 

The advisory board can have up to 16 members, representing groups like healthcare professionals, advocates and consumers. 

The House speaker and Senate president each appoint one nonvoting member. Pham was recently appointed to the board. The Senate is looking for someone to fill its slot, a spokesperson said.

Under state law, Gov. Tina Kotek is responsible for appointing the remaining 14 members. But of those 14 seats, only four are currently filled.

The hospital and Oregon Health Authority have “worked with the Governor’s office to try to recruit new members but there currently are not enough active members for a quorum,” said Amber Shoebridge, a spokesperson for Oregon State Hospital. 

Shoebridge was unable to provide an estimate of when the advisory board meetings will resume.

Spokespeople for Kotek’s office did not answer questions about why the vacancies have not been filled, whether the office is actively reviewing applications and what the timeline is for filling the vacancies.

‘A heads up’

On March 28, 2025 — 10 days after Hass died — Brandy Hemsley, executive appointments adviser for Kotek, emailed Dr. Sara Walker, then the interim superintendent of Oregon State Hospital.

Hemsley sought a meeting with Walker and Amy Baker, Kotek’s behavioral health initiative director. The goal: Discuss the hospital advisory board and “some possibilities for how the group could be best utilized in the future.”

“I wanted to give you a heads up so you knew what the meeting was about,” Hemsley wrote in the email.

It’s unclear if that meeting happened. Within weeks, Walker resigned from Oregon State Hospital. 

Public records show Baker emailed a couple of board members about Kotek’s replacement of Walker. 

“OHA and the Governor’s office are working on a plan to assess and stabilize the situation at OSH,” Baker wrote April 12, 2025. “Our intention is to communicate with the OSH board to ensure that you are informed about the plan as it unfolds. Please let me know when your next board meeting is scheduled and thank you for your patience as we navigate this situation together.”

Three months later, the advisory board had its most recent meeting.