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The Marion County District Attorney’s Office released a 55-page grand jury report on patient care and working conditions at Oregon State Hospital, where Lane County patient Kenneth Hass died in a seclusion room in March 2025. The six-month inquiry included testimony from about 40 witnesses.
One week before Kenneth Hass died in Oregon State Hospital, a staffer filed a complaint with her bosses about the way the 25-year-old from Lane County was treated.
That same staffer was demoted from her leadership role about two months after Hass died in a feces-filled seclusion room at the state-run psychiatric hospital in Salem, according to her testimony to a grand jury convened by Marion County District Attorney Paige Clarkson. That account is among the examples of staffers sharing their concerns and fears about retaliation at the hospital in sworn testimony contained within the 55-page grand jury report Clarkson released Wednesday, Sept. 30.
The report is the result of a six-month inquiry that heard 47 hours of testimony from about 40 witnesses, including a former patient, current and past staffers and others who work closely with the hospital, which can hold about 600 patients. As the district attorney in Marion County, Clarkson has the authority to convene a grand jury to investigate conditions at Oregon State Hospital in Salem and other state-run facilities in that county.
The release comes amid heightened scrutiny of Oregon State Hospital, which has experienced, in addition to Hass’ death, four other unexpected deaths since 2023 and years of struggles and litigation to force timely admissions of patients from jails to the hospital for court-ordered treatment. The hospital also has struggled to find a permanent superintendent, with the state firing one after about a month on the job after a national search.
“While this inquiry and the resulting report could never encompass all the multifaceted issues faced by the Oregon State Hospital, it serves as confirmation that the hospital continues to fall short in its crucial obligation to our communities and our most vulnerable Oregonians,” Clarkson said in a statement. “Our communities should expect better from the state’s behavioral health system and that must start with increased capacity at all levels, improved staff safety, an up-stream focus on civil commitment rather than reliance on the criminal justice system, and — perhaps most important of all — dependable leadership that creates a culture where this is all possible.”
The report looks at the deaths and broader issues: limited capacity to admit patients, a toxic workplace culture with fears of retaliation for raising concerns and gaps in patient care.
“Instability has created a culture of fear, people are afraid of speaking up because of [possible] retaliation,” the report said, quoting a former hospital employee.
It recommends systemic changes to behavioral health and how the hospital cares for the state’s most vulnerable, usually people arriving from throughout the state after an arrest because they need court-ordered behavioral health treatment to face criminal charges.
Oregon State Hospital spokespeople and communications staffers with Gov. Tina Kotek’s office had no immediate response to the report and its recommendations. In an Oregonian report published today, Kotek said she wants to introduce legislation in the 2027 session that would separate Oregon State Hospital from the Oregon Health Authority and make the institution its own agency.
Findings of the report
The staffer’s account of being demoted after raising concerns about Hass’ treatment is just one piece of evidence, but also points to a pattern the grand jury found.
Specifically, the report found staffers are afraid that pointing out shortcomings could lead to retaliation.
“Instability in OSH leadership has created a culture of fear, uncertainty and chaos in the organization,” the report said. “Specifically, employees who suggest changes have faced demotion, a change in their position, or termination. This leads to staff being fearful of retaliation for raising concerns or suggesting improvements.”
Staffers raised similar concerns in an internal analysis of Hass’ death. When Lookout Eugene-Springfield published the analysis, the state launched an investigation to find who had leaked it to the news organization, according to an email staff received.
Other findings in the grand jury report:
- Oregon State Hospital lacks the capacity to meet the needs of all patients who require services.
- Due to ongoing litigation about patient admissions and a court order, the hospital must accept patients based on the severity of the alleged crime rather than the severity of the mental illness.
- A medical provider is not present 24/7 on site and overall staffing is too low, leading to burnout and poor morale. Inadequate staffing has led to “unsafe conditions” for patients and staff.
- Training is not tracked and onboarding for new employees has gone from a 20-day process to five days.
- Overall, training has declined in quality. De-escalation training to prepare staff for critical situations has been replaced by training in “physical takedowns” of patients.
Hass death
The grand jury examined the case of Hass, who died March 18, 2025, after being in seclusion for about seven months. During that time, he often was moved from one room to another every few days because the rooms would become unsanitary and too filthy for habitation, the report said.
Those details and others, such as the excessive water consumption that caused his death, are also contained within other reports that the Oregon Health Authority concealed and redacted.
On the day of his death, Hass drank about five gallons of water within 3½ hours. On that night, he also fell several times and was motionless in the seclusion room where he died for more than four minutes before any hospital staffer went into the room to check his vitals.
Lookout Eugene-Springfield has previously reported these details and others from unredacted documents provided by whistleblowers concerned about Hass’ treatment.
The grand jury report is the first time the head of a government agency has released a detailed account of Hass’ death and the shortcomings in his care.
The grand jury found that seclusion is used too frequently and for periods of time that are too long. That echoed a state-hired consultant who expressed similar concerns to former Oregon Health Authority director Sejal Hathi in a report four months before Hass died. Hathi has since resigned.
Hass’ family has since filed a wrongful death lawsuit.
Even after his death, concerns linger, the report said.
“Despite the death of Mr. Hass, multiple witnesses expressed ongoing concern about the length of time patients are remaining in seclusion,” the report said.
Report recommendations
The report’s recommendations for state leaders include:
- Explore some form of mental health treatment to serve people in jails, allowing them to get help without a trip to the hospital.
- Increase the number of community residential treatment facilities and secure residential treatment facilities, which have more safeguards for patients, throughout the state.
- Increase the presence of managers and administrators within the hospital’s secure perimeter to eliminate the “perception of a divide in staff hierarchy.”
- Keep a medical doctor available on site 24 hours a day, seven days a week.
- Formalize a system of properly documenting critical incidents and add staffing.
- Increasing patient capacity to treat more people.
As for retaliation concerns, the report recommends: “Foster open, non-threatening dialogue between staff and management/administration to create a culture where innovation and change are encouraged rather than penalized.”
