Sister sues state over Lane County patient’s death in Oregon State Hospital 

Kenneth Hass’ sister has filed a wrongful death lawsuit, alleging that Oregon State Hospital failed to prevent his death in a seclusion room and violated “constitutionally protected ‘fundamental rights.’”

The lawsuit, filed by Sierra Hass, on Monday, July 13, in U.S. District Court in Portland, comes nearly 16 months after Kenneth Hass’ March 18, 2025 death at the state-run psychiatric hospital in Salem.

The hospital, overseen by the Oregon Health Authority, is responsible for the care of nearly 600 patients in Salem and also has a Junction City campus with capacity for up to 145. Most of the patients who arrive at Oregon State Hospital do so through the criminal justice system because they need treatment so they can aid in their defense.

Hass’ was the fifth unexpected patient death on the Oregon State Hospital’s record since November 2023. Patients during that time span have died under circumstances in which investigating federal regulators found violations. Among the other cases: A patient died of a fentanyl overdose, another died in a seclusion room after complaining of breathing difficulties and another was declared dead shortly after his arrival at the hospital, when staffers failed to check his vitals.

Among defendants named in the lawsuit are: Sejal Hathi, the outgoing director of the Oregon Health Authority; Dolores “Dolly” Matteucci and Sara Walker, both former hospital superintendents; and Karen Jamieson, the hospital’s chief financial officer.

Eight treating doctors are also named defendants: James Peykanu; Ryan Bell; Les Christianson; Kyle Bowers; Poornima Ranganathan; Rubina Gundroo; Bhargav Muppaneni; and Jigar Chotalia. Also named is a psychiatric nurse practitioner, Robert Hiester.

In addition, the lawsuit names four nurses: Mohamed Darami; Kelly Cockroft; Mofoluwasho Adenakan; and Nicole Okeke. Also named are Joseph Kamandi, a medical technician, and Leti Ortega, a medical provider.

The lawsuit alleges “extreme neglect and abuse” while Hass was involuntarily housed from February 2022 until his death at age 25 more than three years later.

The defendants “had a constitutional duty to protect Mr. Hass’s life and his liberty interests from known and threatened harm, including their own conduct,” but instead violated his rights under the 14th Amendment in failing to protect him, among other claims made on behalf of Hass and his sister.

Those named in the lawsuit “relied on the extensive use of isolation and four-point restraints” as well as “excessive doses” of certain medications instead of properly diagnosing Hass and developing a treatment plan, the lawsuit alleges.

Four-point restraints “consist of tying each of a patient’s four limbs to a bed so they cannot move at all,” according to the lawsuit. 

The lawsuit describes staff placing Hass in four-point restraints for many hours at a time — commonly more than eight hours at a time, and several times for more than 24 hours at a time. In October 2024, Hass charged the door when staff with shields entered his room and was placed in four-point restraints for 54 hours and 43 minutes; in September 2024, Hass “ran towards security” armed with shields and was placed in four-point restraints for 51 hours and 55 minutes, according to the lawsuit.

For Hass, “locked seclusion and manual restraint were often used as punishment and in lieu of actual treatment,” and the lawsuit alleges “many other patients at OSH were subject to prolonged and repeated use of seclusion, often without active treatment or clear, behaviorally defined criteria for release.”

The lawsuit states Hass lived in isolation for 250 consecutive days at the end of his life, during which he was denied clean clothing and not allowed a shower. Hass was “left in locked rooms smeared with feces and urine,” the lawsuit states. 

He was considered a fall risk and known to drink “dangerous amounts” of water, and in “the last hours of his life, he was repeatedly allowed to engage in dangerous, life threatening behavior,” the lawsuit contends.

“No one stopped him or helped him, despite repeated requests by staff,” the lawsuit states.

The lawsuit seeks no less than $225,000 in combined damages to be decided by a jury that would factor in economic losses and penalties for “reckless and outrageous indifference.” Further, the lawsuit seeks “treble damages,” or, triple the award, under a state law aimed at protecting vulnerable adults.

It also seeks no less than $75,000 for Hass’ sister, Sierra, a Lane County resident.

The lawsuit refers to “many years” of past lawsuits and public investigations into Oregon State Hospital, and asks the court to appoint a “Special Master to oversee a review of policies and procedures at the Oregon State Hospital through the use of an outside panel of experts.”

In a statement, Sierra Hass said her brother experienced abuse as a child “yet he was the greatest protector and friend to myself, my children, everyone.”

“I believe this lawsuit will bring about whatever form of justice can be left in this situation. Kenneth would be honored to know that his death can serve to change how those still living at the hospital are treated,” Sierra Hass said.

She and her brother’s estate are represented by attorneys Tom D’Amore and Ben Turner of D’Amore Law Group, which has offices in Lake Oswego and elsewhere in the state as well as in Washington, and also by Lake Oswego-based attorney Michelle Burrows.

The attorneys, in a joint statement, said Hass “endured three years of misconduct.”

“This wasn’t just medical malpractice. It was a violation of Kenneth’s most basic constitutional rights to safety and dignity,” the attorneys said. “We intend to hold the state of Oregon fully accountable, and force real change so no other patient endures what Kenneth did.”

Spokespeople for the Oregon Health Authority and the state hospital declined to comment.

‘The Plan’

Hass first arrived at Oregon State Hospital in 2022 for court-ordered treatment to face charges in Lane County, where he was often homeless. Prosecutors eventually dropped those charges after the court determined he did not improve enough at the hospital to aid in his defense, court records show.

Hass continued to stay at Oregon State Hospital on a civil commitment order until his death.

The lawsuit fills in additional details about Hass’ life before 2022. It also describes a document referred to as “The Plan,” with a focus on Oregon State Hospital staff safety rather than therapeutic treatment, as guiding how staff responded to Hass.

Among the named defendants, Peykanu, a psychiatrist who began treating Hass in September 2022, is alleged in August 2024 to have described Hass as having a “terminal psychotic illness,” a term that’s “not a recognized medical diagnosis,” the lawsuit states.

Some hospital staff tried to help Hass but were ignored, according to the lawsuit.

Early struggles 

Also included in the lawsuit is a description of Hass’ early life, starting with his premature birth at 30 weeks and five days of gestation. 

Doctors diagnosed Hass as having mild cerebral palsy with spastic diplegia, a type of movement disorder that increases risk of falling, but the condition was “well-managed” before his admission to Oregon State Hospital. 

Hass, however, “suffered from physical abuse and neglect” as a child, including “physical beatings” and “sexual trauma,” the lawsuit states.

He huffed paint at 7 years old and began drinking alcohol at 10. While he struggled in school, Hass “repeatedly tested as having ordinary intelligence,” the lawsuit said.

After a time living in Texas with his mother and graduating from high school, Hass returned to Oregon, where he “continued to struggle with drug and alcohol use.” The lawsuit describes continued use of methamphetamine from 2019 to 2021.

In 2021, Hass “voluntarily sought help” and was allowed to sleep in the emergency department of “Sacred Heart,” the lawsuit states, presumably a reference to one of the PeaceHealth emergency departments open at the time in Springfield and Eugene.

But additional arrests would follow. At one point, Hass asked to be admitted to a behavioral health unit but was denied.

In November 2021, Hass refused to leave a detoxification center where he had sought help, and staff called Eugene police.

“Upon arrival, officers observed Mr. Hass talking to himself and drinking water out of the toilet. Mr. Hass told the officers his family was being held hostage and he needed to negotiate their safe release,” the lawsuit states.

He was arrested after kicking one officer and attempting to kick another, according to the lawsuit, and while in Lane County Jail his defense attorney requested an Oregon State Hospital evaluation that eventually resulted in a 2022 commitment to the hospital.

Hass “alternated between radically different behaviors over short periods of time,” the lawsuit stated. “He could range from calm and lucid to withdrawn to aggressive in a matter of hours.”

Problems at Oregon State Hospital

The lawsuit repeatedly refers to instances of Hass drinking from a toilet, but states that a compulsion to drink excessive water “is an extremely common condition among psychiatric patients,” with an estimated 6% to 20% having the condition.

Excessive water consumption is harmful, decreasing the concentration of electrolytes and causing vomiting, confusion and potentially death.

Overall, the lawsuit alleges that Hass’ “symptoms were worsened by neuroleptic malignant syndrome,” described as “a rare life-threatening reaction to antipsychotic medication.”

Hass spent most of September, October and November 2022 in “locked seclusion” at Oregon State Hospital, the lawsuit states. The term refers to leaving a patient alone in a locked room.

“The seclusion rooms in which Mr. Hass spent most of the rest of his life consisted of concrete walls, a concrete floor, and a bare mattress with a small attached bathroom that was sometimes accessible,” the lawsuit stated. “More often, the bathroom was locked and a bedpan was placed in the seclusion room.”

Hass was discharged February 2023 but the hospital recommended Lane County pursue a civil commitment, eventually leading to his readmission to the hospital after some time in Lane County Jail.

He was readmitted to Oregon State Hospital on March 20, 2023, on an involuntary civil commitment, and a day later took off his clothes and “began kicking and spitting at OSH staff,” leading to him being placed in mechanical restraints and locked seclusion.

“Mechanical restraints were removed after four hours, but Mr. Hass was kept in locked seclusion for over a week,” the lawsuit states.

Treatment by hospital staff

“By the fall of 2023, OSH staff created the Kenneth Hass Safety/Risk Mitigation Plan (the “Plan”),” the lawsuit alleges, with “The Plan” “not designed to treat Mr. Hass’s mental illness, but to address staff safety and reduce the risk of staff injury.”

The lawsuit alleges that when staff saw Hass begin to take off his clothing, “they would place him in restraints and keep him in seclusion for days.

“Oftentimes, Mr. Hass would be placed in restraints and kept in seclusion for days without displaying any aggression.”

The plan “encouraged staff to initiate or continue locked seclusion” if Hass was not answering questions or not eating, for example, in addition to being naked.

The lawsuit noted that none of “these behaviors presented a likelihood of injury, and only the first could be considered a precursor of violence.”

According to the lawsuit, the plan “instructed OSH staff to continue locked seclusion unless” Hass was fully clothed, “medication compliant,” responding “appropriately” to staff assessment and had “verbally agreed to safety expectations.” 

The lawsuit noted that all the conditions had to be met or locked seclusion would continue, according to “The Plan.”

Hass “developed a urinary tract infection and blood clots due to prolonged seclusion and restraint,” leading to a four-day stay at Salem Hospital in March 2024. 

“Upon return, Mr. Hass showed marked psychiatric improvement. He was off all psychiatric medications and was not placed in seclusion,” the lawsuit states.

In April 2024, Hass received a consultation from a psychologist at Oregon State Hospital, Jennifer Snyder, that resulted in “four pages of detailed recommendations” that ended up being “largely ignored,” the lawsuit claims.

The lawsuit also claims that by “early 2024,” there were “many staff” who “recognized that seclusion had become a serious issue for the Hospital generally and Mr. Hass specifically.”

“These OSH staff tried to help Mr. Hass and others like him. They were consistently ignored or rebuffed by OHA and OSH leadership,” the lawsuit alleges.

During his time at the Oregon State Hospital, Hass “experienced repeated falls, unsafe behaviors, and environmental risks within seclusion, including climbing onto fixtures, ingesting unsafe substances, and exposure to unsanitary conditions,” the lawsuit contends. “These events were not isolated. They were recurrent, documented, and known to staff and providers across disciplines.”

Peykanu’s use of the “terminal psychotic illness” term “simply means that, for the last seven and a half months of Mr. Hass’s life, his treating doctor expected him to die in the Hospital,” the lawsuit claims.

The lawsuit also says the “terminal psychotic illness” term was used by Walker, at the time the hospital superintendent, after she visited him, and that the term “was repeated dozens of times by many different OSH staff members.”

“By the end of his life, the idea that ‘Kenneth will die in this hospital’ was a running joke among OSH staff,” the lawsuit alleges.

Sister visits

Sierra Hass saw her brother for the first time in years in December 2024.

“Hass was ‘hostile and irritated’; he insisted that Ms. Hass was not his real sister, refused to engage with her, and started yelling profanities,” the lawsuit claims.

But after other visits, Hass “stopped calling Ms. Hass a ‘demon,’ listened to memories that they shared, and corrected Ms. Hass when she got small details wrong,” the lawsuit stated.

Sierra Hass was denied a visitation in January 2025 and then “repeatedly turned away,” the lawsuit contends.

The lawsuit alleges that Sierra Hass was appointed her brother’s legal guardian in November 2024, and in January 2025 instructed Peykanu to stop all his medications. 

But “[d]espite verbally agreeing to cease all medications, Defendant Peykanu did not change Mr. Hass’s medications in any way,” the lawsuit states.

Last day

The last day of Hass’ life began with a request: He “‘said that he wanted to get out and get some fresh air,’” the lawsuit states, referring to Okeke, the psychiatric nurse practitioner, who noted that Hass was “‘much more verbal’” than he had been in previous weeks. 

Hass offered to be put in shackles, and Okeke “made a plan” with steps for Hass to fulfill before being allowed outdoors.

With the bathroom often locked, as part of the plan, Okeke opened the door and allowed Hass access despite knowing him to have a “habit of repeatedly drinking from the toilet” and issues with falling and “self-harm.”

“While there were many relatively safe ways that Mr. Hass could ‘demonstrate safety,’ Defendants Okeke, Peykanu, and other OSH staff chose an option that posed a clear danger to Mr. Hass’s wellbeing,” the lawsuit states.

The lawsuit goes on to describe Hass as drinking 35 cups of water from the toilet from 7 to 8 p.m., but the information was not being documented or passed on to other staff in any way, despite a staffer being assigned to one-to-one supervision of Hass.

The pattern continued, according to the lawsuit, with hours passing and staffers not documenting the “excessive water intake.”

“At 9:32 p.m., Mr. Hass climbed onto the toilet seat. In doing so, he slipped on the slick toilet seat” and “hit his head on the bathroom wall as he fell to the ground,” the lawsuit alleges, with a staffer, Darami, neither responding nor informing anyone about the fall.

Another staffer, Michelle Tellez-Calzada, not named in the lawsuit, began watching Hass at 10 p.m. and “did not know that Mr. Hass had consumed 89 cups of water (about 5.1 gallons) in the past three hours.”

Tellez-Calzada reported a fall by Hass but was told that unless Hass hit his head there was no need “to chart it.”

While Tellez-Calzada told a nurse, Adenakan, that Hass “was a fall risk, that he should change rooms, and that they should let the lead nurse know about these issues,” Adenakan allegedly responded “‘it’s too late. I’m not going in. You’re crazy. Let the lead know what?’”

Hass fell again at 10:27 p.m., and then at 10:34 p.m. tried to stand on the toilet but “his foot slipped inside the bowl.”

“Mr. Hass fell backward off the toilet, struck his head on the door, and fell to the floor. Mr. Hass vomited as his head struck the door and floor,” the lawsuit states.

Tellez-Calzada called a nurse, Cockroft, to request a “Code Blue,” meaning that there was a life-threatening emergency.

Cockroft responded by assembling “a team to help secure Mr. Hass,” according to the lawsuit.

“More than four minutes after Mr. Hass’s fall, OSH staff entered his room and checked his pulse,” the lawsuit claims. 

Hass was pronounced dead 47 minutes after his fall, according to the lawsuit. He died from water intoxication, the lawsuit states.

The 114-page complaint references the fictional depiction from more than 50 years ago of the Oregon State Hospital in the famous novel and subsequent film “One Flew Over the Cuckoo’s Nest,” in which a character referred to the hospital as “‘The Combine,’ a factory-like system designed to strip away patients’ individuality and turn them into compliant, emasculated beings.

“The Oregon State Hospital performed exactly in the same way to Kenneth Hass and it killed him in the end.”

After Hass’ death, the state hospital reported it to the federal Centers for Medicare & Medicaid Services, which inspects the facility and conducts surveys after unexpected patient deaths or other events with harm. After the report came back, the Oregon Health Authority concealed details about the death and violations from the public, releasing a heavily redacted version. 

That approach differed from the hospital’s past practice of releasing reports that didn’t identify patients by name but which were generally unredacted. The redactions in the Hass case covered more than medical information, including details about the hospital’s failures to have adequate training for staff to respond to life-threatening emergencies. 

Oversight efforts continue 

The hospital is now in compliance with Centers for Medicare & Medicaid Services regulations and officials have pointed to improvements, including more oversight of seclusion cases and improved training for staff members. But officials have stressed that the hospital is a work in progress and improving the hospital’s culture and practices is a long-term goal.

Before reaching this point and well before Hass’ death, state officials were aware that the state hospital needed attention, records show. 

Lookout Eugene-Springfield’s reporting has shown that health authority officials, including Hathi, the authority’s outgoing director, received information about seclusion problems in general months before Hass died.

Chartis, a consulting company that the health authority hired to improve the hospital, sent Hathi and other top agency leaders a report with findings that patients stayed in seclusion for “days and weeks” without justification, records show.

That information came to Hathi and others in November 2024, about four months before Hass died. 

Local officials and state lawmakers are paying attention. 

In March, Marion County District Attorney Paige Clarkson announced her office is conducting a grand jury inquiry to look into overall management and conditions at the state hospital. It’s unclear to what extent that inquiry will examine patient deaths, but her office will release a public report with findings after the grand jury’s work.

In recent months, state lawmakers have held hearings about Oregon State Hospital and its path forward. State Rep. Hai Pham, D-Hillsboro, has said he wants to see more accountability and oversight to help patients at the state hospital, potentially through  legislation introduced in the 2027 session.