Gov. Tina Kotek’s decision to install Dave Baden to oversee the Oregon State Hospital makes him the third person to lead the institution during a 15-month period marked by stress, turmoil and continued scrutiny. And it signals another turbulent chapter for the troubled institution, which cares for patients deemed in need of hospital-level psychiatric care.
But one prominent lawyer tracking the hospital said Kotek’s move to accept the immediate resignation of interim hospital superintendent, Dr. Sara Walker, may not signal a change for the better.
“This leadership vacuum is a big deal,” said Tom Stenson, deputy legal director of Disability Rights Oregon, a nonprofit group that is pursuing a contempt order against the Oregon Health Authority over lack of capacity at the facility. “I am concerned that things are not turning in the right direction.”
He added, “There's not been any real transparency around (Walker’s resignation) that would help us understand what's going on.”
The governor’s office announced late Friday night that Kotek had accepted the resignation of Walker, who was also the hospital’s chief medical officer. Baden, Walker’s replacement, told hospital staffers he would hold the job for just 30 days as he develops an improvement plan for public consumption.
The release stated that Kotek made the move due to safety concerns after Oregon Health Authority, which oversees the facility, shared with the governor unspecified new “details” about a recent patient death at the hospital.
A Kotek spokesperson, Lucas Bezerra, declined to provide specifics of what those details were, but suggested it may simply have been that Kotek learned more about the death, helping push her to the decision.
“There was no written report that she received,” he said of the unspecified details. “It was new information to her.”
Kris Kautz, another deputy director at the health authority, added another wrinkle to questions around the move in an email to staff Monday, saying Kotek’s direction to install a new superintendent was based on “advice” from health authority “leadership.”
If true, that would appear to be a change of heart. A month ago, in a March 12 federal court hearing, Oregon Health Authority leaders cited reforms Walker was helping with to argue against a proposed federal contempt order.
Oregon Health Authority Director Sejal Hathi testified under oath that Walker is well-qualified and one of three people at the agency she considers “subject matter experts that I deeply trust.”
Hospital’s new leader tasked with PR, ‘politically charged’ issues
Baden, named to replace Walker, left the federal government six years ago to join the Oregon Health Authority as a financial executive. Last year, however, Director Sejal Hathi promoted him to be her deputy director overseeing the agency’s public relations office, among other functions, and tasked him with navigating “time-sensitive, politically charged issues,” public records show.
Inspectors have found the hospital in violation for conditions related to the unexpected deaths of three patients in the last 12 months, including one last month. That’s the death Kotek referred to while removing Walker.
The patient was in a locked seclusion room and was supposed to be under observation. But that observation was inadequate, and the patient died on March 18 after losing consciousness, according to a March 31 federal inspection report obtained under Oregon Public Records Law. The patient did not receive “an immediate medical emergency response.”
In a March 26 letter, the Joint Commission, a nonprofit that accredits health care providers, informed Oregon health officials of “conditions that pose a serious threat to public or patient health and safety” following an inspection in response to the patient’s death.
The letter said staff did not follow emergency protocols. It also faulted the hospital’s leadership for not effectively implementing patient safety procedures. The letter was echoed by federal inspectors’ findings.
According to the state, 21 patients have died while in state hospital custody since 2020, nine of which were unexpected.
In a press conference Tuesday, Kotek said bringing in Baden was about making a “fresh start” for the agency, according to KATU.
However, Stenson, the attorney, said that he’s not sure Baden’s experience makes him qualified to tackle the challenges at the psychiatric hospital.
Considering recent firings of top managers at the Oregon Youth Authority and Department of Corrections, Stenson added, “I'm concerned that we've now seen three different long-troubled agencies just fire a high ranking official or two with the intimation that everything's sort of going to be okay now —notwithstanding the fact that there seems to be fairly large systemic problems that were clearly bigger than one person. And without a very clear roadmap for what's going to happen next and why it's going to be better.”
Facilities under pressure
Oregon State Hospital facilities in Salem and Junction City house vulnerable patients, often homeless and facing criminal charges, who are deemed either a danger to themselves or others or lacking the ability to assist in their criminal defense.
The state hospital’s main campus in Salem can house 558 patients at a time. The campus in Junction City has beds for 145 patients.
In recent years facility officials have reported an increase in the physical and mental challenges of those admitted to the hospital. Staff have also experienced an increase in workload due to a federal judge’s order in 2022 that set discharge deadlines for the people housed there, causing some to complain it had created a “revolving door.”
Not only that, but the state has struggled to add nurses to meet a new state minimum staffing law, sparking complaints of excessive mandatory overtime and forcing the state to hire costly temps to fill shifts.
Meanwhile, federal officials have required the hospital to hire several new staffers to help improve care and oversight. The temps and other unexpected staffing costs added up to $60 million just last year.
Walker held two key jobs at the facility
It’s unclear whether Walker played any role concerning the unspecified details that the governor cited in making the change.
But the longtime state hospital psychiatrist held a central position at the hospital while holding down two jobs for more than a year.
She’d accepted the post of interim superintendent after Dolly Matteucci announced her retirement unexpectedly in March 2024. Walker took over the institution’s operations while the state launched a national search for a new superintendent. She retained her responsibilities as chief medical officer overseeing care and medical staff.
That meant implementing new oversight systems mandated by the federal government, coping with an influx of temporary workers, and working on behavioral health reforms as the state tries to avoid being held in contempt for repeated violations of federal court oversight.
Records show Walker emailed Kautz notifying her of her immediate resignation at 8 p.m. Kautz replied at 8:09 p.m, accepting it. The Kotek press release announcing Walker’s resignation went out at 8:58 p.m.
The decision to remove Walker came not long after the digital publication Lookout Eugene-Springfield reported that well before the latest death, last August, Hathi met with state hospital managers and other staff and heard complaints about safety, lack of accountability and a culture of retaliation for speaking up.
Hathi reportedly told staff that she’d been pressing for change to address their concerns: “I continue to ask for a plan and don’t receive a plan.”
No such plan has materialized since Hathi’s complaint, the article noted.
Plan underway but concerns linger
Kotek announced that she directed the health authority to come up with a 30-day plan to improve patient safety and care issues at the hospital.
In an all-staff email Monday morning, Baden said that he’ll hold his new post for only 30 days.
“My main task while I am here is to prepare and communicate a thirty-day plan around patient care and safety. The goal is not to create one more plan,” he wrote, “but to be able to show Governor Kotek and the public what OSH is doing around safety and care daily and what can be done to continuously improve.”
In her proposed budget to lawmakers, Kotek has called for a 20.5% increase for the state hospital, bringing its two-year funding to over $1 billion. The additional funding is intended to help with staffing challenges and complying with orders from regulators.
But it’s unclear what happens when Baden steps down in 30 days and who takes over as superintendent and chief medical officer.
The state has twice advertised for candidates to replace Walker and still hasn’t hired someone, although Hathi was supposed to announce a new hire in January, suggesting at least one recruitment effort has failed.
“It points out how hard it is to hire somebody into a troubled institution,” Stenson said, adding that he’s concerned the situation is just the latest in a worsening cycle.
“We've seen over and over again that something bad happens, we get a very sunny report about how everything is going to get fixed, and then that plan never materializes. There's never any information about it, there's no transparency about it. And then the next thing that hits the news is somebody else has died,” he added. “I don't know where all this is headed right now, but it's hard to see the light at the end of this particular tunnel.”
He said the state needs to provide more transparency around the decision to change leadership.
“That's a matter of public importance,” he said. “People need to understand whether or not people are safe at the hospital. People need to understand whether there's a coherent plan to fix known problems.”
