The recent leadership shakeup at the Oregon State Hospital has put the already embattled institution at further risk of upheaval, according to the latest review by a court-appointed expert.
The report calls out Gov. Tina Kotek’s dismissal of interim superintendent Dr. Sara Walker, who was asked to resign April 11 after reports that a patient died at the hospital in March. It was the third death at the hospital in the past year.
While interim superintendent, Walker was also the hospital’s chief medical officer, and holding both positions at once, at the state’s largest psychiatric facility, was setting her up for failure, the report suggests.
“Dr. Walker had been tasked with a nearly impossible workload of being the Chief Medical Officer and the Superintendent,” writes Dr. Debra Pinals, who was assigned by a federal judge in 2021 to monitor the hospital. Given Walker’s knowledge of policy and practice at the facility, Pinals said it is “concerning” that her resignation from both positions was so abrupt.
“Without someone with her experience, OSH is at risk for having a significant vacuum at the facility,” Pinals writes, calling the circumstances around her resignation “vague.”
Kotek ordered Walker’s removal with the support of the Oregon Health Authority, which oversees the hospital. She had held the superintendent's job on an interim basis for a year. Kotek immediately named Dave Baden, a deputy director with the OHA, as the acting superintendent. Dr. Ryan Bell, the hospital’s director of psychiatry, was named as the interim chief medical officer.
Pinals questioned the health authority’s response to the hospital’s needs prior to Walker’s resignation, which she said could have had an impact on the safety of patients and patient outcomes.
“If it was known that Dr. Walker had too much on her plate with two major positions being held for a prolonged period of time, it is unclear what was being done about this,” Pinals wrote.
When asked for comment from the governor’s office, spokesperson Lucas Bezerra responded in an email that the governor values Pinals’ work, but “respectfully disagrees with the characterization of Dr. Walker’s departure from the Oregon State Hospital.”
The health authority has been working for more than a year to find a permanent replacement for the superintendent’s position. The hospital hasn’t had a permanent superintendent since Dolly Matteucci stepped down in March, 2024. Matteucci led the state hospital since 2018.
In her report, Pinals’ raised the contrast of Walker’s dismissal with the praise Walker had received in a federal court hearing in March. During that hearing, Oregon Health Authority Director Sejal Hathi testified under oath at a court hearing that Walker is well-qualified and one of three people at the agency she considers “subject matter experts that I deeply trust.”
Oregon State Hospital provides psychiatric care for people, most of whom are facing criminal charges, who are deemed either a danger to themselves or others or lacking the ability to assist in their criminal defense. Between its main facility in Salem and its Junction City campus, it has the bed capacity for nearly 750 people, and serves more than 1,500 people a year, according to the Oregon Health Authority.
The state hospital's troubled legal and regulatory history can’t be making the hiring process easy. For years the hospital has been the target of disturbing reports over its operations, staffing and safety issues, including a 102-page report issued by the Centers for Medicare and Medicaid Services in 2023 indicating a pattern of systemic problems. A slew of compliance violations have put the hospital repeatedly in jeopardy of losing its Medicaid accreditation, only to come back from the edge by making changes to its safety and other policies.
Since 2002, the hospital has been under a court order to admit patients on a timely basis, terms it has repeatedly failed to meet, and it is currently under the threat of a contempt ruling in federal court that could result in significant fines.
According to the state, 21 patients have died while in state hospital custody since 2020, nine of which were unexpected. In the case that triggered Walker’s departure, a patient was left locked in a seclusion room without adequate observation and subsequently died after losing consciousness.
With the leadership change in April, Kotek ordered Baden to produce a plan to improve patient care and safety at the hospital. The three-page plan, released weeks after Baden’s appointment, focuses on identifying the risk of future deaths and major injuries, increasing staffing to operate more like a 24/7 hospital, and providing clearer direction and empowerment to staff to keep patients safe.
