Oregon Gov. Tina Kotek replaced the head of the Oregon State Hospital Friday night after senior state health officials shared additional details about a patient who died at the hospital last month.
The psychiatric hospital’s Chief Medical Officer, Dr. Sara Walker, who for the last year had also taken on the additional role of interim superintendent, resigned at 8 p.m. on Friday.
Walker’s departure comes as a federal judge is currently weighing whether or not to hold the facility in contempt. For years, the hospital has struggled to admit mentally ill patients charged with crimes from local jails so they can receive treatment that would allow them to continue with their case. If the state is found in contempt, the judge could require policy changes costing tens of millions of dollars per year.
Late Friday, Kotek’s office announced that state health officials “shared information with the Governor’s Office less than 24 hours ago regarding a recent fatality at the hospital.” A spokesperson for the governor declined to share what new details it learned about last month’s death in the hours before Walker resigned.
“I know that the governor did not request a report, did not receive a report in her inbox,” Lucas Bezerra, a spokesperson for the governor said Monday.
Public records obtained by OPB provide further details about the patient death. On March 18, a patient died in a secure room while experiencing an emergency and the “hospital’s medical emergency response to the patient’s loss of consciousness was not timely nor effective,” according to a preliminary finding from the Centers for Medicare and Medicaid Services, which provides federal funding to the hospital.
A courtyard area inside the Oregon State Hospital in Salem, March 8, 2023.
Kristyna Wentz-Graff / OPB
Hospital officials wrote back plans to improve care for patients in seclusion, including video monitoring and “shift huddles” detailing the patient’s status, risks and emergency plan.
Records also show that days after the patient death, the hospital was notified it was at risk of losing accreditation.
The preliminary denial came from The Joint Commission, a nonprofit that evaluates and accredits health care organizations, which conducted an unannounced review after the hospital reported the patient death.
“Preliminary Denial of Accreditation is appropriate due to an Immediate Threat to Health or Safety that exists for patients, staff or the public within the hospital program,” the March 28 letter details. A follow-up survey is expected this week.
Walker joined the Oregon State Hospital in 2006 as a unit psychiatrist before she became chief of psychiatry in 2014. Walker was named Chief Medical Officer in 2020 and took on the additional role of Interim Superintendent last year. She could not be reached for comment Monday.
Walker spoke to OPB about the role in August after patient deaths put the hospital at risk of losing federal funding.
“It’s been a lot more difficult than I was anticipating,” she said. Walker took over the position April 1, 2024, and was immediately confronted with two unexpected patient deaths, one in April and one in May.
“We serve thousands of patients and have a very, very small number of patient deaths, certainly unexpected patient deaths,” Walker told OPB in August. “From a priority perspective, ‘standards compliance’ is really about excellence in patient care and patient safety. That is the hospital’s priority.”
Emily Cooper, legal director for Disability Rights Oregon, a nonprofit advocacy group behind the latest legal effort to find the state and hospital in contempt, said she was surprised when she learned Walker was ousted.
Cooper said that during recent tour of the hospital, she was struck by Walker’s rapport with patients and staff.
“This is someone who cares about relationships and also recovery,” Cooper reflected during an interview Monday.
While hospital staffing and patient care are critically important, Cooper also said that one facility cannot do it all and stressed that Oregon needs more treatment for mental health.
“Dr. Walker inherited a crisis at the Oregon State Hospital without the adequate resources to solve the problems,” Cooper said.
The Oregon Health Authority’s Dave Baden has stepped in as the state hospital’s acting superintendent for the next 30 days. Baden told staff Monday that the governor wants a plan that shows both her and the public “what OSH is doing around safety and care daily” and how to improve.
“Patients and their families deserve a hospital that meets the highest possible standard of care,” Kotek said in her Friday night statement.
OPB’s Michelle Wiley contributed reporting.
