The Marion County District Attorney’s Office released a 55‑page grand jury report on Oregon State Hospital, the state‑run psychiatric facility in Salem, highlighting serious concerns about staff safety, patient care, and institutional leadership.
Key findings
The six‑month inquiry heard roughly 40 witnesses, including former patients, current and former staff, and others familiar with the hospital’s operations. The report documents a pattern of retaliation against employees who raise concerns. One staff member who complained about the treatment of 25‑year‑old patient Kenneth Hass was demoted two months after Hass died in a feces‑filled seclusion room.
According to the report, “instability in OSH leadership has created a culture of fear, uncertainty and chaos in the organization.” Employees who suggest changes have faced demotion, reassignment, or termination, leading many to stay silent about problems.
Patient‑care shortcomings
Hass died on March 18, 2025, after spending about seven months in seclusion. The report notes that he was moved frequently because the rooms became unsanitary, and that he consumed roughly five gallons of water in a short period before collapsing. Staff did not check his vitals for more than four minutes after he became motionless.
The grand jury found that seclusion is used too often and for periods that are too long. Training has shifted from de‑escalation techniques to physical takedowns, and onboarding for new hires has been reduced from a 20‑day program to just five days.
Systemic issues
Other deficiencies cited include:
- Insufficient capacity to meet the needs of all patients requiring services.
- Admission decisions driven by the severity of alleged crimes rather than the severity of mental illness, due to ongoing litigation and court orders.
- Absence of a 24‑hour on‑site medical doctor and overall low staffing levels, contributing to burnout and unsafe conditions.
- Lack of consistent training documentation and declining training quality.
These factors have created an environment where both patients and staff are at risk.
Official response and next steps
District Attorney Paige Clarkson said the report confirms that the hospital continues to fall short of its duty to Oregon’s most vulnerable citizens. She called for increased capacity, improved staff safety, a shift toward civil commitment rather than reliance on the criminal‑justice system, and dependable leadership.
Governor Tina Kotek’s office has not yet responded to the report, but an Oregonian article notes that Kotek plans to introduce legislation in the 2027 session to separate Oregon State Hospital from the Oregon Health Authority, making it an independent agency.
The report’s recommendations include expanding mental‑health treatment options in jails, increasing community residential treatment facilities, keeping a medical doctor on site 24/7, formalizing critical‑incident documentation, and fostering open, non‑threatening dialogue between staff and management to eliminate retaliation.
Legal action
Hass’s family has filed a wrongful‑death lawsuit, and the grand jury’s findings may influence future litigation and policy reforms aimed at protecting patients and staff alike.
Original reporting: Homepage – Lookout Eugene-Springfield — read the source article.
