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Governor Kotek Orders Leadership Shakeup at Oregon State Hospital After 21st Patient Death Since 2020 News By Diane Megaw On Apr 13, 2025 Oregon State Hospital | Credit: Wayne Hsieh After another patient died at the Oregon State Hospital, bringing the number to 21 since 2020, Governor Tina Kotek announced a leadership overhaul at the hospital, including a new acting superintendent. Kotek directed Kristine Kautz, the acting Director at the Oregon Health Authority (OHA), to install new leadership to enhance patient safety less than 24 hours after the Governor’s Office received information about the death. Dr. Sara Walker, the Interim Superintendent and Chief Medical Officer, resigned, and the governor’s orders, effective immediately, were: Dave Baden, the current Deputy Director of Policy and Programs at OHA, was appointed Acting Superintendent. The agency must create a 30-day plan to address patient care and safety issues. Federal investigators indicated that hospital staff failed to conduct hourly checks to ensure patients were alive and breathing, leading to a patient being found dead last May. Of the 21 patients who died at the Oregon State Hospital since 2020, nine were unexpected, and the hospital was previously warned about the risk of losing Medicaid and Medicare reimbursement eligibility. The hospital is not currently at risk of losing certification with the Centers for Medicare and Medicaid Services as it has since implemented corrective measures. The OHA is developing an immediate plan to provide increased oversight from the Governor’s Office. Kotek said. “Patients and their families deserve a hospital that meets the highest possible standard of care.” Share Twitter Facebook ReddIt WhatsApp Pinterest Email