Whistleblowers are among them: men and women with the courage and grit to expose misconduct, protect the vulnerable and force the facts into the open.
And at Oregon State Hospital (OSH)—the state’s only public psychiatric hospital, with campuses in Salem and Junction City—three whistleblowers announced they are suing, alleging they were punished after they spoke out to protect patients’ lives and health.
Their actions came too late to save 25-year-old Kenneth Hass, who had been held for months in a filthy seclusion room after a civil commitment order. He died there on March 18, 2025, after a fatal fall.
“Retaliation is alive and well in this organization.”
Hass was imprisoned and alone—with only a mattress, a urinal and a bedpan in a room strewn with feces. Staff documented him eating food mixed with waste, denied even a fresh meal.
On the night of his death, Hass had been granted access to the seclusion bathroom unsupervised—even though, for months, staffers knew he had tried to jump off the sink and toilet onto the floor.
This time, he did. He leapt from the top of a toilet, struck his head and died. No one came to help him for more than four minutes. By that time, he was long gone.
Nine days earlier, deputy chief nursing officer Lindsey Sande, concerned over Hass’ terrible condition, filed a formal complaint.
“I was aware and had reiterated my concerns about the ongoing seclusion,” she said. “I felt, and my boss felt, that we just were not making any traction on making changes as fast as we felt that we needed to. And I think it came to a point where I felt so helpless that I was willing to take the risk that I knew was probably coming my way to make the formal complaint about his care.”
She said she believed Hass’ death could have been avoided if her complaint had received the proper attention.
Instead a man died, and Sande and two other whistleblowers who raised alarms over patient safety faced retaliatory punishment.
“I took a significant pay cut,” Sande said. Nicole Mobley, another whistleblower and the hospital’s former chief nursing officer, was stripped of her position and pushed out of her job. Katie Iv, the director of nursing excellence, was likewise demoted.
But the women are not backing down, and the hospital now faces at least four additional staff lawsuits alleging retaliation and other charges.
“Retaliation is alive and well in this organization,” Heidi Scott, a program director, said. “If you speak out, or if you rub people the wrong way, something will happen.”
And the whistleblowers weren’t warning about an isolated failure.
A secret 61-page report on the hospital, marked “not for distribution” and obtained by a local publication, found that OSH suffers from a “culture of complacency in which safety issues can be overlooked or ignored.”
Asked for a response, hospital spokesperson Marsha Sills did not address the report’s findings. “Oregon State Hospital (OSH) declines to respond to questions based on an improperly disclosed report,” she wrote.
Between November 2023 and May 2025, five OSH patients died unexpectedly—one after complaining of breathing problems, another on his first day at the facility after no one checked his vital signs, and another from a suspected fentanyl overdose.
Since May 2022, the hospital has also recorded a dozen patient falls resulting in bone fractures or other serious injuries, including intracranial bleeding; four incidents of nonconsensual sexual activity; and three patient-on-patient assaults resulting in serious injury.
The federal Centers for Medicare & Medicaid Services issued a lengthy report on OSH, citing failures in leadership and policy, and warning that the hospital would lose its certification and ability to bill Medicare and Medicaid unless it submitted a correction plan and addressed the deficiencies by August 4, 2025.
Federal findings addressed Hass’ death directly. “The hospital’s medical emergency response to the patient’s loss of consciousness was not timely or effective,” an inspector wrote in a preliminary report.
On April 11, 2025, Dr. Sara Walker, interim superintendent at the hospital, resigned abruptly from her $435,420-a-year job after Governor Tina Kotek’s office learned more about the March 18 death of Kenneth Hass.
At least that’s a start. But it took whistleblowers risking their jobs to force the facts into the open.
When the state locks a patient inside a mental hospital, it assumes a duty to protect his life. In Kenneth Hass’ case, that duty was abandoned—leaving him isolated, degraded and dead on the floor.
