For the third time in two years, the Oregon State Hospital has a new leader. The most recent departure follows the sudden death of a patient last month and mounting safety concerns at the state’s only psychiatric facility.

Sara Walker, the interim superintendent and chief medical officer at the hospital, resigned on Friday, April 11. She will be replaced by Dave Baden, deputy director of policy and programs at the Oregon Health Authority.

In a statement released Friday, Oregon Gov. Tina Kotek said she directed the Oregon Health Authority, which oversees the 700-bed facility, to name a new superintendent following Walker’s resignation.

“Patients and their families deserve a hospital that meets the highest possible standard of care,” Kotek said.

Few details have been released about the patient’s death, which occurred March 19. The Oregonian reported that the patient was in seclusion and fell, and a report by the Joint Commission, a nonprofit responsible for accrediting hospitals across the country, said hospital staff failed to provide timely care to the patient, which resulted in their death.

The death is the latest in a string of safety problems at the hospital.

According to OHA, 21 patients have died in the facility since 2020. Some died of natural causes, but nine died unexpectedly. According to Willamette Week, a patient in custody on aggravated attempted murder charges escaped the facility three times. In addition, the Joint Commission reported multiple safety violations at the hospital and said it failed to properly implement policies for patient assessment and emergency response.

Most of the patients at the Oregon State Hospital are undergoing psychiatric treatment to allow them to stand trial on criminal charges. The state hospital is based in Salem, with a smaller satellite campus in Junction City, north of Eugene.

The hospital has been under near-constant litigation for decades for the speed it admits and treats patients.

The hospital has been undergoing a national search for a permanent replacement for the past year. Prior to her resignation, Walker — who has worked at the hospital since 2006 — replaced former Superintendent Dolores “Dolly” Matteucci, who retired from the facility in 2024.

Baden said OHA is working on an immediate plan to address problems at the hospital.

“The Oregon Health Authority shares the Governor’s concerns and urgency regarding this matter and are resolved to do everything in our power to improve patient safety at OSH,” Baden said.

The joint commission is expected to release a follow up report later this month, to determine whether the hospital has addressed key deficiencies.