By Noelle Crombie
oregonlive.com
PORTLAND, Ore. — The Oregon Department of Corrections director on Monday fired two top administrators who oversaw medical treatment for Oregon’s prisoners after an outside investigator made a series of scathing findings about their decision-making, supervision and overall leadership.
The state hired attorney Jill Goldsmith last summer to investigate complaints filed by Department of Corrections physicians against Dr. Warren Roberts, the chief medical officer, and Joe Bugher, Roberts’ boss.
Goldsmith’s 84-page report details a health system in crisis, with front-line physicians lacking confidence in Roberts’ clinical skills and believing his management harmed both patients and employees.
One physician quit over Roberts’ “poor leadership” and the resulting “substandard medical care” prisoners received, Goldsmith noted.
She concluded that the witnesses she interviewed had a “reasonable, good faith basis” to believe that Roberts lacked the expertise and leadership required for the position, that he “at least occasionally” denied appropriate medical care for prisoners and that his management of the review process for outside medical care led to “significant” delays and hurt patients.
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The report calls out Bugher for both his awareness of the concerns and his failure to adequately respond to them.
Medical care in Oregon’s prisons has long been criticized by prisoners and their advocates. In multiple state and federal court filings spanning years, prisoners accuse the state of failing to treat everything from asthma to traumatic head injuries — and in many cases the courts have sided with them.
Goldsmith interviewed Roberts and Bugher and delivered blunt assessments of their overall honesty. She wrote that she did not find Roberts to be credible and that Bugher “obfuscated, deflected and attempted to confuse me.”
Under the terms of Goldsmith’s contract, the state agreed to pay up to $249,000 for her to carry out the investigation. Her final report is dated Dec. 17.
Roberts and Bugher were placed on leave about two weeks before Goldsmith submitted her final report.
Roberts was hired in 2019 and served as chief medical officer for the entire prison system.
Bugher began his career as a corrections officer in eastern Oregon in 2004 and rose through the ranks to become assistant director of health services, a division with 634 employees.
The Department of Corrections released the report Monday in response to a records request from The Oregonian /OregonLive. The agency heavily redacted the records, though it is clear that the complaints against the two managers stemmed from physicians.
In announcing the firing of Roberts and Bugher, Oregon Corrections Director Michael Reese said the health and well-being “of those in our care is a high priority.”
“Too often the people coming into our prison system have complex medical conditions, high mental health needs, substance use disorders, and co-occurring disorders,” Reese said in a statement. The department is dedicated to addressing the complex medical needs of the prison population, he said.
In a message to agency employees, Reese said he reached the decision to fire the two managers “after careful review of the investigation and supporting documents.”
Roberts and Bugher each indicated they will sue the department.
Roberts’ lawyer, Bryan J. Davis, said his client is “deeply disappointed” in the agency’s investigation and decision to fire him.
Davis said the Department of Corrections retaliated against Roberts because he had been critical of the agency for failing to respond to racial discrimination that he said he and other corrections employees of color experienced on the job.
Roberts, through his attorney, said his efforts to improve the quality of care drew backlash from other doctors in the prison system who, he alleged, complained about him “to cover over their own failure to provide quality care to inmates in custody.”
Bugher plans to sue the agency, citing whistleblower claims, according to his attorney Randy Harvey . Harvey said the Department of Corrections is scapegoating his client and covering up its own failures to hold employees accountable.
Goldsmith’s report depicts a health system in disarray, with Roberts at the helm. Doctors, the report notes, repeatedly questioned Roberts’ ability to manage the delivery of primary care to the state’s estimated 12,000 prisoners given his specialty as a board-certified neurosurgeon and lack of training in internal medicine.
Said one employee who was interviewed by Goldsmith: “I cannot imagine a more dysfunctional chief of medicine. We could not do worse. He is responsible for 12,000 lives and it scares the hell out of me.”
Goldsmith’s report notes multiple instances when she found Roberts and Bugher were evasive, untruthful or where they offered explanations that were not credible or retaliated against colleagues.
She found Roberts made decisions that delayed patient care “and when brought to his attention, denied accountability.”
She noted that she had “concerns about Roberts’ use of complaints against employees who disagree with him.”
She concluded that one of the employees who complained about Roberts qualified as a whistleblower, finding that the employee raised concerns about patient care with Roberts and Bugher and experienced retaliation as a result.
Among the instances of retaliation cited in Goldsmith’s report: placing an employee on paid leave.
Goldsmith also found that meetings Roberts claimed he had with subordinates to discuss their concerns — meetings noted in the state’s human resources system – did not happen.
“It is undisputed that these meetings did not occur,” Goldsmith wrote.
Goldsmith found that one witness she spoke with had a “reasonable, good faith basis” to conclude that Roberts’ lack of primary care knowledge harmed women prisoners in particular.
She pointed to the care of women diagnosed with genital herpes. A medical provider whose name was redacted told Goldsmith that the standard of care is to “trust” women who say they are experiencing an outbreak of the virus and to provide them with the prescription medication they can use to “suppress” the virus’s painful symptoms, according to the report.
Goldsmith noted that a witness reported Roberts required women to undergo “numerous genital examinations to verify whether they had genital herpes outbreaks,” calling the practice “below the standard of care and unnecessary.”
The practice, the report said, risked compounding the trauma of invasive exams for women who “often have histories of sexual abuse.”
Reese said the Department of Corrections will now undertake “a comprehensive review” of corrections health care.
It has hired Chicago-based Falcon Correctional and Community Services to carry out the review. The national consulting firm employs former corrections administrators who serve as expert witnesses in court proceedings and advise state and local governments on mental health and health care in prisons and jails.
A copy of the Department of Corrections agreement with Falcon was not immediately available, nor was the estimated cost of the organization’s review of the health care system.
The Oregon Department of Justice has also hired Falcon to help with corrections-related litigation. The state agreed to pay Falcon up to $250,000 for those services, according to the contract, which extends through November 2027.
The Department of Corrections also plans to hire a health services recruiter to draw doctors, nurses, mental health providers and support staff.
Deputy Director Heidi Steward will oversee the department’s Health Services Division and Reese tapped Dr. Michael Seale to serve as interim chief of medicine. Seale previously served as medical director for corrections in Multnomah County.
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