The Oregon State Penitentiary in Salem. (Ron Cooper/Oregon Capital Chronicle)
UPDATED at 5:03 p.m. on Monday, Feb. 3, 2025 with information about the investigation.
The Oregon Department of Corrections has fired two leading health care managers who oversaw a division responsible for the medical care of about 12,000 inmates in a dozen state prisons.
The corrections agency on Monday said it had moved to “separate” with Health Services Assistant Director Joe Bugher and the agency’s medical chief, Dr. Warren Roberts, and conduct a comprehensive review of the agency’s health care system. The actions come after a tumultuous year for the corrections agency, which has faced mounting criticism and scrutiny for its health care system, including its care for women in custody.
In early December, the agency disclosed it had put Bugher and Roberts on administrative leave. By then, problems had already surfaced publicly about the agency’s health services division, which has 634 employees statewide and often contracts with outside providers for specialty care. A year ago, an outside accrediting agency found a backlog of nearly 600 medical appointments at Coffee Creek Correctional Facility, Oregon’s women’s prison.
Termination letters sent to both men on Monday show the agency’s top brass met with them and their attorneys on Jan. 23 — before Oregon Department of Corrections Director Mike Reese, who joined the agency in October 2023, fired them.
Their termination came after the agency completed an internal investigation, which included reviews of other health care staffers. The agency, in response to a Capital Chronicle records request, released a heavily-redacted 84-page report of its findings, which show a litany of problems uncovered from a review of inmate records and interviews with other staffers.
Among them: systemic delays in inmate care, including for appointments outside that needed Roberts’ approval and harmed patients. In some cases, patients waited over a year for care.
Staffers also told investigators they didn’t believe Roberts, who had a background as a neurosurgeon, had the appropriate background and knowledge to make decisions about care. The investigation found failings in treating women in particular, with Roberts requiring inmates who might have suffered sexual trauma to have medically unnecessary and repeated examinations to access medication for genital herpes.
Investigators found the two were untruthful when questioned about a tort claim an inmate filed and untruthful during the agency’s fact-finding after the claim was filed. The report also said the two were evasive and untruthful at different points during questioning and found Roberts fabricated meetings in subordinates’ work records that did not take place and retaliated against staff who raised concerns.
Attorneys for Roberts and Bugher did not immediately respond to requests for comment.
In a statement, Reese said the health care of people in the system is a high priority, with challenges that include mental health and addiction and an aging population with about 1,400 who are 60 or older.
“As we move forward, I am committed to a transparent process of change in our Health Services Division to ensure we have the leadership, resources and support needed to provide the highest standard of care,” Reese said in a statement.
The agency said it hired Falcon Correctional and Community Services Inc., an Illinois-based consulting firm that specializes in health care in prisons, to provide “immediate and substantial technical assistance” in a comprehensive review of the agency’s system. The one-year contract will cost the Oregon Department of Corrections an estimated $550,000 and follows previous work by Falcon to help the agency identify the sources of its “significant issues.”
“ODOC has been facing significant issues in its Health Services Division, as evidenced by complaints and lawsuits over medical treatment for a wide range of conditions, including the treatment of acute or chronic conditions or illnesses,” the contract states.
Falcon will be expected to complete the agency’s review by looking at its policies, practices and the quality of care, the contract says.
During the review, Deputy Director Heidi Steward will lead the health services division. The agency appointed Dr. Michael Seale, who has 28 years of correctional medical experience, as the interim chief of medicine, the statement said.
Separately, the agency will hire a health services recruiter to hire well-qualified professionals, including doctors, nurses, mental health professionals and other support staff.
The agency is also working on an electronic health records system to improve documentation and track data across the prisons, it said. In the past, the agency has been unable to provide basic data to the Capital Chronicle, including statistics for drug overdoses at a prison.
The two former officials earned six-figure salaries.
Roberts, paid a salary of nearly $381,000 annually, joined the agency as a corrections physician at Coffee Creek in 2019, and in September 2020 he became a clinical director before his December 2020 promotion as the agency’s chief of medicine.
Oregon prisons lack oversight, critics say, with agency failing to track key data
Bugher, who is not a doctor, was paid an annual salary of $241,000. He started in 2004 as a correctional officer at Snake River Correctional Institution in Ontario. In 2008, he became a counselor and in 2013 moved into a management role in the prison’s behavioral health unit. In 2017, he was promoted to assistant director.
The toll of poor medical care can continue for years, even after someone exits prison.
In 2023, a former inmate at the women’s prison settled a lawsuit for $1.5 million after alleging inadequate treatment for a traumatic brain injury after emergency room doctors recommended a neurologist.
The agency currently faces two wrongful death suits, both alleging a failure to provide timely care. The suit filed in December says the agency did not give an inmate the mental health care he needed, leading to his death, and one filed in January alleges that it did not provide timely medical care that could have prevented the man’s death.
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