This is part 2 of a series examining what’s driving the deadliest period in Oregon Department of Corrections’ modern history. Street Roots released part 1 on May 29, 2024.
Editor’s note: This story contains descriptions of sexual and medical misconduct.
“Patient is sent for current numbness aching (sic) now weakness and pain in both upper extremities (sic) left is worse,” Dr. Robert Hansen wrote in his examination notes Nov. 20, 2015, according to court records.
The patient, Richard Weaver, suffers from ulnar neuropathy in both elbows — pinched or damaged nerves causing pain, weakness and numbness in the forearms and hands.
Weaver, a prisoner at Two Rivers Correctional Institution, or TRCI, first received a diagnosis from Oregon Department of Corrections, or ODOC, physician Dr. Garth Gulick on June 2, 2015. Gulick recommended imaging to assess the ulnar neuropathy over a month later, on July 21, 2015, according to court records.
Imaging conducted by an outside provider confirmed Gulick’s assessment on Aug. 7, 2015, though it found the neuropathy was worse than Gulick suspected. Weaver needed surgery on both elbows.
PART 1: Deaths in Oregon prisons rise, while prison population falls
However, due to ODOC’s health care procedures regarding outside providers, Weaver wouldn’t receive his first surgery until January 2016 — over four months after Gulick’s first assessment. He wouldn’t receive his second surgery until Nov. 21, 2017 — over two years after his first diagnosis. Weaver complained of worsening pain, weakness, numbness and tingling the entire time, according to court records.
Weaver ultimately sued ODOC, his first of several lawsuits against the department regarding corrections health care, and settled for $20,000 in 2018. In another lawsuit, a Marion County judge found ODOC treated Weaver’s health conditions — which include lung and heart problems, according to court records — with “deliberate indifference” in 2021.
Much of Weaver’s legal claims against the department stem from a practice that dozens of prisoners sued ODOC over in the last two decades. ODOC employs a system of committees — Therapeutic Levels of Care Committees, or TLCs — that decide if and when a patient can undergo certain procedures and receive medical devices like eyeglasses and hearing aids.
The department uses different medical TLCs covering different prisons, as well as TLCs for behavioral health and medication-assisted treatment.
TLCs also decide if and when prisoners receive care from outside providers because ODOC medical staff sometimes can’t provide care for reasons like staffing and lack of expertise. Court records indicate these cases are particularly problematic.
With ODOC health care at the center of concerns around a now years-long trend of increased deaths in Oregon’s prisons despite a declining population — a 45% increase in the annual average number of deaths since 2020 — TLCs’ decisions on outside care are perhaps the biggest point of contention.
Dr. Warren Roberts, ODOC chief of medicine, is the “final authority in any review,” according to state rules, meaning the committees’ decisions are ultimately up to him.
Roberts, a neurosurgeon hired by ODOC in late 2020, can’t perform surgery in Oregon due to an agreement with the Oregon Medical Board following the board issuing a complaint and notice of proposed disciplinary action “alleging violations of the Medical Practice Act (state law) regarding unprofessional or dishonorable conduct, and gross or repeated acts of negligence.”
Roberts and the board struck an agreement in 2020 to conclude the investigation without any findings after initially proposing a $10,000 fine and revocation of his medical license if he did not complete mentorships to assess his “medical knowledge, clinical judgement and ability to safely practice.”
Roberts can’t perform surgery unless he submits a board-approved re-entry plan involving a surgical mentorship. Roberts also settled a malpractice lawsuit for $1 million in 2017.
Corrections medical staff, including Roberts, doctors, nurses, pharmacists and others, receive invitations to committee meetings. However, the department denied Street Roots’ requests for complete meeting invitations and attendance records, citing patient privacy.
Juan Chavez, attorney and Civil Rights Project director for the Oregon Justice Resource Center represented plaintiffs in numerous cases against ODOC. Chavez said ODOC health care is the most common issue he hears about from clients.
“Bar none, calls about inadequate medical care outnumber every other problem I hear in prisons, and there are plenty of other problems in prisons,” Chavez said. “Most fundamentally, people are losing body parts and organs and their sanity to the medical care there. So I would not be surprised if that is the most significant contributing factor to high rates of death in Oregon’s prisons.”
Doctors, attorneys, advocates and prisoners say the committees — from their structures and processes to who potentially serves on them — are deeply and dangerously flawed. At the time of publication, ODOC did not answer questions about why its providers’ referrals or opinions on prisoner requests need further approval from TLCs. It also did not answer questions about how it evaluates TLC performance or how many requests and referrals it approves or denies.
Numerous lawsuits allege medical TLCs, which are scheduled to meet once per week, delay or deny timely care. Some cases allege committee members lack credibility or have a pattern of showing “deliberate indifference” to prisoners’ suffering.
“It is TLC that drags these things out and doesn’t order appropriate care,” Chavez said.
ODOC did not answer questions about whether it tracks how many prisoners die with a pending TLC request or how many prisoners die after a TLC denies their request.
A recent whistleblower lawsuit by a former ODOC health care administrator also points, in part, to the TLC system as a problem for prisoners in need of care.
Caryn Ricks, former ODOC nurse manager who oversaw nursing and other health care operations at Oregon State Correctional Institution, or OSCI, and Santiam Correctional Institution, or SCI, filed a whistleblower lawsuit against ODOC in March. Ricks, who worked for ODOC from April 2023 until September 2023, alleged prisoners faced “unreasonably long delays to receive specialist appointments outside of the institution, even once the treatment had been approved” by TLCs. Ricks said she discovered ODOC maintained no tracking system to ensure staff even scheduled prisoners for outside care after approval, let alone received that care.
“Based on information and belief, there were hundreds of outside specialist appointments needed for prisoners that had not been scheduled by ODOC,” the lawsuit said. “Ms. Ricks learned of a prisoner whose specialist appointments had been so delayed by the lack of a tracking system for outside referrals that he had an inoperable tumor that had doubled in size and become life-threatening.”
Advocates and attorneys say the purported issues are caused not only by disorganization or poor decision-making but also by the structure itself.
Chavez said the policies governing TLCs enshrine a culture of delaying and denying care.
“That is kind of built into their levels of care policy where, basically, they let everything get so bad that people just get into these catastrophic situations where finally, DOC might intervene at that point,” Chavez said. “That’s the kind of tortured logic of it — once you get to that catastrophic state, yeah, sure, we’ll finally ship you out to a hospital with a real doctor who can treat you, but it does seemingly take you getting to that catastrophic state before they intervene.
“This all goes back to kind of a centralized committee at DOC that denies people health care left and right.”
The policies Chavez referenced are factors for TLC decision-making laid out in the state’s administrative rules. Chavez said the committees often deny or delay care to save money.
Case notes revealed in a 2019 lawsuit in which a prisoner required a hip replacement read, “Not at this time cont. eval monitor—post-pone (sic) as long as possible.” It took another four months for the prisoner to receive the surgery, according to court records, which was over two years after the prisoner first complained of hip pain and decreased mobility.
Language within some factors focuses on the ramifications of delaying or denying care without discussing the potential benefits of approving and providing care. Another factor specifically references the cost of care.
“The urgency of the care and treatment, and the length of the (prisoner’s) remaining sentenced stay,” begins the first factor listed in state rules for TLCs to consider. “Whether the care and treatment could be or could not be reasonably delayed without causing a significant progression, complication, or deterioration of the condition and would not otherwise be in clear violation of sound medical principles.”
The Oregon Legislature also applies a key performance metric for TLCs seeking to keep 99% of all corrections care within prison walls, incentivizing the committees to approve as few requests — often originating from corrections health care workers and prisoners — as possible.
Like most corrections departments, ODOC keeps a tight lid on information regarding its practices and refused to release complete TLC attendance records in response to a Street Roots public records request. ODOC also refused to provide a complete list of invitees to TLC meetings, which are held in a hybrid manner, allowing invitees to attend in person or via videoconference.
However, virtual invitations obtained by Street Roots via the initially denied public records request show multiple TLC invitees have disciplinary histories with medical boards.
If past performance is any indication
ODOC employed 18 doctors across its 12 prisons to treat its approximately 12,000 prisoners, according to 2023 state salary records. In addition to Roberts, at least two others have disciplinary histories with the Oregon Medical Board or have been prohibited from practicing medicine in certain cases.
Dr. Thomas Bristol, an ODOC physician specialist who made $294,520 last year, can’t legally practice medicine on female patients in Oregon after repeatedly exhibiting “unprofessional or dishonorable conduct” in violation of the state’s Medical Practice Act, according to Oregon Medical Board records.
The Oregon Medical Board placed Bristol on five years probation, fined him $1,000, ordered him to undergo a boundary course and prohibited him from conducting any breast or pelvic examinations without a chaperone in 2006. The first disciplinary action was a result of Bristol remaining present while an adult female patient removed her clothes for an examination and allegedly assisted in removing her underwear, according to Oregon Medical Board records. Bristol also admitted to asking another adult female patient, who was also his coworker, “to ride in his red Corvette convertible.”
Bristol later self-reported two additional incidents with female patients that resulted in his termination from Salem Hospital in 2007. As a result, the board modified the agreement to stipulate Bristol would not “examine any female patient 10 years of age or older without a chaperone present for the entire course of the examination or treatment.”
A 2009 complaint and subsequent Oregon Medical Board investigation found Bristol again engaged in “unprofessional or dishonorable conduct” against a female patient. The board and Bristol then entered into an agreement prohibiting him from practicing medicine on female patients.
State salary records show Bristol working for ODOC by 2015.
A male Oregon prisoner sued ODOC in 2021, alleging Bristol “sexually molested him during a medical exam at (Columbia River Correctional Institution, or CRCI).” A judge granted the state’s motion to dismiss the case on the grounds that the prisoner failed “to exhaust his claims pursuant to the Prison Litigation Reform Act,” which dictates prisoners can’t sue personnel, prisons or departments over conditions or treatment until “administrative remedies as are available are exhausted.”
Bristol is also named as a co-defendant in multiple lawsuits regarding ODOC’s medical care, including some cases specifically involving TLCs.
ODOC did not return requests for comment on Bristol’s apparently continued employment, whether Bristol has ever practiced medicine on female prisoners or if the department investigated the male prisoner’s claims. ODOC also would not comment on whether Bristol has ever served on a TLC making decisions regarding female prisoners’ health care, although virtual invitations show he was invited to or attended multiple TLC meetings covering Deer Ridge Correctional Institution, Eastern Oregon Correctional Institution, Snake River Correctional Institution and TRCI.
Another ODOC physician was investigated for writing herself prescriptions in 2001 and 2002 and was limited to working 32 hours per week and required to “abstain from the use of alcohol and … not take any controlled substances or other medications not approved by the Health Professionals Program,” in addition to being “limited to administrative medicine or a clinical setting where she is part of a multidisciplinary team.”
The board terminated the agreement in 2006, allowing the doctor to return to normal practice.
UPDATE: Street Roots first published this story in its Wednesday, Dec. 4 print edition. On Thursday, Dec. 5, The Oregonian reported the Oregon Department of Corrections placed Dr. Warren Roberts, ODOC chief medical officer, and Joe Bugher, ODOC assistant director of health services, on leave “amid a review of the department’s health care services.”
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This article appears in December 4, 2024.
My husband is in a life-threatening medical situation and SCRI is denying him care