Problems remain after prison officials pledged to overhaul health services

A year after Oregon prison officials pledged to overhaul health services, an inspection by a national accrediting group found the women’s correctional facility still isn’t meeting standards.

During a September visit, inspectors found administrators weren’t ensuring prisoners are healthy enough to work, nurses’ competencies weren’t reviewed annually and that staff lacked training needed to respond to medical needs. The report also cited delayed documentation of a prisoner’s death.

The findings come from the National Commission on Correctional Health Care’s follow-up inspection. The group placed the prison on probation last year after its 2024 annual inspection found prisoners waited as long as six months for exams and specialist care on top of lacking care for chronic conditions.

The serious shortcomings identified in the earlier inspection were part of a wave of troubling news regarding health care in Oregon’s prison system, which is responsible for caring for an aging population with high needs. The follow-up inspection report, obtained through a public records request, provides an outside look at the progress of reforms promised by officials.

The report notes improvements in streamlining prisoners’ health care appointments and an effort underway to replace paper medical records with an electronic system.

But Angela Kim, a legal assistant with the nonprofit law firm Oregon Justice Resource Center, called the latest report “kind of more of the same,” and said updating processes in the prison health system isn’t enough to improve prisoners’ care.  

“Even if they had an electronic health record, it’s just going to make it easier for you to continue to do things you do, but faster, right?” she said. “That doesn’t improve care, which I think is probably what the number one thing people would like to see happen.”

Oregon Department of Corrections spokesperson Amber Campbell responded to the inspection with a statement reiterating the department’s commitment to “building and maintaining a correctional healthcare system that is safe, responsive, and continuously improving.” That commitment includes “delivering timely, evidence-based, and equitable care to every individual in our care,” Campbell wrote.  

The department is responsible for roughly 12,000 prisoners across a dozen facilities, many of whom are aging and have health care challenges. 

Prison nursing staff care for more than 600 patients each day across the state, Campbell wrote. Physicians and other medical staff also provide about the same number of on-site primary care appointments each day, with prisoners requiring more care referred to outside providers, she wrote. 

Wanda Bertram, spokesperson for research and advocacy group Prison Policy Initiative, said other states struggle to provide adequate health care to prisoners — and some are actively hostile to their care. 

Unlike other states, Oregon has an Office of Corrections Ombudsman, someone specifically appointed to address complaints. That makes the state better positioned to hold its prison system accountable, she said. The commission’s accreditation process is not a substitute for genuine oversight, she added. 

“There’s not much that accrediting bodies can do to force facilities to get better,” she said.

Prison officials, for their part, say they’re moving forward with a plan to address the problems identified by the inspection and by other sources. 

Ongoing problem

The accrediting commission’s most recent inspection of Coffee Creek, a Wilsonville-based facility that currently houses 468 prisoners, focused on problems with processes related to prisoner health. 

The commission’s report directed Coffee Creek — Oregon’s sole women’s prison — to develop a plan to screen and monitor prisoners to ensure they are healthy enough to work while incarcerated. The report noted that prisoners are expected to work in the kitchen for six months if they are able.

Kim, a former critical care nurse who was incarcerated at Coffee Creek for more than 17 years, described working in the kitchen as physically taxing and a place where fights can break out among newly incarcerated people. While incarcerated, Kim recalled seeing a new prisoner with broken wrists and another with a broken shoulder. She said new prisoners could also have communicable diseases.  

Keeping track of prisoners’ medical conditions would help ensure that someone with a physical impairment is given a lighter job, like mopping and wiping tables, she said.

The accrediting commission could not confirm that at least 75% of the staff at Coffee Creek who work with prisoners have received health training.

Kim said training matters because prisoners often turn to correctional officers for help getting medical care. But officers’ responses differ, with some calling health services right away and others telling prisoners to formally request a medical appointment, she said

“It’s kind of the roll of the dice for (which officer) you get for that day,” she said.

The report also found that the facility wasn’t annually reviewing nurses’ competency. Kim said routine reviews are important to spot problems, like a male Coffee Creek nurse who was sentenced to 30 years for sexually assaulting at least nine prisoners.

The accrediting commission also directed Coffee Creek to develop a plan to ensure it completes clinical mortality reviews of prisoner deaths within 30 days. 

Those reviews are meant to identify factors that led to the death. Bertram, of the Prison Policy Initiative, said the reviews can give families closure, particularly if there was any ambiguity around the death.

Inspectors found that after a patient died of natural causes in September 2024, the mortality review didn’t happen until July the following year, once the facility had hired a new physician in charge.

During the inspection’s timeframe, the department’s Health Services Division was navigating a change in leadership, according to Campbell. Since then, Coffee Creek has “maintained thorough and timely tracking of deaths,” she wrote. 

Additionally, the department has hired Dr. Richard Toy as a physician at Coffee Creek and Dr. Michael Seale as chief of medicine. Seale has 28 years of leadership experience in correction medicine “with a track record of integrating medical, dental, and behavioral health services for acute and chronic conditions,” Campbell wrote. 

The department is working to address issues identified by the commission and will submit in writing what corrective actions it has taken by March 31, according to Campbell.

Signs of improvement

Kevin Bovenkamp, the recently hired head of prison health services, told lawmakers during a September hearing that the department has already improved scheduling and the time it takes to get prisoners across the system to specialists and other off-site medical appointments.

At Coffee Creek, the number of grievances related to delays in off-site medical visits has decreased as a result of officials’ efforts, according to the accrediting commission’s most recent inspection. In December 2024, there were 64 grievances. By April 2025, that number dropped to under 10.

The report noted that prison officials hired additional scheduling staff and contracted with another hospital system after experiencing delays with a different provider.

Additionally, Coffee Creek found a cardiologist to see patients at the facility and is working with a company to provide telehealth appointments, according to the report.  

However, the electronic health record system officials planned to have in place at Coffee Creek by March 2025 had been pushed back a year, the report found.

That effort is part of a broader, delayed push to modernize health care technology at the department dating back to 2013. 

“Things can get missed pretty easily, because everything’s done on paper records,” Kim said.

Paper records make medication errors more likely, as well as other mistakes, Kim said. Prisoners can end up with three large file folders while serving their sentence, and it’s easy to mix up common names, she said.

Since then, the department has implemented an electronic health records system at the Oregon State Penitentiary in Salem. Bovenkamp said that by May, the rest of the facilities should make the switch.

Move to reform

Concerns about prisoners facing delays in obtaining medical care emerged in 2024. Many of those were documented by Street Roots, including an analysis finding that 49 prisoners on average died each year while in custody, an increase of 45% since 2020.

The department later hired a law firm whose investigation led to the ouster of top health officials, finding they routinely delayed necessary care and retaliated against staff who spoke up.

Last year, consulting firm Falcon Correctional and Community Services completed a report that described the prison health system as “fragmented, disorganized and inefficient,” and outlined steps to remove bureaucratic barriers to care. That department says it’s using the report to guide reforms. 

ODOC Director Mike Reese told lawmakers during a September hearing that Falcon’s report found that Oregon leads the national trend toward an increasingly older prison population. He said the state prison system has more than a thousand adults who are at least 60 with health care needs of people 15 years older.

“We have a population that’s very high needs,” he said. “There’s a lot of addiction issues, and there’s a lot of mental health issues.”

State Rep. Thuy Tran, D-Portland, remarked that the Falcon report “is not really an independent review of our system” that would offer complete solutions to the prison health care system. Instead, she said it was written with a view of what the state could afford to fix.

Reese responded that the department worked with the firm to prioritize fixes and to make sure “they didn’t come at us with a report that said, ‘You have to do it all today.’”

“Because that’s not possible,” he added.

This article appears in February 25, 2026.

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