The two former health care leaders at the Oregon Department of Corrections routinely delayed medical treatment for people in custody, and retaliated against health care staff when they raised reasonable concerns about the care of patients across Oregon’s 12 prisons, according to an internal investigation.
The findings come as Chief of Medicine Dr. Warren Roberts and his boss, Assistant Director of Health Services Joe Bugher, were fired on Monday.
“I have determined it is appropriate to end your employment, based on the findings in a recently concluded personnel investigation that was earlier provided to you and your legal counsel,” Department of Corrections Director Mike Reese wrote in a termination letter sent to Roberts and Bugher.
FILE - Oregon State Penitentiary in Salem, Ore., May 19, 2021. Two Oregon prison health leaders were fired for delaying inmate care and retaliating against staff, an internal investigation found.
Kristyna Wentz-Graff / OPB
Roberts' attorney, Bryan Davis, said his client was deeply disappointed in the investigation that resulted in his firing.
“Dr. Roberts believes that the decision to terminate his employment was a pretext for retaliation in response to Dr. Roberts’ vocal criticism of the Department of Corrections’ lack of sensitivity and responsiveness to Dr. Roberts’ reports of racial discrimination in the workplace against him and other Department employees of color,” Davis said in a statement.
According to Roberts, he was retaliated against by employees in an effort to “cover over their own failure to provide quality care to inmates in custody.”
An attorney for Bugher also claimed the firing was the result of retaliation.
“Joe Bugher’s termination places him among a growing list of employees targeted by the DOC for striving to bring about much-needed reforms. His dismissal raises serious questions about the agency’s commitment to transparency, accountability, and ethical governance,” Attorney Randy Harvey said in a statement.
The health leaders have been on leave since Dec. 5. Less than two weeks later, attorney Jill Goldsmith, who was hired by the agency to investigate, delivered an 84-page report. It found that Roberts oversaw bureaucratic policies that led to significant delays in life-saving health care deemed necessary by nurses and doctors who work in the state’s prisons.
Specifically, the report found medical orders that would allow people in custody to get outside care, such as surgery and oncology, expired every six months. That required health care providers to return to a committee — the Therapeutic Levels of Care Committee, or “TLC” — that Roberts oversaw to once again advocate for ongoing treatment.
“Please remember TLC approvals are active for six months,” Roberts wrote in an email included in the report. “After six months, the TLC approval will need to be re-presented by a provider.”
Despite that email, Roberts initially said he was unaware how his directions were being interpreted by health care staff.
“It is clear that Roberts’ direction was precisely that the providers’ order would expire after six months, necessitating a return to TLC,” Goldsmith wrote. “Bugher told me the six-month rule had only been in place a few months. This claim is also untruthful. Both were aware the six-month rule was in place for years, it was delaying patient care, concerns were brought to their attention and neither did anything about it.”
Goldsmith also uncovered a number of instances where correctional health care staff were effectively disciplined for advocating for their patients. Goldsmith concluded that staff members “had reasonable, good faith cases for raising the concerns they raised, and they were retaliated against by Bugher and Roberts for raising those concerns.”
FILE - The Coffee Creek Correctional Facility in Wilsonville, Oregon, opened in 2001. Dr. Warren Roberts claims his firing was retaliation for reporting racial discrimination, but an internal investigation found he delayed life-saving prison medical care.
Aaron Scott / OPB
‘Roberts does not understand female health care’
One area that Goldsmith focused on was the way the prison system treated women’s health. In one case, she found the standard of care for women in custody diagnosed with genital herpes was “unnecessarily humiliating and also traumatizing,” especially since many “have backgrounds of sexual trauma.” Rather than providing medication to treat herpes before it became an outbreak, Roberts required the patient in custody to have “six visualized outbreaks” during a year, outside the standard of care.
“The outbreaks had to be visualized by the nursing staff and documented before TLC would approve suppressive therapy,” the report states. “This meant that women had to have genital examinations and a swab of the lesion to prove they had an outbreak.”
The report also notes Roberts overrode female providers more often than male providers, and undermined appropriate care for women — especially those who were pregnant.
“There is evidence to suggest that Roberts does not understand female health care and is dismissive of the needs of female adults in custody,” Goldsmith concluded.
Goldsmith said she interviewed Roberts and Bugher numerous times as far back as June 2024. She concluded many of their explanations and responses were not credible and that they did not answer truthfully to many of her questions.
“Despite an enormous amount of information to the contrary, Bugher told me he had no concrete information that Roberts negatively impacted patient care and he did not deem any of the complaints coming to him about Roberts as valid,” Goldsmith wrote.
OPB initially requested a copy of Goldsmith’s findings Dec. 6, and were denied, citing attorney-client privilege. After the two men were fired, OPB again requested the same findings and received a redacted copy of the report.
The effect on cases could be sweeping.
Over the years, attorney Tara Herivel has worked with hundreds of clients involving people in prison who have sued to get medical care they need while incarcerated. She said Goldsmith’s findings affect “every case involving medical care at the Department of Corrections.”
She said clients have sued for basic health care, which the U.S. Constitution says must be provided for people who are incarcerated.
“It’s not about great medical care, it’s about adequate medical care,” Herivel said. “They have nowhere to turn. They don’t have choices.”
Herivel also said that poor medical care while inside can make it harder for people to reintegrate into society when they leave prison.
Last month, the Department of Corrections moved to hire an Illinois-based consulting firm to assess its health care system, according to a state contracting document. The Department of Corrections noted that the company, Falcon Correctional and Community Services Inc., was already doing work for the state and the prison system. The agency said it would pay an estimated $550,000.
“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 contracting document states.
Bugher and Warren earned monthly salaries of $20,098 and $31,727, respectively.