BACKGROUND: In June of 2021, a heatwave resulted in high mortality across the Pacific Northwest region. The city of Portland, Oregon, had many advantages: emergency response personnel, science-based policies, political support for climate change adaptation, and collaboration among municipal, county, state, and federal authorities. Though the city's response likely prevented many deaths, heat-related mortality was high. METHODS: This study presents a retrospective case analysis of the 2021 Western North American Heatwave in Portland, Oregon. Specifically, the study examines the limitations of current heatwave response paradigms by means of a narrative review of the heatwave response and impacts. RESULTS: Most deaths occurred at home, and most of those who died lived alone. Most of the deceased did not have access to functioning air conditioning. CONCLUSIONS: Heatwaves exhibit high predictability in the demographics of those most affected and have rising rates of recurrence. Given the effectiveness of residential cooling systems in preventing heat-related mortality, findings suggest that future public health and policy initiatives should put increased focus on the primary prevention of heat exposure.