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Committee: 'Perfect Storm' Conditions Preceded Holyoke Home Tragedy

The Soldiers' Home in Holyoke, Massachusetts.
Miriam Wasser
The Soldiers' Home in Holyoke, Massachusetts.

The Massachusetts Legislature should require the Holyoke Soldiers' Home superintendent to be a licensed nursing home administrator, elevate the secretary of veterans' services to the Cabinet, create a paid ombudsman position at both state-run soldiers' homes, and impose a raft of chain of command protocols and training requirements, a panel of lawmakers concluded after reviewing the deadly COVID-19 outbreak that struck the facility last year.

In a sweeping report that directed blame at the Baker administration for failing to address poor leadership and leaving key positions unfilled, a special committee created to probe the tragedy punctuated its findings with a long list of recommended legislative actions.

Like the June 2020 report from former U.S. Attorney Mark Pearlstein, the committee's investigation found glaring deficiencies in former Holyoke Soldiers' Home Superintendent Bennett Walsh's decision-making leading up to the deadly outbreak and in his preparedness for the job. Lawmakers wrote in their summary, provided to reporters on Monday ahead of a final vote to release the report on Tuesday, that Pearlstein's report "generated more questions than answers for the committee."

"Therefore, the findings presented to you focus on both the how and the why of this tragedy," the committee's chairs, Rep. Linda Dean Campbell of Methuen and Sen. Michael Rush of West Roxbury, said in a joint statement. "They highlight how governing structures in place at this time created a perfect storm for this COVID outbreak to become a tragedy."

The panel questioned why Walsh remained in his position for years, despite apparent awareness among Health and Human Services Secretary Marylou Sudders and former Veterans' Services Secretary Francisco Urena about issues during his tenure. They concluded that a "breakdown in communication" between Walsh, Urena, Sudders and Gov. Charlie Baker "contributed substantially to the tragedy."

At least 76 veteran residents of the facility died with COVID-19.

The committee also found that the facility had already been in a precarious position before COVID-19 hit due to several broader problems. Among those were "serious problematic short- and long-term staffing issues," which lawmakers said contributed to the ill-fated decision to combine two dementia units early in the outbreak.

In their report, lawmakers listed 14 major findings and recommendations. Their suggestions include requiring the governor rather than boards of trustees to appoint soldiers' home superintendents, launching a hotline for staff and family to report concerns, and transforming the Holyoke facility into a Centers for Medicare and Medicaid Services facility like the Chelsea Soldiers' Home.

Downing calls on Baker to testify

A candidate for Massachusetts governor wants Governor Charlie Baker to testify about the Holyoke Soldiers' Home. Former state Senator Ben Downing's statement came after new reporting by the Boston Globe on the facility.

Walsh was hired more for his political connections than his background, according to the Globe, and Sudders knew Walsh was in over his head before the pandemic began.

Downing said Baker should appear before the Legislature.

"I don't think we can say that we have a full accounting of the facts or an undisputed accounting of the facts currently and that's why we need to have the governor testify," he said.

A spokesperson for Baker declined to directly respond to Downing's call for him to testify. In a statement, she denied that politics played a role in Walsh's hiring. She said the Baker Administration has "taken accountability for this gut-wrenching tragedy."

Two veterans advocates say the Globe's reporting shed new light on what the happened at the Soldiers' Home during the pandemic and why.

John Paradis served as the deputy superintendent of the facility until 2015.

"It was particularly heart-wrenching to see how veterans suffered due to systemic leadership failures and also difficult to read, understanding how much stress the staff that provide care for veterans were under," Paradis said.

Steve Connor, who oversees veterans services in parts of Hampshire County, said the biggest thing the Globe reporting revealed for him involved Walsh and Sudders.

"Secretary Sudders had met and knew of the difficulties Bennett was having with his staff and just being overwhelmed with the job," he said.

Both men said their focus now is on getting Baker to sign a bond bill to build a new Soldiers' Home in Holyoke. It was approved by the Legislature last week.

This story contains reporting from Chris Lisinski of State House News Service and NEPM's Alden Bourne.

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