Updated at 2:44 p.m.
The former superintendent and top medical staff at the Soldiers' Home in Holyoke failed to protect elderly veterans there from the COVID-19 outbreak that claimed the lives of at least 76 residents since March.
That’s the finding of an independent investigation into one of the nation’s deadliest outbreaks of COVID-19, released Wednesday by Gov. Charlie Baker.
The report by former federal prosecutor Mark W. Pearlstein pointed to a range of failures leading to the tragedy and “substantial errors and failures by the home’s leadership that likely contributed to the death toll during the outbreak.”
Pearlstein’s 174-page report flagged actions by Bennett Walsh, the Holyoke home’s superintendent, who was placed on administrative leave in late March in the wake of dozens of COVID-19 deaths at the Holyoke facility.
“Some of the critical decisions made by Mr. Walsh and his leadership team during the final two weeks of March 2020 were utterly baffling from an infection-control perspective, and were inconsistent with the Home’s mission to treat its veterans with honor and dignity,” the report stated. “Our analysis of the Home’s preparations for and response to COVID-19 in light of existing public health recommendations has identified substantial errors and failures by the Home’s leadership that likely contributed to the death toll during the outbreak.”
Baker, in a midday press conference, took some of the blame, saying his administration had failed to oversee the veterans’ home and its management.
“The report makes clear that the Department of Veteran Services, which oversees the Soldiers’ Home, didn't properly oversee Holyoke or Bennett Walsh. And that one's on us,” said Baker.
In addition to the 76 veterans who have died of COVID-19 at the home since March, more than 80 staff tested positive for the virus.
Late Tuesday, before the release of the report, Secretary of Veterans’ Services Francisco Urena resigned from his post.
Watch live at noon: Gov. Charlie Baker addresses investigation into the COVID-19 outbreak at the Holyoke Solders' Home:
Baker said the events that took place at the Soldiers Home in Holyoke were “horrific” and details in the report by Pearlstein “gut-wrenching.”
The investigation said biggest mistake made by the home’s leadership came on March 27, moving all veterans from one of the two dementia units into another dementia unit.
“The consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25,” the report stated. “This overcrowding was the opposite of infection control; instead, it put those who were asymptomatic at even greater risk of contracting COVID-19.”
Staff told Pearlstein that crowding veterans into the single unit was “total pandemonium.” They said veterans were “terrified” and likened the unit to “a battlefield tent where the cots are all next to each other.”
Three days later, the report stated, a healthcare administrator who visited the unit saw “some veterans clothed, some unclothed, and some obviously in the process of dying from COVID-19.”
Baker promised to announce changes at the facility tomorrow, both in oversight and in capital improvements. Some of those recommendations will come from the Pearlstein report.
Criticism of Baker came Tuesday from Attorney General Maura Healey and Massachusetts Democratic Party Chair Gus Bickford.
"Today's report reveals that there is plenty of blame to go around within the Baker administration for the tragedy that took place at the Holyoke Soldiers' Home. This administration installed and left in place as Superintendent an individual that was not qualified,” said Bickford in a prepared statement. “Who knows how many veterans would still be alive if the Baker administration demonstrated basic leadership and management skills."
Healey’s statement pointed to “systemic failures of oversight by the Baker Administration in adequately preparing, staffing, and responding to this crisis to protect our veterans.”
This is a developing story and will be updated.
