Holyoke Soldiers’ Home report details ‘crisis of leadership’ 

A REPORT BY a legislative committee formed to investigate the COVID-19 outbreak at the Holyoke Soldiers’ Home that left 77 veterans dead faulted a “crisis of leadership” for substantially contributing to what it called a “perfect storm” and a “preventable tragedy.” 

“As we outline in this report, the causes were both immediate, including inexplicable decisions made by the Home’s leadership in the days and weeks preceding the outbreak, and long-standing, including systemic issues that left the Home mismanaged, understaffed, lacking sufficient oversight, and ill-equipped to protect its residents from a deadly infectious disease,” the committee, which was chaired by Rep. Linda Campbell of Methuen and Sen. Michael Rush of Boston, concluded. 

The report was being circulated to members of the committee Monday evening. The committee will vote on releasing it Tuesday. 

The oversight committee was formed by the Legislature to investigate the causes of the deadly COVID-19 outbreak and make recommendations to prevent future tragedies. It came in addition to an independent investigation commissioned by Gov. Charlie Baker and conducted by attorney Mark Pearlstein.  

In a joint statement, Campbell and Rush wrote that the Pearlstein report “generated more questions than answers,” and their report attempts to go deeper. “The findings presented to you focus on both the how and the why of this tragedy,” Campbell and Rush wrote. “They highlight how governing structures in place at this time created a perfect storm for this COVID outbreak to become a tragedy.”  

The report issues a scathing indictment of Superintendent Bennett Walsh, who was fired immediately after the outbreak and is now facing criminal charges in connection with the outbreak. “Our investigation indicates that the Home’s Superintendent failed to discharge his duties successfully,” the report writes. “While his lack of medical and technical experience likely played a significant role in his failures, his most glaring deficiencies appear to have been in the areas of sound management, human relations, and leadership.” The report finds that Walsh created a “toxic” work environment where employees feared challenging his authority.  

Bennett Walsh, the former superintendent of the Holyoke Soldiers’ Home. (Twitter photo)

But the problems were not confined to Walsh. In a not-so-subtle dig at Baker, the report says, “The Special Committee questions why Superintendent Walsh was chosen for this key leadership position and why action was not taken to remove him from his duties before the tragedy emerged.” 

This past weekend, the Boston Globe reported that Walsh was hired due to his extensive political connections, and Secretary of Health and Human Services Marylou Sudders knew of his management problems before the outbreak. 

The report also emphasizes that “there existed a muddled, and seemingly ineffective, chain of command” going from the Holyoke Soldiers’ Home through the Board of Trustees through the Executive Office of Health and Human Services and the Department of Veterans Services and up to Baker. This led to a breakdown in communication between Walsh, Sudders, and Secretary of Veterans’ Services Francisco Urena as the crisis was unfolding. “Testimony begged the question: who did the Superintendent really work for?” the report asks. 

Urena resigned the day Pearlstein’s report came out. 

It also flagged the fact that some high-level positions were unfilled, and it identified inconsistencies between the governing structures between the two state-run soldiers’ homes. For example, the Chelsea Solders’ Home is accredited by Medicare and subject to federal inspections; the Holyoke home is not. “This report raises important systemic and governance issues that need to be addressed legislatively in order to avoid tragedy arising from a crisis, whatever might generate that crisis,” the report found. 

The report makes numerous recommendations that may now become part of any legislative package responding to the tragedy. While Baker introduced his own reform bill in June 2020, lawmakers have held off on passing it until the report was released.  

The recommendations include rewriting staffing standards, hiring a full-time medical director, enhancing inspections of the facility, clarifying the chain of command, changing the home’s governance structure, and creating more avenues for families to report concerns. The report recommends elevating the commissioner of veterans’ services to a cabinet level position, rather than keeping veterans’ services under the auspices of the Executive Office of Health and Human Services.