How vets died of COVID-19 and no one knew

Officials at Holyoke facility, in Baker administration failed to report deaths

IT TOOK EIGHT VETERANS’ DEATHS and five days before the head of the Holyoke Soldiers’ Home informed state and local public health authorities about the extent of the COVID-19 outbreak at the facility.

The first death occurred Wednesday, according to Holyoke Mayor Alex Morse, who learned about them Sunday.

“I was shocked on the phone call when the superintendent let me know there had been eight veteran deaths between Wednesday and Sunday without any public notification,” Morse said. “Without any notification to my office, no notification to state government that oversees this facility in the first place.”

By Monday, Holyoke Soldiers’ Home Superintendent Bennett Walsh had been placed on paid administrative leave, and the state sent in a team of medical experts to take over. By Tuesday, the death toll at the home would climb to 13. The exact timing of each death is unclear, but it appeared they came in a rush.

The outbreak at the state-run facility illustrates the quick spread of the dangerous virus but also lays bare what appear to be significant management failures that endangered residents and staff.

Gov. Charlie Baker on Tuesday promised that the state will investigate, once it accomplishes its short-term goal of supporting residents’ health and safety. “We will get to the bottom of what happened and when,” Baker said. “We will figure out what happened, and we will deal with that.”

The Holyoke Soldiers’ Home is one of two long-term residential care facilities run by the state for aging veterans in Massachusetts. It had a $25.4 million budget in fiscal 2020.

Bennett Walsh, the superintendent of the Holyoke Soldiers’ Home, who was put on administrative leave on Monday. (Twitter photo)

The home has around 250 nursing home beds and another 30 veterans who live independently but are given rooms, meals, and social services. It is almost exclusively male, and almost all residents are over 70. Older people, particularly those with underlying health conditions, are those most vulnerable to COVID-19.

US House Ways and Means Chairman Richard Neal, a Springfield Democrat, has an uncle in the home. He said one of the challenges of the facility is the building is old and veterans in some units “literally sit on top of each other, inches away.” Almost everyone shares a bedroom, residents eat in close quarters, and they play checkers and chess together. “Social distancing, I’m sure, would not have occurred,” Neal said.

According to the state Executive Office of Health and Human Services, the home restricted visitors on March 14, began taking the temperature of employees and residents regularly, gave employees personal protective equipment, and regularly cleaned the facility.

The home publicly announced its first case of COVID-19 on Sunday, March 22.

But Brenda Rodrigues, president of SEIU Local 888, which represents more than 200 Holyoke Soldiers’ Home employees, questioned whether management followed the protocols on taking temperatures or issuing protective equipment.

On March 18, she said, an employee noticed that a veteran had symptoms consistent with the coronavirus. “He asked for protective gear and was then written up by management and told that he was instilling fear in the worksite,” Rodrigues said.

According to Rodrigues, Walsh told employees March 22 that the resident who tested positive would be isolated. But workers reported that never happened, and the resident remained with the general population.

Walsh did not respond to requests for comment left by phone and email.

Rodrigues said the union has raised concerns with management for the last two weeks about the amount of available personal protective equipment, the lack of isolation for sick residents, and the lack of testing for employees. The union did not receive any response.

“It appeared that protocol wasn’t being followed by isolating those that were sick. The staff were not being tested, then they were told to come to work whether they were sick or not,” Rodrigues said. She said some staff received tests from their own doctors.

“It seemed to me they just weren’t facing the facts, there was very poor management, no one was taking any responsibility,” Rodrigues said.

On Friday, workers started making their concerns known. Rodrigues said union members called her and said residents were dying, employees did not have sufficient protective equipment, and employees were rotated between departments, worrying that they were spreading the virus.

Steven Connor, director of Central Hampshire Veterans Services, also began hearing rumors Friday that the virus was spreading. “It wasn’t a complete shock because we figured with one case it was going to spread,” he said. By Saturday, he received calls from other veterans services officers saying they heard that “it’s worse than anybody’s letting on.”

Morse was in a similar boat. Although his public health nurse is supposed to be notified of the number of COVID-19 cases and deaths in Holyoke, he only learned Friday that one case of a COVID-19 infection at the Soldiers’ Home had turned into several. On Saturday, he received an anonymous email describing deteriorating conditions there. His board of health reached out to the Soldiers’ Home and got no response, so on Sunday Morse called Walsh directly.

That call, Morse said, was the first he heard of any deaths. He said he was shocked.  “I made it clear we had a concern that they alert the public as soon as possible to what steps they’re taking,” Morse said. “There was a lot of fear and anxiety among staff, family members, and friends.”

Morse said he was “incredibly disappointed” that Walsh exhibited “a clear lack of urgency.” Morse said Walsh told him individuals who died had underlying health conditions. But, Morse said, “That’s certainly was not an excuse for improper isolation of those folks that did test positive.”

As of Tuesday, of 13 residents who died, six tested positive for COVID-19; one tested negative; one was unknown; and five were awaiting test results. Ten additional veterans and seven staff tested positive for COVID-19, while 25 veterans were awaiting test results. Information was not available as to when they had been tested. Holyoke Medical Center would not say how many Soldiers’ Home residents had been treated there.

By Sunday, both Connor and Morse began contacting the region’s state legislators.

“With all the information going on every day from all different sectors and parts of the state, I was a little bit surprised to get this information late in the game,” said Holyoke Rep. Aaron Vega. “I don’t think they were hiding it. From what it sounds like, it sounds like it moved a lot faster than anyone sensed it would perhaps.”

Morse said he had a call with Walsh and state Veterans’ Services Secretary Francisco Urena on Sunday, but “still didn’t feel there was a sense of urgency in that conversation.” He then called Lt. Gov. Karyn Polito, and within half an hour got a call back from Health and Human Service Secretary Marylou Sudders, who is leading the state’s response to COVID-19.

At a press conference Tuesday, Sudders and Baker both said they learned about the deaths Sunday and had a team on site by Monday.

Sudders said there is a process by which the Soldiers’ Home should have reported any critical incidents to state officials, and no notifications were made. Sudders said administration officials are still looking into when individuals died, when they were tested, when families were notified, and why the deaths were not reported to the state. She didn’t mention what role, if any, Urena played in alerting the administration.

“As soon as the Executive Office of Health and Human Services learned of the extent of the COVID-19 outbreak at the Holyoke Soldiers’ Home, it took immediate action, including instituting a leadership change and implementing a clinical command structure to bring rigor and clinical expertise to support the residents and staff,” Brooke Karanovich, a spokeswoman for the Office of Health and Human Services, said in a statement.

By Monday afternoon, Walsh was put on leave, Western Massachusetts Hospital CEO Val Liptak was brought in to lead the home, and the state had assembled a team of medical, epidemiological, and operational experts to stabilize the home. By Tuesday, a hotline was set up for families. Plans were being made to test every resident and employee.

On Tuesday, the state rolled out a pilot mobile testing effort using the National Guard to test nursing home residents on-site under the auspices of the Department of Public Health and the Broad Institute. The site will be set up for the first time at the Holyoke Soldiers’ Home, and then be rolled out to other facilities around the state. Previously, nursing home residents would have had to go to a testing facility at a hospital or doctor’s office to be tested.

The outbreak at the soldiers’ home comes at a facility that Baker described as “an amazing place” that he has found “to be a source of joy and grace and comfort and kindness” to residents and workers.

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Shira Schoenberg

Reporter, CommonWealth

About Shira Schoenberg

Shira Schoenberg is a reporter at CommonWealth magazine. Shira previously worked for more than seven years at the Springfield Republican/MassLive.com where she covered state politics and elections, covering topics as diverse as the launch of the legal marijuana industry, problems with the state's foster care system and the elections of U.S. Sen. Elizabeth Warren and Gov. Charlie Baker. Shira won the Massachusetts Bar Association's 2018 award for Excellence in Legal Journalism and has had several stories win awards from the New England Newspaper and Press Association. Shira covered the 2012 New Hampshire presidential primary for the Boston Globe. Before that, she worked for the Concord (N.H.) Monitor, where she wrote about state government, City Hall and Barack Obama's 2008 New Hampshire primary campaign. Shira holds a master's degree from Columbia University's Graduate School of Journalism.

About Shira Schoenberg

Shira Schoenberg is a reporter at CommonWealth magazine. Shira previously worked for more than seven years at the Springfield Republican/MassLive.com where she covered state politics and elections, covering topics as diverse as the launch of the legal marijuana industry, problems with the state's foster care system and the elections of U.S. Sen. Elizabeth Warren and Gov. Charlie Baker. Shira won the Massachusetts Bar Association's 2018 award for Excellence in Legal Journalism and has had several stories win awards from the New England Newspaper and Press Association. Shira covered the 2012 New Hampshire presidential primary for the Boston Globe. Before that, she worked for the Concord (N.H.) Monitor, where she wrote about state government, City Hall and Barack Obama's 2008 New Hampshire primary campaign. Shira holds a master's degree from Columbia University's Graduate School of Journalism.

But over the last few years, it had challenges. In 2015, Superintendent Paul Barabani and Deputy Superintendent John Paradis resigned abruptly, citing a lack of state support for increased funding and more staff. Paradis, in an interview Tuesday, said the home lost 50 staff in one day when Baker instituted an early retirement buyout program in 2015. While state officials said at the time that the home’s budget had increased, Paradis said the state never gave Barabani the support he needed to make major capital improvements – for example, to give residents larger, more private rooms.

In 2017, Connor wrote to then-Rep. Peter Kocot of Northampton on behalf of the Western Massachusetts Veteran Service Officers Association, arguing that there was a disparity in funding between the state’s two Soldiers Homes, in Chelsea and Holyoke, with Holyoke getting the short end of the stick. He voiced safety concerns, questioned whether the state’s oversight structure was appropriate and called for a legislative investigation into the home’s operations.