FORMER HOLYOKE Soldiers’ Home superintendent Bennett Walsh and former medical director David Clinton have been indicted on criminal charges related to the COVID-19 outbreak that killed 76 veterans at the state-run home and sickened another 84.
Attorney General Maura Healey announced the charges, which relate to five specific veterans, on Friday.
The charges center on a decision Soldiers’ Home leaders made to combine two dementia units at the beginning of the outbreak, leading to overcrowding among residents, some of whom had tested positive for COVID-19.
“We are alleging that Superintendent Walsh and Dr. Clinton were ultimately responsible for the decision on March 27 that led to tragic and deadly results,” Healey said.
Although nursing homes were a center of the epidemic in Massachusetts and many other states, Healey said this case is the first time criminal charges have been filed in connection with a COVID-19 outbreak in a nursing home. Healey has said her office is investigating outbreaks at other private nursing homes in the state.
A separate investigation into the Soldiers’ Home outbreak by US Attorney Andrew Lelling is ongoing.
Walsh’s attorney Tracy Miner accused Healey of “scapegoating” Walsh. Miner said in a statement, “It is unfortunate that the Attorney General is blaming the effects of a deadly virus that our state and federal governments have not been able to stop on Bennett Walsh… He, like other nursing home administrators throughout the Commonwealth and nation, could not prevent the virus from coming to the Home or stop its spread once it arrived there.”
Miner said Walsh asked for help from the state and the National Guard and at all times, he “relied on the medical professionals to do what was best for the veterans given the tragic circumstances of a virus in a home with veterans in close quarters, severe staffing shortages, and the lack of outside help from state officials.”
Walsh, 50, of Springfield, was put on leave as soon as the outbreak was discovered, and Secretary of Health and Human Services Marylou Sudders fired him in June, although a judge recently ruled that his firing was done improperly and voided it.
Clinton, 71, of South Hadley, had been drawing a $116,680 annual salary for working 20 hours a week as the home’s medical director. He announced his intent to resign in May, though he planned to stay on the medical staff part-time.
Both Walsh and Clinton are facing 10 counts each related to the five veterans: five charges of being a “caretaker who wantonly or recklessly commits or permits bodily injury to an elder or disabled person” and five charges of being a “caretaker who wantonly or recklessly commits or permits abuse, neglect, or mistreatment to an elder or disabled person.”
Each count of criminal neglect carries a potential state prison sentence of up to three years, and each count of permitting bodily injury carries a potential state prison sentence of up to 10 years.
The two men will be arraigned in Hampden Superior Court.
The five veterans involved in the case were asymptomatic residents of the Soldiers’ Home who were moved into the combined dementia unit, which Healey alleged put them at higher risk of contracting COVID-19 and of death. Three of the five residents got COVID-19 and one died.
Healey said the results of her criminal investigation were consistent with what independent investigator Mark Pearlstein found in his own report, which was commissioned by the governor. Pearlstein’s report found “substantial errors and failures by the Home’s leadership that likely contributed to the death toll during the outbreak.”
According to Pearlstein’s report, which also flagged the decision to combine the units as problematic, the decision was made on Friday, March 27, to combine two locked dementia units, each of which had 21 residents. This resulted in veterans being crowded into rooms and common spaces, including a dining room, with beds “inches apart.” The two units contained residents who were symptomatic and those who had no symptoms, as well as residents who had been diagnosed with COVID-19, those who were awaiting test results, and those who had not been tested. In the report, which describes the conditions on the unit as “deplorable,” staff members described “pandemonium” and one staff member compared it to moving veterans to a concentration camp.
Healey said at a press conference, conducted via Zoom, that six or seven veterans were crowded into rooms meant for four, and nine residents were placed in the dining room. Residents were mingling together regardless of COVID-19 status. “This never should have happened from an infection control standpoint,” Healey said. “The decision put veterans who were asymptomatic at greater risk of contracting COVID-19 and higher risk of death.”
Clinton told Pearlstein’s investigative team that he was not involved in the decision to combine the two units and would not have approved the decision if he had been asked. Pearlstein’s report said Clinton’s claim was not credible. Walsh affirmed the decision to combine the two units, but said he was following the advice of the “medical team.” Pearlstein called this evidence that Walsh “abandoned his managerial responsibilities.”
Chief nursing officer Vanessa Lauziere, who did admit to participating in the decision-making, was not charged. Lauziere, according to the Pearlstein report, said she made the decision with the approval of Walsh because 40 staff had called in sick, apparently due to the spreading pandemic, and there was not enough staff to cover the two units. Pearlstein said Lauziere’s decision was “inconsistent with her training, inconsistent with reasonable judgment, and inconsistent with her duty to the veterans at the Soldiers’ Home.”
Healey was asked why she only charged Walsh and Clinton, and whether criminal charges were being considered against other staff, including Lauziere. Healey said Walsh and Clinton “were the ultimate decision makers,” though if new evidence comes to light against other staffers “we’d look at that.” Healey did not directly answer a question about whether charges against other individuals were considered by the grand jury.
Managing Attorney Kevin Lownds, of Healey’s office, said investigators spoke to 90 families during the investigation. Healey spoke to veterans’ families via a Zoom call on Friday. Healey said she wanted to express her condolences to the families and inform them of the criminal charges.
“While this criminal indictment cannot bring back their loved ones, I do hope sincerely that it provides those affected by this tragedy some solace that we are doing everything we can to hold accountable the individuals we believe are responsible here,” Healey said.
There have been questions raised since the outbreak about whether Walsh, a Marine veteran from a politically connected family, was qualified for the superintendent’s job, given his lack of experience in health care administration. Asked whether she believes Walsh was qualified for the job, Healey said no. “I think this criminal case clearly demonstrates he was not qualified to hold this position,” Healey said.
Healey did not criticize Baker’s handling of the situation at the Holyoke Soldiers’ Home. She praised the governor for commissioning the Pearlstein report and for recommending a series of reforms to the operation of the facility.
Sheryl Blais, whose father Robert Blais died of COVID-19 at the Soldiers’ Home days after his 90th birthday, said she is happy about the criminal charges. “I’m very happy that things are moving forward and there’s going to be justice hopefully,” Blais said.
Blais said she is angry that Soldiers’ Home officials never isolated the first veteran who tested positive for COVID-19 – a problem laid out in Pearlstein’s report. Her father was one of those who was put in the combined dementia unit. “My dad died from negligence,” Blais said.
Blais said she believes many people at the home should be held accountable, including Lauziere, but she recognizes that Walsh and Clinton were the decisionmakers. “I believe they should be going down because they should have been watching over the whole Soldiers’ Home and they weren’t,” Blais said. “They weren’t looking out for the health of the veterans that were there.”
This story was updated with Blais’s comments.