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Learning from the deadly outbreak in Holyoke

The investigator of the coronavirus tragedy at the veterans home should scrutinize the state’s history of oversight at the facility.

Workers dispose of trash at the Holyoke Soldiers’ Home last week. The state-run elder care facility is the site of the state's largest fatal outbreak of COVID-19.Erin Clark/Globe Staff

The sudden rash of deaths at the Holyoke Soldiers’ Home — where, as of Monday, 25 veterans have died since late March, at least 18 of whom tested positive for the coronavirus — has sparked an independent investigation into what went wrong and why. As the inquiry begins, and damning details emerge of years of lax management under the Baker administration, a fundamental question is whether safety protocols were breached at the state-funded home for veterans and what the state can learn from alleged leadership failures at the facility in order to protect many other vulnerable seniors in similar settings.

The only thing that’s clear so far is that there are more questions than answers.


“I’ve been ready to punch a wall,” Patrick Plourde, whose 88-year-old father died from the virus last Wednesday at the Soldiers’ Home, told the Globe. “This is my Dad, I’m going to defend him, and I felt his needs weren’t being covered.”

The Baker administration moved swiftly to respond once news of the outbreak broke, placing the facility’s superintendent on paid leave and ordering the inquiry, to be led by former federal prosecutor Mark Pearlstein. But for that investigation to be thorough and credible, it must look not just at what unfolded over the last few weeks, but also whether the leadership and oversight provided by the state was sufficient in the years leading up to the deaths.

Plourde, like other relatives of veterans at the home, only learned of the outbreak at the facility from news reports last Monday. And that happened only after Mayor Alex Morse spoke on the phone with Bennett Walsh, the facility’s superintendent, last Sunday night. The day before, the mayor received an e-mail from a worker at the home sounding the alarm about conditions there.


During Morse’s call with Walsh, “there was little sense of urgency” about the outbreak, the mayor said. Morse learned then that eight veterans had died in five days without the public or local officials knowing. Why weren’t these eight patients moved to a hospital?

For his part, Walsh said he never concealed the impact of the coronavirus at the home. According to the state, the facility started restricting visitors on March 14 and took other measures, like regular temperature checks of staff and residents.

The investigation should also dig into whether Walsh, who comes from a politically connected family in the area, has the right experience and qualifications to run a veterans home. How was he picked for the job? That’s a question the investigation must answer, no matter who might be embarrassed.

It’s important to know because workers at the facility have painted a dismal picture of how the place was being run. One caregiver who had tended to the first veteran who showed symptoms of the coronavirus wore protective equipment the next day while working with other veterans. Management reprimanded the worker in a disciplinary letter he received on March 20, alleging he had put on the protective gear without permission or need. “Your actions are disruptive, extremely inappropriate and have caused unnecessary resources to be deployed that may be needed in the future,” the letter read. “Your behavior unnecessarily disrupted and alarmed staff.”

In the middle of such an unprecedented public health emergency, it’s shocking that management at any long-term senior care facility would blatantly disregard safety precautions. But it seems to fit a pattern: Managers told the Globe that understaffing over the years has resulted in crowded units, which allowed the virus to spread faster at the state-run home. During the Baker administration, three administrators at the home resigned because of understaffing.


An investigation could also help provide a template, going forward, for how to protect nursing home patients. Morse says the state should have moved faster to isolate residents once cases were detected. “If we want to properly stop the spread, we should have established central quarantine facilities weeks ago,” the mayor said. “We identified extra space, like hotels and gyms, and we’ve offered them to the state to serve as quarantine places. We should open the Big E in Springfield. . . . We should have done more, quicker, as a state.”

Nursing homes and places where the elderly live or get care are proving to be hot spots for the virus around the country. Yet, until last Thursday, the state wasn’t informing the public of the status of infections in these types of facilities, creating a public health risk for everyone in these communities. As of Monday, more than 800 residents and workers in more than 100 long-term elder care facilities statewide have tested positive for COVID-19.

There will be no shortage of death and grief in the weeks to come. But the questions over how the state handled the Soldiers’ Home must not be forgotten. The debt we owe to our veterans should include a determination to get to the bottom of such a tragic lapse in their care.


Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.