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The house of cards that was the COVID-19 plan at the Holyoke Soldiers’ Home began toppling with the very first case of the deadly virus, according to a damning state report released Wednesday.

The date: March 21, four days after a disoriented veteran in the dementia unit had been tested because of coronavirus symptoms.

That night, the Soldiers’ Home notified the state Department of Public Health of the veteran’s positive test, as required. But what followed was a series of baffling decisions that delayed an emergency response by the state and presumably compounded the spread of the virus in the hilltop facility that houses approximately 250 veterans.

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Over the next few weeks, at least 76 veterans would die of COVID amid an escalating tragedy that unfolded largely out of public view. The catastrophe was exacerbated by a days-long string of poorly communicated and misunderstood information that began flowing to state officials from Superintendent Bennett Walsh, according to the state review.

Transparency was lacking throughout the ordeal, according to the report.

Less than two hours after the first positive test, Walsh e-mailed state Veterans’ Services Secretary Francisco Urena, who supervised Walsh, that “we have isolated said veteran and quarantined the unit.”

Later that night, at 1:21 a.m., Urena passed along the report to Daniel Tsai, acting secretary of the state’s Executive Office of Health and Human Services. Later that morning, Tsai informed Marylou Sudders, the HHS secretary who had been named to lead the state’s COVID task force.

But that information — shuttled along a trail from Walsh to Urena to Tsai to Sudders — was incorrect. The infected veteran had not been isolated pending the results of his test, but instead continued to mingle with other vulnerable elderly residents.

The life-threatening missteps did not stop there. Eventually, two dementia wards would be combined into one unit crowded with veterans — infected, suspected, and uninfected alike.

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Nurses floated between wards that held COVID patients and wards that did not. Upwards of 80 staff members and an additional 84 veterans tested positive. And more than a week would pass before top state officials learned the full extent of the crisis.

“The Soldiers’ Home did nothing to isolate Veteran 1 at the time of his test,” according to the report, referring to the first patient.

“He remained on the dementia unit, living in a room with three roommates, spending time in a common room, and wandering the unit. Only when his result came back positive four days later did the staff move his roommates out and make efforts (largely unsuccessful) to keep Veteran 1 in his room."

Urena resigned Tuesday. Walsh was placed on administrative leave March 30, shortly after Sudders reprimanded him in a phone call, expressing “outrage and disappointment” over discrepancies in the number of deaths reported at the facility.

The state’s figures for victims at Holyoke were significantly lower than the actual figure for more than a week after the first test result. The discrepancy arose because Walsh — as required by the state — had reported only those fatalities where a veteran had tested positive for COVID-19.

That requirement “explicitly did not require disclosure of the deaths of people suspected of having COVID-19, but for whom a positive test result had yet to be obtained,” according to investigators.

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Top state leaders did not understand that distinction, the report said. And that lack of understanding helps explain the confusion in a March 29 phone call where Sudders and Holyoke Mayor Alex Morse disagreed over the number of deaths.

The mayor, who had been in contact with an alarmed union official, told Sudders that eight deaths had occurred. Sudders said he was mistaken, and that there had been only two. In reality, the home at that time had recorded four positive COVID deaths and four suspected fatalities.

Sudders was furious with Walsh.

“A sign of strength is asking for help,” she said in a subsequent phone call that included Walsh, a retired Marine lieutenant colonel who had no prior experience in health care administration. Sudders later said she felt “deceived or lied to,” according to the state report.

The breadth of the tragedy apparently stunned state officials in Boston, according to a timeline reconstructed by investigators. As the crisis expanded, Walsh had conveyed a sense of control to state officials, they said.

In a phone call with DPH epidemiologists on March 25, Walsh did not “ring any alarm bells,” although he expressed concern about having enough personal protective equipment and staffing, the health officials said.

But two days later, Walsh asked Urena for National Guard assistance to augment his staffing. Until that time, investigators said, Urena recalled that he did not have “a sense that the place was being overrun” by COVID-19.

Urena also said he had not been told of the plan to combine the two dementia wards, and that Walsh had asked for the Guard with “a level of calmness.”

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But at the home, signs of outrage were emerging.

A 7 p.m. on March 28, Sudders and Urena received an e-mail from Brenda Rodrigues, the president of the union local, saying that six veterans had died within 24 hours. But Sudders later told Rodrigues, “All I can say is we have one death,” according to the state review.

In addition, Walsh was becoming irritated with Morse’s alarms about the evolving crisis. At 6:30 p.m. on March 29, Walsh declined Morse’s offer of help. Shortly before 7 p.m., he complained to Urena that Morse was about to circulate an anonymous letter that “was not true ... was not accurate.”

Walsh added that Morse “was not a good guy."

At 8 p.m., Urena spoke by phone with Morse and Walsh, who each confirmed that eight veterans had died at the home, instead of the two that Urena had just reported to top HHS officials. Urena said this was the first time he had heard the information.

After the call, Morse texted Lieutenant Governor Karyn Polito with the report of eight deaths, setting off a flurry of contacts involving Polito, Sudders, Urena, Morse, and Governor Charlie Baker, among others. Sudders began assembling an emergency team to report to Holyoke in the morning.

At 7 a.m. on March 30, Walsh phoned Urena to “apologize for not telling you about all these deaths.”

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By then, Walsh’s fate had been sealed.

At 1:36 p.m., acting HHS Secretary Tsai texted Urena that “I will be sending a simple letter to Superintendent Walsh relieving him of his duties/terminating him effective immediately.”

Sudders was more succinct: “Just fire him. I’ll deal with any fallout.”


Brian MacQuarrie can be reached at brian.macquarrie@globe.com.