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When it comes to the Holyoke Soldiers’ Home, Governor Charlie Baker first needs to say three words.

It’s on me.

Then, right after that, Baker should commit to taking whatever steps are necessary to reform a system that put the lives of vulnerable veterans who served our country into the hands of an unqualified political appointee — one who got the job, thanks to Baker.

As documented in a devastating Globe Spotlight team report, Baker played a major role in steering Bennett Walsh, a politically connected veteran who lacked any health care credentials, into a job heading the Holyoke facility. When COVID-19 struck and 77 veterans died because of poor decision-making on Walsh’s watch, a report ordered up by Baker conveniently shifted blame to others. Confronted last week with the Spotlight team findings, Baker called what happened a “terrible tragedy — and it’s on us.”

“It’s on us” is not good enough. Especially since, as usual, Baker went on to try to pin the blame elsewhere, babbling about Mark Pearlstein, the former US attorney, who had “100 percent carte balance latitude . . . to go wherever he thought that report was going to take him.” Somehow, Pearlstein’s thorough investigation didn’t take him to Baker; and although Pearlstein interviewed the governor, the Pearlstein report contains not a single quote from Baker, nor a word suggesting gubernatorial responsibility.

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Yet the Spotlight team details plenty of it. Contrary to his public declaration that the first time he ever met or talked to Walsh “was when we swore him in,” Baker was personally involved in Walsh’s hiring and even interviewed him. Yet he still doesn’t think the buck stops with him.

To those who say no one could have predicted a pandemic would strike, leaving someone like Walsh in charge of making life and death decisions for vulnerable, elderly vets, Walsh was a poor choice even without a pandemic. He had no health care background and no experience overseeing medical or long-term care facilities. Yet the most popular governor in America went to bat for him, apparently to curry favor with political operatives in Western Massachusetts. Once Walsh got the job, his leadership deficiencies were obvious and well known to Health and Human Services Secretary Marylou Sudders, Baker’s top lieutenant. Yet she, too, is spared any accountability in Pearlstein’s report and has been protected from criticism by Baker.

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At this point, apologies for what happened at Holyoke are meaningless. The best tribute to the veterans who died from COVID-19 and to those who still reside there is a commitment to change the way the place is run. Last year, Baker filed a bill that called for some governance reforms, but didn’t change the requirements for superintendent. He didn’t push it, and it went nowhere on Beacon Hill.

In a just-released report, a special legislative committee that was convened to investigate the COVID-19 deaths at the facility outlined systemic problems that include a flawed process by which the superintendent is selected; insufficient qualifications for health care leadership positions; unfilled management positions; staffing and training deficiencies; and, perhaps most critically, a muddled chain of command between the soldiers’ home and the governor’s office.

That muddled chain of command gave Baker cover to ignore his own role in putting Walsh in the job and instead focus on the failures of others below him and Sudders. But a true leader, and especially one who has been selling himself to voters as a manager extraordinaire, would step up and accept responsibility for the broken system over which he presides.

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Of course, Baker wasn’t responsible for the poor clinical judgments made on the scene, nor even for the delays in responding to calls for help. As the COVID-19 crisis was breaking over the state and the country, he was swamped with judgment calls that affected everyone in Massachusetts. But in his heart, he must know he’s responsible for putting someone in the Holyoke job who wasn’t up to it. He must know moral accountability for what happened doesn’t end with Walsh, or with Francisco Ureña, the secretary of veterans’ services who was forced to resign when the Pearlstein report was released.

Changing the system means changing laws, ruffling feathers, and putting the well-being of veterans ahead of political fiefdoms. For Baker, it also means taking responsibility for the role he played in putting Walsh in that job and for once admitting, “That’s on me.”


Joan Vennochi can be reached at joan.vennochi@globe.com. Follow her on Twitter @joan_vennochi.