Holyoke Soldiers' Home Coronavirus Deaths: Leaders Blamed

HOLYOKE, MA — An investigation into the coronavirus outbreak at the Holyoke Soldiers' Home ordered by Gov. Charlie Baker found "substantial errors" in decisions made by leaders at the long-term care facility, where 76 residents have died of the disease so far.

The Holyoke facility was hit especially hard at the beginning of the outbreak due to "utterly baffling" infection control procedures made by Superintendent Bennett Walsh, the report says. The Massachusetts Department of Veterans' Services also failed to provide proper oversight of the facility — and Secretary Francisco Urena was asked to resign Tuesday. Baker on Wednesday said he would end Walsh's employment.

In addition to the 76 deaths, 84 veterans and more than 80 staff members at the facility contracted the coronavirus.

The worst error came on March 27, when facility leaders combined two dementia units, mixing patients who had tested positive for coronavirus with ones who had not, according to the report. The decision to combine the dementia units was made due to a staff shortage; however, the facility's leaders should have sent the patients to local hospitals, the report says.

"Rather than isolating those with the disease from those who were asymptomatic — a basic tenet of infection control — the consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25," the report says.

The staff who helped with the move did so under duress, the report says. One therapist told investigators she felt like she was "walking [the veterans] to their death," while a social worker compared it to moving a concentration camp.

Aside from Walsh and Nursing Director Vanessa Lauziere, no one at the Holyoke home admitted to making the decision to combine the units, the report says. The medical director, Dr. David Clinton, told investigators he was "not involved in, or consulted" on the decision, which the report deems "not credible."

"[A]t the very least ... Dr. Clinton was aware (or should have been aware) of the move and did nothing to stop it," the report says.

The first resident tested positive for COVID-19 on March 17, but was only tested after weeks of showing signs of a respiratory illness. The resident, identified in the report as Veteran 1, lived in a room with other patients and was allowed to walk around the facility. The soldiers' home created space in the building to isolate infected residents but didn't use it, according to the report.

"It appears that Dr. Clinton concluded that because Veteran 1 had already been walking around the unit, the whole unit should be considered contaminated," the report says.

The report concludes that the coronavirus likely would have infected and killed some residents even if better precautions had been taken. But the errors made were so severe that the coronavirus outbreak was much worse than it should've been, according to the report.

Baker's investigation is one of several into the errors made in Holyoke. State Attorney General Maura Healey, U.S. Attorney Andrew Lelling and the state Office of the Inspector General are also investigating what happened at the facility.

The report was conducted independently by the Boston law firm McDermott, Will and Emery, according to Baker.