Moving Beyond the Blame Game
Family members of veterans living at the Holyoke Soldiers’ Home didn’t need a 174-page review by a former federal prosecutor to tell them that something went terribly wrong at that facility in March and April, leading to the deaths of 75 residents.
But the report did what it was commissioned to do — analyze the facts concerning what happened at the home and come to a conclusion as to how this tragedy was allowed to play itself out and answer what was, for a time, the most pressing question about all this: ‘who is to blame?’
Indeed, in the wake of the deaths and hospitalizations at the Soldiers’ Home, Gov. Charlie Baker and the Legislature both used the phrase ‘get to the bottom of this’ (unofficially or unofficially) as the scope of the tragedy grew, as did the thirst for answers. And the report has certainly identified some people to blame.
Starting with state officials for not only giving the job of running the home to a veteran (Bennett Walsh) who had no experience leading a long-term-care facility, but then failing to provide adequate amounts of oversight to Walsh and others charged with the care of veterans. But Walsh is also singled out for triggering a series of decisions that allowed COVID-19 to race through the home, affecting residents and staff members alike.
With language that can only be described as heartbreaking, the report recounts the thoughts of one staff member after management merged two locked dementia units on March 27, a decision investigators described as a catastrophe: “[I] will never get those images out of my mind — what we did, what was done to those veterans … my God, where is the respect and dignity for these men?” Other staff members were quoted as saying, “all in this room will be dead by tomorrow.”
While the report is certainly a valuable document, the veterans who died, their families, and staff members who lived through this horrible tragedy want so much more than a document that chronicles what happened and assigns blame. They want and need for this catastrophe to lead to meaningful and permanent changes that will ensure that no one will ever say, ‘where is the respect and dignity for these men?’ again.
That is our hope as well, and while the governor and legislators sound sincere when they say this is their overriding concern with the regard to the Soldiers’ Home, we know from history that when stories disappear from the front pages of newspapers, the will to implement meaningful change dissipates.
We can’t allow that to happen in this case.
Changes proposed by the governor, including several not in the report, include creation of a consistent policy at Holyoke and its sister facility in Chelsea for the hiring of a superintendent; creating more oversight by hiring an assistant secretary within the state Department of Veterans’ Services who would serve as an executive director for the state’s two soldiers’ homes and report directly to the secretary of Veterans’ Services; expanding the board of trustees at both the Holyoke and Chelsea facilities from seven to nine and requiring that the two additions each have either a clinical or administrative background in healthcare; and, most importantly, perhaps, making immediate and long-term capital improvements to modernize residential units and furnishings to address infection control — renovations are currently underway on one floor, but a more comprehensive plan of modernization and improvements is certainly needed.
History also shows us that, following some of the worst tragedies in history — the Triangle fire in New York City, the Cocoanut Grove fire in Boston, and even the Titanic’s sinking — reviews that initially focused on laying blame eventually led to serious, and often historic, reforms.
If that can happen with the case of the Holyoke Soldiers’ Home tragedy, then perhaps those veterans who bravely served their country will not have died in vain.