Nearly 100 residents died from the outbreak at the central Massachusetts home for aging veterans, considered the deadliest outbreak at a long-term care facility in the U.S. However, the most recent death announced by the state’s Executive Office of Health and Human Services was a veteran resident who tested negative for the virus.
The investigation into what went wrong—conducted by private attorney Mark Pearlstein, a former federal prosecutor—included 111 interviews with 100 witnesses and analysis of over 17,000 documents.
The report reviews the several aspects of the Soldiers’ Home, including staffing levels, legal structure, funding, management, a history of events contributing to the way the facility operated in the lead up to the outbreak. Finally, it includes a detailed chronology—”in heartbreaking detail,” according to Baker—of how the coronavirus developed within the facility’s walls.
Although the report documents repeated failures in the way leadership—in particular, Superintendent Bennett Walsh, who was placed on leave on March 30—responded, it also identifies attempts to get help from the state and other outside sources. It also includes recommendations for improving operations at Holyoke Soldiers’ Home.
Gov. Baker plans to hold a press conference at noon in the Gardner Auditorium at the State House to respond to the report.
A federal investigation into the outbreak at Holyoke Soldiers’ Home is still ongoing.
Take a look at the entire 174-page report: