Two former leaders of a Holyoke, Massachusetts soldiers’ home were indicted on charges of criminal neglect in connection to the deaths of at least 76 residents from COVID-19, the state’s attorney general said on Friday.

Former Superintendent Bennett Walsh, 50, and former Medical Director Dr. David Clinton, 71, were indicted Thursday by a state grand jury on charges related to their work at the facility the Soldiers’ Home. 

The Soldiers’ Home in Holyoke is a state-run facility that provides healthcare, hospice care, and other assistance to veterans. It came under scrutiny in early April when the AG’s office said it learned of “serious issues with Covid-19 infection control procedures.”

“We began this investigation on behalf of the families who lost loved ones under tragic circumstances and to honor these men who bravely served our country,” Attorney General Maura Healey said on Friday at a news conference. The 174-page report blasted the senior hospital staff for reckless decisions that caused the coronavirus to run rampant in the home. 

“We allege that the actions of these defendants during the COVID-19 outbreak at the facility put veterans at higher risk of infection and death and warrant criminal charges.”

“We believe this is the first criminal case in the country brought against those involved in nursing homes during the Covid-19 pandemic,” Healey added.

70 veterans die in horrific conditions in a Massachusetts soldiers’ home

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Walsh and Clinton face felony charges and if convicted they could be facing years or even decades in prison. They were indicted on charges of a caretaker who wantonly or recklessly commits or permits bodily injury to an elder or disabled person (five counts for each), and of a caretaker who wantonly or recklessly commits or permits abuse, neglect, or mistreatment to an elder or disabled person (five counts for each).

The two men made some seriously questionable decisions.

The investigation by the AG’s office found that on March 27 the staff decided to consolidate 40 veterans from two locked dementia units into one space designed to hold 25. While both units had confirmed cases of COVID-19, there were patients in them who were healthy. Rather than separate the healthy from the already infected patients, they combined both units in the tightly packed space. 

A social worker attempted to raise concerns. Yet, the chief nursing officer replied, “it didn’t matter because [the patients] were all exposed anyway and there was not enough staff to cover both units,” the report added. 

One hospital staffer who helped move the dementia patients into the tight confines of the overcrowded room told investigators she felt like she was “walking [the veterans] to their death.” Another nurse commented that the packed dementia unit looked “like a battlefield tent where the cots are all next to each other.”

“The residents in the consolidated unit were allegedly mingling together, regardless of Covid-19 status,” the report stated. It added that this decision was reckless from an infection control perspective and placed the healthy veterans at “an increased risk of contracting Covid-19.”

“It is unfortunate that the Attorney General is blaming the effects of a deadly virus that our state and federal governments have not been able to stop on Bennett Walsh. Mr. Walsh has spent his entire life in the service of our country, first in active duty in the Marine Corps for 24 years and then serving other veterans as the Superintendent of the Holyoke Soldiers Home,” Walsh’s attorney, William Bennett said. 

“The Attorney General should not be scapegoating Mr. Walsh, who was on the front lines trying his best to do whatever he could to help the Veterans of the Holyoke Soldiers Home, including asking for help from state officials and the National Guard, which arrived much too late,” Bennett added.

Walsh and Clinton, who were not taken into custody, will be arraigned in Hampden County Superior Court. A date is yet to be specified. Clinton resigned after the release of the report, while Walsh was placed on administrative leave on March 30.

A statement from the Holyoke Soldiers’ Home Coalition said that their hope was the state moves forward with the case so a similar situation will never happen again.

“Our Veterans and senior citizens deserve the greatest respect and should always receive care with the greatest honor and dignity as is the mission of our state for the Soldiers’ Home,” the Coalition’s statement read. “We now hope that justice will prevail and that the state builds a new Home in Holyoke as a lasting memorial to all those who have died. We will remain active in our community in ensuring all current and future Veterans get the best care they have earned.”