The Holyoke Tragedy: Demand Accountability

By: State Rep. Linda Dean Campbell – June, 2021

The Special Joint Oversight Committee charged with investigating the COVID-19 related deaths of veterans at the Holyoke Soldiers’ Home released a comprehensive report in late May outlining both the immediate and underlying causes of this tragedy.

The committee, which I co-chaired with a fellow veteran, Senator Mike Rush, completed its months-long intense and comprehensive investigation prior to publication of the Globe Spotlight report, as the committee heard and received testimony from several of the individuals cited in the Globe report.

The committee’s report includes the testimony of former Secretary Francisco Ureña.
Most crucial was the testimony presented by staff and family members of residents at the Home during our initial hearings in Holyoke. Their courage in coming forward to speak before us cannot be commended enough, as the tragedy was so fresh and raw at that time. This report honors their courage and demands that our work here is followed by legislation to improve Veteran care at our Soldiers’ Homes and throughout the Commonwealth. Legislation will be filed very shortly to carry out the committee’s recommendations and ensure that a tragedy of this kind never happens again.
The gut-wrenching testimony of family members and staff described the chaos that led to the deaths of Veterans, some who passed without proper medical treatment, and some completely alone. Family members and staff will never recover from what they saw and experienced.

Their courageous testimony led this committee to dig deeper and investigate not only how this tragedy progressed from a COVID-19 outbreak to the death of so many in the short-term – but also how long-term deficiencies allowed it to occur. We are grateful for Attorney Pearlstein’s report and his testimony before our committee, however, we found that his report generated more questions than answers.

In our report, we make clear that all who abdicated responsibility and the great trust placed in them need to be held accountable. We also take a most important additional step and make specific recommendations for governance reforms.

The findings presented in the report describe how current governing structures in place at the time created a perfect storm for this COVID outbreak to become a tragedy. The muddled chain of command created the perfect recipe for an absence of accountability.

The report discusses, among other systemic problems: a Superintendent that was selected based upon political calculations rather than qualifications; a Superintendent that created a toxic working environment long before the COVID outbreak at the Soldiers’ Home and who should have been removed well before the crisis hit; a flawed process by which we select (and relieve if necessary) the Superintendent for each Soldiers’ Home; insufficient healthcare qualification requirements for the Superintendent position; important management and leadership positions that were not filled, or filled too late; staffing and training deficiencies at the Holyoke Soldiers’ Home; a muddled chain of command and insufficiently defined responsibility and accountability between the Holyoke Soldiers’ Home and the Governor’s office; the need for a Secretary of Veterans Affairs who has a seat in the Governor’s cabinet; lack of structures for coordination between the two Soldiers’ Homes; and additional findings that point to systemic flaws in governing that must be addressed in order to prevent a similar tragedy from occurring.

My colleagues in the Legislature and I are committed to passing legislation to put into statute the recommendations included in this report. Our Veterans and their families deserve nothing less. This, we believe, is the way to honor those who have sacrificed for our country.

State Representative Linda Dean Campbell represents the cities of Methuen and Haverhill in the State Legislature. She serves as House Chair of the Joint Committee on Advanced IT, the Internet and Cybersecurity and as Chair of the Special Joint Oversight Committee on the Holyoke Soldiers’ Home COVID-19 Outbreak. She can be reached at or (617) 722-2380. ◊