Francisco Urena had to leave. Thumbing through a report on the failures of the Holyoke Soldiers’ Home to protect its residents from COVID-19 — which surely contributed to the deaths of 76 veterans who’d served their country with honor — it would be impossible to draw any other conclusion.

The home’s failures weren’t just so many “substantial errors and breakdowns,” as former federal prosecutor Mark Pearlstein and his team detailed in 174 pages of findings. They were the result of incompetence and broken leadership.

Gov. Charlie Baker rightly sought Urena’s resignation as secretary of veterans services just before the report’s release this past week. Baker is justly working to fire Bennett Walsh, the home’s superintendent, based on the independent investigation.

But what happened at the Holyoke Soldiers’ Home cries for something more than the ouster of a couple of top leaders and Baker’s promises of resources and changes to procedure. It cries for an assurance that he and other state leaders will be hard pressed to deliver to families of veterans left at the home, or really anyone in the state's care.

The treatment of the home’s veterans is a chilling example of how a vulnerable population was endangered by the same political and management struggles one might find in most offices. This wasn’t any office environment in any normal setting, however. “Veterans who deserve the best from state government got exactly the opposite,” Baker himself reflected Wednesday. “And there’s no excuse or plausible explanation for that.”

It’s hard to say what might have happened had the Holyoke Soldiers’ Home been graced with the best management. COVID-19 has cut a tragic path through longterm care facilities whose populations are among the most vulnerable to the disease. Pearlstein’s report notes as much.

Still, his investigation catalogues “baffling” decisions such as the mixing of veterans who were stricken and dying from COVID-19, with those who had no symptoms.

Descriptions by some of the 100 witnesses to what happened inside the home are heartbreaking. There was the social worker who talked about consoling a dying patient, across from another man who was “actively dying and moaning,” while at the same time distracting a third man who was “alert and oriented, pleasantly confused, and talking about the Swedish meatballs at lunch.” He wasn't aware, it seemed, of what was happening next to him.

Another member of the staff said it felt like a concentration camp where “we (were) moving these unknowing veterans off to die.” Other residents were quite conscious and were “terrified.”

The report places much of the blame for what transpired on Walsh, the superintendent whom it noted was unqualified as a nursing home administrator. Indeed, until now, that has not been a requirement for the superintendents of the state’s two soldiers homes.

But investigators traced the root of so many poor clinical decisions to Urena, who “did not take sufficient action” to address what he knew to be problems at the home long before the coronavirus was a concern.

“A key oversight function,” the report finds, “is to make sure the right people are in important jobs.”

Urena’s resignation is its own tragedy, albeit small by comparison. The ex-Marine and Purple Heart recipient has built the early part of a career on his compassion for, and dedication to helping, fellow veterans. A former veterans agent in Lawrence, he is widely respected.

Yet, as any student of military leadership knows, the marker of an honorable leader is confronting one’s own failures and being accountable. Urena’s resignation from the cabinet position he’s held since 2015 reflected as much.

The state’s response to this sad affair cannot end there. Nor should it end with Baker’s promised reforms. Legislative leaders pledge their own investigation. Rep. Linda Campbell, D-Methuen, whose military career included service in the 18th Airborne, wants an even deeper dive into how the state treats its veterans. All of these should happen, though they still won’t feel adequate. Nothing will.

For all the good that Baker and his administration have done, and their remarkable efforts in guiding Massachusetts through a pandemic, what happened in Holyoke is a dereliction of duty that cannot be forgotten.

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