An epic collapse of management and oversight of the Holyoke Soldiers’ Home, contributing to the deaths of 76 veterans from COVID-19, has now been investigated by a formal federal prosecutor, Attorney General Maura Healey, the Boston Globe Spotlight Team and a special legislative committee headed, in part, by Rep. Linda Dean Campbell, D-Methuen. Due to their work we know some of the home’s most glaring problems, especially details of the “toxic” environment created by former Superintendent Bennett Walsh, as the legislative report described, who was also unqualified for his position.

Still, large questions remain. They include the extent to which Gov. Charlie Baker and his cabinet knew of problems with Walsh and his management of the home but chose not to act.

A legislative committee that interviewed more than 30 people involved at the home over the course of eight public hearings, in preparation of a 181-page report released this past week, has not heard testimony from the governor himself. It is a glaring omission in its work. Baker should testify.

Given the scope of tragedy in Holyoke; the suffering of veterans in state care including more than six dozen who died; and the layers of administration that could have blunted if not completely avoided these deaths, Baker should publicly answer lawmakers’ questions about his role, his decisions, and most essentially, how the state will avoid a similar tragedy from happening again.

Our state’s legislative leaders, including House Speaker Ronald Mariano, who so far has shrugged at the suggestion that Baker testify, should insist that he do so.

“Our report clearly indicates that information was presented to them that was not acted upon,” Campbell told State House News Service last week, speaking of the governor and his secretary of Health and Human Services, Marylou Sudders. “The qualifications of Bennett Walsh were clearly questioned, officially, and documented,” she said. “His qualifications were clearly a question. I think his job performance was clearly identified as being toxic. These points were clearly brought to the attention of the secretary.”

Walsh and the home’s former medical director, Dr. David Clinton, face criminal charges for their role in the COVID-19 bloom at the soldiers’ home. The charges focus specifically on their involvement in a decision to place residents sickened with COVID-19 in a ward with residents who showed no symptoms. Both have pleaded not guilty. Both have said they’re being made into scapegoats.

The outbreak at the home also forced the resignation of Francisco Urena, former Lawrence director of veterans services who was state secretary of veterans services when the pandemic began. Investigations have questioned the extent to which Urena acted on his doubts about the leadership in Holyoke, though they’ve also noted limitations on his authority to have actually done anything about it. The legislative committee calls for a clearer chain-of-command and the elevation of the secretary of veterans services to the governor’s cabinet.

In total, the committee’s report makes 14 findings, some of which point directly to Baker and his deputies. Regarding the home’s “toxic leadership environment (that) contributed substantially to the tragedy,” for example, the report concludes that Baker, Sudders and Urena all knew about Walsh’s “leadership deficiencies” yet did not adequately address them. Baker’s office has said he acted once the extent of Walsh’s failures was clear.

The legislative report also includes a number of recommendations, which Campbell and her co-chair, Sen. Michael Rush, D-West Roxbury, are currently packing into legislation. Hopefully those can prevent a similar tragedy from occurring at the Holyoke or Chelsea soldiers’ homes in the future.

As lawmakers debate those proposals, if not sooner, they deserve to hear directly from the governor about his choices and those made by members of his cabinet.

Seventy-six veterans who lived in the Holyoke Soldiers’ Home may not have died in active service to their country, as is the case with those we honor this weekend. But their service warranted a greater level of respect and care than they were ultimately given. Instead they were either subjected to COVID-19 needlessly and fatally, or mistreated in their dying days. And Gov. Charlie Baker should answer directly for his administration’s role in that tragedy.

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