Title: Commonwealth v. Clinton

State: massachusetts

Issuer: Massachusetts Supreme Court

Document:

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
volumes of the Official Reports.  If you find a typographical 
error or other formal error, please notify the Reporter of 
Decisions, Supreme Judicial Court, John Adams Courthouse, 1 
Pemberton Square, Suite 2500, Boston, MA, 02108-1750; (617) 557-
1030; SJCReporter@sjc.state.ma.us 
 
SJC-13335 
 
COMMONWEALTH  vs.  DAVID CLINTON 
(and nine companion cases1). 
 
 
 
Hampden.     January 4, 2023. - April 27, 2023. 
 
Present:  Budd, C.J., Gaziano, Lowy, Cypher, Kafker, Wendlandt, 
& Georges, JJ. 
 
 
Grand Jury.  Practice, Criminal, Grand jury proceedings, 
Indictment.  Probable Cause.  Evidence, Grand jury 
proceedings.  Wanton or Reckless Conduct.  Veteran.  
Nursing Home.  Statute, Construction.  Words, "Caretaker," 
"Create a substantial likelihood of harm." 
 
 
 
Indictments found and returned in the Superior Court 
Department on September 24, 2020. 
 
Motions to dismiss were heard by Edward J. McDonough, Jr., 
J. 
 
The Supreme Judicial Court granted an application for 
direct appellate review. 
 
 
Anna E. Lumelsky, Assistant Attorney General (Kevin Lownds, 
Assistant Attorney General, also present) for the Commonwealth. 
Jeffrey J. Pyle (John F.X. Lawler & James W. Lawson also 
present) for David Clinton. 
 
 
1 Four against David Clinton, and five against Bennett 
Walsh. 
2 
 
William M. Bennett (Meredith G. Fierro also present) for 
Bennett Walsh. 
The following submitted briefs for amici curiae: 
Judith M. Flynn for Long Term Care Community Coalition & 
others. 
Nina Loewenstein, of New York, & Tatum A. Pritchard for 
Disability Law Center. 
Anna Richardson for Veterans Legal Services. 
 
 
 
WENDLANDT, J.  The grand jury indicted the defendants, 
Bennett Walsh and David Clinton, the superintendent and medical 
director of the Soldiers' Home in Holyoke (Soldiers' Home), 
respectively, for elder neglect in violation of G. L. c. 265, 
§ 13K (d 1/2) (elder neglect statute), in connection with their 
alleged failure to provide treatment or services to the veterans 
there housed.  The grand jury heard testimony that, seventeen 
days after the Governor declared a state of emergency in the 
Commonwealth because of the COVID-19 pandemic, these decision 
makers directed their staff to consolidate two floors of elderly 
veterans, some of whom had dementia, onto one floor.  Forty-two 
disabled veterans, five of whom were named in the indictments 
(named veterans), were crowded into a locked space designed to 
house at most twenty-five patients.  As one witness told the 
grand jury, there were "bodies on top of bodies."  "[T]ightly 
packed together and sick," and "coughing on top of each other," 
the veterans at this State-run facility were left in their 
"johnnies," were placed in beds less than two feet apart, and 
were deprived of adequate hydration and food.  The grand jury 
3 
 
heard that some veterans were nonresponsive; others lay 
listless, mouths agape.  Those with COVID-19 symptoms 
intermingled with those without.  Record-keeping was abysmal.  
It was, as one witness told the grand jury, "like a war zone."  
Three days after the decision to consolidate, as many as ten 
veterans had died from COVID-19. 
 
The grand jury also heard that the consolidation ran 
against known infection control protocols.  Medical best 
practices at the time recommended isolation of patients who were 
symptomatic from those who were not.  Indeed, we were all being 
told in the nascent days of the pandemic to remain at a 
prescribed "social distance" from each other. 
 
And the grand jury were told that this tragedy could have 
been avoided; the defendants were presented with options that 
comported with expert advice and infection control guidelines.  
Clinton, who absented himself from the Soldiers' Home for his 
own health, was told by the chief operating officer of a nearby 
hospital that the hospital stood ready, willing, and able to 
assist.  The grand jury heard that Walsh received calls from the 
same hospital official, but he did not return the calls; and he 
had daily telephone calls with the Secretary of the Department 
of Veterans' Services (DVS) to discuss the Soldiers' Home's 
COVID-19 response, yet he hid the mounting staffing crisis and 
emergence of COVID-19 symptoms within the Soldiers' Home from 
4 
 
the secretary.  Instead, the defendants chose silently to 
consolidate this vulnerable population together without adequate 
space or sufficient staffing to care for them.  Because these 
facts and other information presented to the grand jury 
constituted probable cause to believe that the defendants 
violated the elder neglect statute, the Superior Court judge 
erred in dismissing the indictments. 
 
Of course, sometimes bad things happen for no discernable 
reason, and no one is to blame.  At any subsequent trial, 
prosecutors will need to prove their case.  We conclude only 
that they will have the opportunity to do so.2 
 
1.  Background.  We recite the facts presented to the grand 
jury in the light most favorable to the Commonwealth, see 
Commonwealth v. Washington W., 462 Mass. 204, 210 (2012), 
reserving some details for subsequent discussion. 
 
a.  The Soldiers' Home.  At all relevant times, the 
Soldiers' Home was a State-run facility for eligible veterans3 in 
Holyoke, with a long-term care unit and independent living 
 
 
2 We acknowledge the amicus briefs submitted by the 
Disability Law Center; the Long Term Care Community Coalition, 
Dignity Alliance Massachusetts, and the Disability Policy 
Consortium; and Veterans Legal Services. 
 
 
3 To be eligible, veterans must have served 180 days of 
military service; have served ninety days of military service, 
one of which was during wartime; have received a purple heart; 
or have a service-related disability. 
5 
 
spaces.  The long-term care unit housed veterans needing 
assistance with activities of daily life, and provided nursing, 
medication management, and other services. 
 
In March 2020, about 226 veterans lived in the long-term 
care unit, which was divided among five care centers.4  "Care 
Center 1," which was originally split between two floors ("1 
North" and "2 North"), housed patients with memory issues, 
principally dementia, and was locked from the outside.5  In 
March 2020, there were forty to fifty veterans in Care Center 1. 
 
At all relevant times, Walsh was the Soldiers' Home 
superintendent, the "administrative head of the home," a 
position he had held since 2016.  G. L. c. 6, § 71, repealed by 
St. 2022, c. 144, § 4.  See G. L. c. 115A, § 14, inserted by 
St. 2022, c. 144, § 66.6  As superintendent, he was vested with 
the statutory authority to appoint and remove the medical 
director of the Soldiers' Home.  G. L. c. 6, § 71.  See G. L. 
c. 115A, § 14 (c).  Clinton, who was the medical director, 
"ha[d] responsibility for medical, surgical[,] and outpatient 
 
 
4 Soldiers' Home staff were hired for particular care 
centers, for example, Care Center 1, but would at times be asked 
to "float," i.e., work temporarily in other care centers. 
 
 
5 Veterans in Care Center 1 were typically housed four to a 
room. 
 
6 Effective March 1, 2023, G. L. c. 6, § 71, was repealed 
and replaced by G. L. c. 115A, § 14.  Our disposition would be 
the same with respect to the new statutory language. 
6 
 
facilities," as well as for "mak[ing] recommendations to the 
superintendent regarding the appointments of all physicians, 
nurses[,] and other medical staff."  G. L. c. 6, § 71.  See 
G. L. c. 115A, § 14 (c).  The DVS, which at the time was an 
agency within the Executive Office of Health and Human Services 
(EOHHS), oversaw the Soldiers' Home.  G. L. c. 6A, § 16, as 
amended through St. 2018, c. 154, § 4.  See G. L. c. 6A, § 105, 
inserted by St. 2022, c. 144, § 9.  In March 2020, the secretary 
of DVS was Francisco Urena. 
 
b.  The COVID-19 outbreak.  "On March 10, 2020, the 
Governor declared a state of emergency to support the 
Commonwealth's response to the threat of COVID-19."  Le Fort 
Enters., Inc. v. Lantern 18, LLC, 491 Mass. 144, 147 (2023), 
quoting Committee for Pub. Counsel Servs. v. Chief Justice of 
the Trial Court (No. 1), 484 Mass. 431, 433, S.C., 484 Mass. 
1029 (2020). 
 
On March 17, the Soldiers' Home tested a veteran, HM, for 
COVID-19 because he was showing respiratory symptoms.  HM lived 
on 1 North and had three roommates.  He had a tendency to wander 
in and out of other people's rooms and the common room.  The 
Soldiers' Home chief nursing officer, Vanessa Lauziere, 
suggested to Clinton that HM be isolated pending the results of 
the test; Clinton determined not to do so, stating that 
isolating HM was a "moot point" because HM was in Care Center 1, 
7 
 
a locked dementia unit that was isolated from the Soldiers' 
Home's other units. 
 
On March 21, HM's COVID-19 test results showed that he was 
positive for COVID-19.  Lauziere reported the result to Walsh 
and Clinton.  Clinton told Lauziere that HM should be isolated 
and that other symptomatic veterans should be tested.  HM's 
roommates were moved from HM's room in 1 North to other rooms.  
Lauziere suggested that HM be moved from 1 North to one of the 
Soldiers' Home's COVID-19 isolation spaces, but Clinton said 
that patients in 1 North had already been exposed and that 
moving a wandering patient out of the locked unit would further 
compromise the facility.  Walsh informed the staff of HM's 
positive test, and many staff members became concerned. 
 
In the days that followed, as more veterans showed symptoms 
of COVID-19, staff members absented themselves from work at 
increasing rates because they either had contracted COVID-19 or 
feared they would.  Clinton quarantined at home for about a 
week, stating that he had developed respiratory issues on March 
21, that he was in a high-risk population due to his age, and 
that he could work from home.  Other doctors also spent less 
time than usual at the Soldiers' Home because Clinton told them 
that they were at high risk due to their age and advised them to 
minimize their time at the facility. 
8 
 
 
Carl Cameron, the chief operating officer of Holyoke 
Medical Center (HMC), which was located about a mile from the 
Soldiers' Home, became concerned following the admission of 
Soldiers' Home patients to the HMC emergency department.  During 
the week of March 23, Cameron twice called Walsh to inquire 
whether the Soldiers' Home required assistance in connection 
with its COVID-19 response; Walsh did not return Cameron's 
calls.  Cameron also called Clinton directly on Clinton's cell 
phone.  During two telephone calls, which likely took place on 
March 25 and March 26, Clinton told Cameron about the Soldiers' 
Home's struggle with staff contracting COVID-19.  The grand jury 
heard testimony that Clinton reported to Cameron that the 
Soldiers' Home was "okay" and that they were trying to secure 
additional personal protective equipment (PPE).  Clinton did not 
indicate that the Soldiers' Home was in "dire straits" regarding 
staffing, and Cameron did not sense any panic in Clinton's 
voice. 
 
Nevertheless, Cameron "reiterated to . . . Clinton that if 
the Soldiers' Home needed help or they wanted to hospitalize 
veterans, . . . Clinton should reach out to . . . Cameron so 
that he could help manage the [e]mergency [r]oom."  However, 
Clinton declined the offer of assistance; importantly, Clinton 
did not inquire whether he could transfer veterans -- 
symptomatic or asymptomatic -- to the HMC, and he did not ask 
9 
 
for other types of support from HMC, such as nursing staff or 
PPE.  Cameron did not hear back from Walsh or Clinton after this 
call. 
 
By March 27, about one day after Cameron volunteered HMC's 
assistance, the staffing shortage at the Soldiers' Home reached 
critical levels.  On March 27 or one to two days before then, 
the chief of staff of DVS recommended to Walsh that he contact 
HMC for assistance.  Walsh did not do so. 
 
At some point in March, Urena had instituted 10 A.M. daily 
telephone calls with Walsh and others to discuss COVID-19-
related issues.  Walsh provided updates to Urena, including 
about the preparation of COVID-19 isolation rooms at the 
Soldiers' Home and HM's COVID-19 test.  Walsh told Urena that HM 
had been isolated from the other veterans while the test was 
pending, even though HM had not been.  At no time before March 
27, and even during a call on the morning of March 27, did Walsh 
disclose to Urena that there was any problem with staffing 
levels at the Soldiers' Home. 
 
After having been absent for about a week, Clinton returned 
to the Soldiers' Home on March 27.  That morning, Lauziere 
expressed her alarm about the staffing crisis to EOHHS personnel 
and suggested that the National Guard be brought in to help.  
Walsh made a request for National Guard assistance to EOHHS and 
DVS, which was denied.  When Urena heard about the request, he 
10 
 
was "in shock"; Walsh had not mentioned it during their call 
that morning and had not previously reported any staffing 
challenges. 
 
c.  The consolidation.  On March 27, Walsh, Clinton, 
Lauziere, and others met to discuss the staffing crisis.  A 
proposal was made to address the staffing shortage issues by 
consolidating the two floors of Care Center 1.  Under the plan, 
approximately forty-six veterans would be placed on one 
consolidated floor, 1 North, which was designed to hold twenty-
five beds.  When Lauziere questioned whether consolidation was a 
viable option, Clinton assured her that it was, reasoning that 
the two floors were self-contained and that everyone housed 
there had already been exposed to COVID-19.  Neither Walsh nor 
Clinton raised the possibility of sending veterans to the HMC or 
other nearby health care facilities, or shared that Cameron had 
offered that option.  According to Lauziere, she would have 
pursued the option had it been presented to her. 
 
Without knowing about HMC's offer of assistance, Lauziere 
and others commenced execution of the decision to consolidate 
the patients onto one floor.  Veterans were grouped loosely by 
COVID-19 status;7 nine veterans (including the named veterans) 
 
 
7 According to Lauziere, the veterans were categorized as 
follows:  veterans who had not been tested or had not 
experienced any symptoms; veterans who were symptomatic and had 
11 
 
who had been exposed to COVID-19, but had not been tested, and 
who purportedly were asymptomatic8 were packed into the dining 
room.  Lauziere, who did not have the requisite authority to 
consolidate the floors without approval from Walsh and Clinton, 
disclosed the detailed plan to Walsh, who declined to evaluate 
it or to review it with Clinton.  Walsh knew that there were 
COVID-19 positive veterans on both floors, but he considered the 
detailed execution of the plan a medical decision as to which he 
deferred to Clinton.  When a social worker raised concerns about 
the consolidation plan, the social worker was told that all of 
the veterans involved had already been exposed to COVID-19. 
 
According to staff members, the situation on 1 North after 
consolidation was "awful"; there were "bodies on top of bodies" 
and "[i]t was just everyone sitting right next to each other, 
just . . . coughing on top of each other," "like a war zone."  
Some veterans were left unclothed, wearing only their hospital 
johnnies.  The veterans did not wear PPE or masks.  Beds and 
rooms were mislabeled, bearing the wrong veterans' names, and 
there were insufficient outlets to supply power to each of the 
veterans' automatic beds, especially in the dining room, which 
 
positive COVID-19 test results; symptomatic veterans who had 
pending results; hospice veterans; and veterans nearing death. 
 
8 As discussed infra, the Commonwealth's experts testified 
that some of these veterans were likely symptomatic. 
12 
 
had only one outlet.  After the consolidation, veterans did not 
receive sufficient medication, food, or fluids. 
 
In terms of infection control, staff testified that there 
was no protection between the rooms with symptomatic or COVID-19 
positive veterans and the dining room; the doors were left open.  
Staff were not instructed to isolate symptomatic veterans from 
the asymptomatic veterans in the dining room, or to change PPE 
between the bedrooms and the dining room.  Veterans of the 
various rooms, including those who were COVID-19 positive, 
commingled in the day room and shared the four bathrooms on 1 
North.  By March 30, eight to ten veterans at the Soldiers' Home 
had died from COVID-19. 
 
d.  Arrival of the National Guard.  On March 30, because of 
the catastrophic conditions at the Soldiers' Home, EOHHS placed 
Walsh on administrative leave and announced the creation of a 
command center, led by Valenda Liptak, the then chief executive 
officer of Western Massachusetts Hospital in Westfield, who 
assumed Walsh's duties.  The National Guard arrived within a 
day. 
 
Upon her arrival at the Soldiers' Home, Liptak toured the 
facility, focusing on 1 North.  She walked through the dining 
room and saw "confusion," "mayhem," and "disarray."  She saw 
veterans with respiratory issues and veterans who were "actively 
dying."  It was not apparent how the veterans had been arranged 
13 
 
from room to room.  Some veterans were in beds –- which were 
less than two feet apart from one another –- and some were 
wandering.  Most veterans were either wearing johnnies or were 
half-dressed.  There were not enough staff members to feed or 
dress the veterans.  Two veterans told her they were hungry.  
She also immediately noted the inconsistent use of PPE across 
the staff; some staff members wore masks, gloves, and gowns, 
while others did not. 
 
The incident commander, who had been a nurse for thirty-
five years and toured 1 North with Liptak, described it as an 
image she would "never forget."  She had "never seen anything 
like [it]."  Veterans were "wall to wall" in the common area.  
Those in the dining room were "tightly packed together and 
sick"; some were nonresponsive, and some lay on their backs with 
their mouths open.  Cross-contamination, she observed, was 
everywhere. 
 
The incident commander found no evidence that the veterans 
were being assessed regularly.  The records were incomplete and 
disorganized.  The Soldiers' Home did not have a total count of 
veterans on 1 North, and the new team did not have accurate 
information about the whereabouts of certain veterans within the 
facility.  Clinton told them that he and the other doctors had 
not been going to 1 North because the doctors were considered 
14 
 
"high risk"; instead, nurses were assessing the patients and 
updating the doctors. 
 
Liptak's team's first concern was the immediate need to 
"separate and hydrate" the veterans.  They consulted infection 
control specialists, who advised Liptak to find a unit for 
COVID-19 negative patients, to shut down open kitchens, to 
encourage more frequent hygiene, and to standardize PPE use.  
Liptak's team tested every veteran for COVID-19 and then began 
to separate them based on their test results.  Meanwhile, 180 
National Guard members focused on hydrating and feeding the 
veterans. 
 
On April 3, about forty veterans who tested negative were 
sent to a satellite space at HMC and another twenty were sent to 
the emergency departments at HMC or Baystate Medical Center 
(BMC).  HMC eventually had three different units dedicated to 
Soldiers' Home patients.  One-half of the veterans who were 
transferred eventually died from COVID-19. 
 
According to the chief executive officer of HMC, if Walsh 
or Clinton had indicated that they were experiencing severe 
staffing shortages or an outbreak, HMC would have been able to 
accommodate those veterans.  The senior director of care 
management at BMC said that BMC, too, had "plenty of capacity 
for COVID[-19] patients who needed admission to the hospital" 
during the week of March 23, when Walsh and Clinton instead 
15 
 
decided to consolidate the veterans, but that she was not aware 
of anyone from the Soldiers' Home contacting her in mid- to late 
March asking for help. 
 
e.  Expert testimony.  The Commonwealth presented the 
testimony of two experts to the grand jury.  Dr. Asif Merchant 
was the chief of geriatrics and extended care at Newton-
Wellesley Hospital, partner at New England Community Medical 
Services, medical director at a few nursing care facilities, and 
clinical professor at Tufts School of Medicine.  He reviewed the 
medical records for the nine veterans who were moved to the 
dining room on 1 North on March 27, as well as the floor plan 
for the unit, testing results, nursing notes, a patients census, 
and materials from interviews.  He testified that the 
consolidation of the two floors of Care Center 1, and the 
aftermath of the consolidation, increased the likelihood of harm 
to the named veterans because, inter alia, they were placed into 
a closely packed dining room with other veterans (unnamed 
veterans), at least three of whom were likely symptomatic. 
 
Dr. Ronald Rosen was the chief of geriatrics at the North 
Shore Medical Center in Salem and was previously medical 
director at North Shore Physicians Group Extended Care.  Rosen 
also reviewed the veterans' medical records and other relevant 
documents; he concluded that at least three of the veterans who 
were relocated to the dining room per the consolidation plan 
16 
 
were symptomatic of COVID-19 prior to consolidation.  He 
testified that housing symptomatic individuals with asymptomatic 
veterans violated basic infection control practices and 
increased the risk that the named veterans in the dining room 
would contract COVID-19.  Further details of both experts' 
testimony are discussed infra. 
 
2.  Procedural history.  In September 2020, the grand jury 
returned five indictments for elder neglect in violation of the 
elder neglect statute, G. L. c. 265, § 13K (d 1/2), one for each 
named veteran, against each defendant.  The defendants filed 
motions to dismiss the indictments.  A Superior Court judge held 
a nonevidentiary hearing and dismissed all the charges.9  The 
judge concluded that the record before the grand jury did not 
support a finding of probable cause that the defendants were 
"[c]aretaker[s]" as defined in G. L. c. 265, § 13K (a), or that 
the defendants created a substantial likelihood of harm with 
respect to the named veterans under G. L. c. 265, § 13K (d 1/2), 
either by increasing the risk that the named veterans would 
contract COVID-19 or by causing the named veterans to suffer 
 
 
9 The grand jury also returned five indictments against each 
defendant for violation of G. L. c. 265, § 13K (e), alleging 
that the defendants permitted serious bodily injury to the named 
veterans; these indictments were also dismissed.  The 
Commonwealth did not appeal from those dismissals. 
17 
 
dehydration and malnutrition.  The Commonwealth appealed, and we 
granted its timely application for direct appellate review. 
 
3.  Discussion.  a.  Standard of review.  "In considering a 
judge's decision to dismiss for lack of sufficient evidence [to 
support an indictment], we do not defer to the judge's factual 
findings or legal conclusions."  Commonwealth v. Stirlacci, 483 
Mass. 775, 780-781 (2020).  Rather, our review is de novo.  
Commonwealth v. Ilya I., 470 Mass. 625, 627 (2015). 
 
Generally, "a 'court will not inquire into the competency 
or sufficiency of the evidence before the grand jury'" so long 
as the grand jury have heard sufficient evidence, when viewed in 
the light most favorable to the Commonwealth, to warrant a 
person of reasonable caution in believing that the identified 
defendant has committed each of the elements of the charged 
offense.  Stirlacci, 483 Mass. at 780, quoting Commonwealth v. 
Robinson, 373 Mass. 591, 592 (1977).  The "probable cause" 
standard is a "'considerably less exacting' standard" than proof 
beyond a reasonable doubt, which is required to support a 
conviction at trial.  Stirlacci, supra, quoting Commonwealth v. 
O'Dell, 392 Mass. 445, 451 (1984). 
 
b.  Caretakers.  The elder neglect statute prohibits a 
"caretaker of an elder or person with a disability" from 
"wantonly or recklessly commit[ting] or permit[ting] another to 
commit abuse, neglect or mistreatment upon such elder or person 
18 
 
with a disability."  G. L. c. 265, § 13K (d 1/2).  The 
defendants contend that the term "caretaker" under the statute 
applies only to frontline workers, who directly care for elders, 
and not to administrative decision makers, like themselves. 
 
i.  Decision makers.  In interpreting statutes, "[o]ur 
primary goal . . . is to effectuate the intent of the 
Legislature."  Conservation Comm'n of Norton v. Pesa, 488 Mass. 
325, 331 (2021), quoting Casseus v. Eastern Bus Co., 478 Mass. 
786, 795 (2018). 
"[T]he general and familiar rule is that a statute must be 
interpreted according to the intent of the Legislature 
ascertained from all its words construed by the ordinary 
and approved usage of the language, considered in 
connection with the cause of its enactment, the mischief or 
imperfection to be remedied and the main object to be 
accomplished, to the end that the purpose of its framers 
may be effectuated." 
 
Oracle USA, Inc. v. Commissioner of Revenue, 487 Mass. 518, 522 
(2021), quoting Commissioner of Revenue v. Gillette Co., 454 
Mass. 72, 76 (2009).  As such, "our analysis begins with 'the 
"principal source of insight into legislative intent"' –- the 
plain language of the statute."  Patel v. 7-Eleven, Inc., 489 
Mass. 356, 362 (2022), quoting Tze-Kit Mui v. Massachusetts Port 
Auth., 478 Mass. 710, 712 (2018). 
 
The elder neglect statute defines "[c]aretaker" as 
"a person with responsibility for the care of an elder or 
person with a disability, which responsibility may arise as 
the result of a family relationship, or by a fiduciary duty 
imposed by law, or by a voluntary or contractual duty 
19 
 
undertaken on behalf of such elder or person with a 
disability.  A person may be found to be a caretaker under 
this section only if a reasonable person would believe that 
such person's failure to fulfill such responsibility would 
adversely affect the physical health of such elder or 
person with a disability.  Minor children and adults 
adjudicated incompetent by a court of law may not be deemed 
to be caretakers under this section."  (Emphases added.) 
 
G. L. c. 265, § 13K (a). 
 
The term "responsibility" commonly refers to "[t]he 
quality, state, or condition of being duty-bound, answerable, or 
accountable."  Black's Law Dictionary 1569 (11th ed. 2019).  The 
term "care" means "charge, supervision," as in "responsibility 
for or attention to health, well-being, and safety," i.e., 
"under a doctor's care."  Merriam-Webster Online Dictionary, 
https://www.merriam-webster.com/dictionary/care [https://perma 
.cc/Q6KX-47YC].  See Black's Law Dictionary, supra at 263 
(defining "care" as "[s]erious attention, heed"). 
 
Under the elder neglect statute, the "responsibility may 
arise" in one of the following manners:  "as the result of a 
family relationship, or by a fiduciary duty imposed by law, or 
by a voluntary or contractual duty undertaken on behalf of such 
elder or person with a disability."  G. L. c. 265, § 13K (a).  
Moreover, the statute further limits the term "caretaker" by a 
rule of reasonableness; in particular, "[a] person may be found 
to be a caretaker . . . only if a reasonable person would 
believe that such person's failure to fulfill such 
20 
 
responsibility would adversely affect the physical health of 
such elder or person with a disability."  Id. 
 
Thus, as it pertains to the defendants, a "caretaker" under 
the statute is an individual who contractually is duty-bound, 
answerable, or accountable for the health, well-being, and 
safety of an elder or person with a disability such that a 
reasonable person would believe that the individual's failure in 
this regard would adversely affect the physical health of the 
elder or person with a disability.10  Nothing in the plain 
language limits the term to frontline workers "directly" 
responsible for the care of an elder or person with a 
disability.11 
 
 
10 The meaning of the statute is plain; contrary to the 
defendants' contention, it is not void for vagueness.  See 
Commonwealth v. St. Louis, 473 Mass. 350, 355 (2015) ("A 
criminal statute must define the offense in terms that are 
sufficiently clear to permit a person of average intelligence to 
comprehend what conduct is prohibited" [quotation and citation 
omitted]).  "[L]egislative language need not be afforded 
'mathematical precision' in order to pass constitutional 
muster."  Id., quoting Commonwealth v. Reyes, 464 Mass. 245, 249 
(2013).  "Caretaker" is sufficiently described and is not a term 
that sets "a net large enough to catch all possible offenders, 
and leave[s] it to the courts to step inside and say who could 
be rightfully detained, and who should be set at large," Reyes, 
supra, quoting Smith v. Goguen, 415 U.S. 566, 573 n.9 (1974), 
and therefore it is not void for vagueness. 
 
 
11 Our construction of "caretaker" to reach decision makers 
is consistent with the construction given to similarly worded 
statutes by our sister jurisdictions.  See, e.g., Estate of 
Wyatt, 235 Ariz. 138, 140 (2014), quoting Webster's New 
International Dictionary 338 (3d ed. 1976) ("'Care' is 
ordinarily understood to mean 'CHARGE, SUPERVISION, MANAGEMENT:  
21 
 
 
Nevertheless, the defendants maintain that the term is 
limited to frontline workers, excluding decision makers who 
(like them) receive a salary and are responsible, ultimately, 
for the care of an elder or person with a disability.  Their 
argument is grounded in the phrase "[r]esponsibility arising 
from a contractual duty," as to which the elder neglect statute 
provides:  "it may be inferred that a person who receives 
monetary or personal benefit or gain as a result of a bargained-
for agreement to be responsible for providing primary and 
substantial assistance for the care of an elder or person with a 
disability is a caretaker."  G. L. c. 265, § 13K (a) (iii).  The 
defendants contend that this phrase further limits "caretakers" 
to "primary" care providers, which in the health care industry 
has a specific and distinct meaning –- namely, "a medical 
professional (such as a general practitioner, pediatrician, or 
nurse) with whom a patient has initial contact and by whom the 
patient may be referred to a specialist."  Thus, they argue, the 
 
responsibility for or attention to safety and well-being"); 
Delaney v. Baker, 20 Cal. 4th 23, 26-27 (1999) (elder abuse 
statute applies to nursing home administrators); Peterson v. 
State, 765 So. 2d 861, 864 (Fla. Dist. Ct. App. 2000) 
("'Caregiver' logically encompasses more than just the person or 
persons who do the actual physical work of caring for an elderly 
or disabled adult.  It also reaches those who in fact are 
'entrusted' with the responsibility for seeing that an elderly 
or disabled adult is being cared for in a proper and humane 
manner"); State v. Boone Retirement Ctr., Inc., 26 S.W.3d 265, 
274 (Mo. Ct. App. 2000) (affirming elder abuse conviction of 
nursing home administrator). 
22 
 
term excludes decision makers who do not provide such "primary 
care" directly to an elder or person with a disability.  We 
disagree. 
 
To begin, the statute states that a contractual duty "may" 
be inferred where a person is compensated for providing primary 
and substantial assistance for the care of an elder or person 
with a disability.12  It does not state that such a duty "may 
not" arise outside of this context or that such a duty "may 
only" arise in such circumstances.  By contrast, where the 
Legislature intended to limit the scope of "caretaker," it did 
so expressly.  For example, the statute provides that "[m]inor 
children and adults adjudicated incompetent by a court of law 
may not be deemed to be caretakers" (emphasis added).  G. L. 
c. 265, § 13K (a).  See id. ("A person may be found to be a 
caretaker under this section only if a reasonable person would 
believe that such person's failure to fulfill such 
responsibility would adversely affect the physical health of 
such elder . . ." [emphasis added]). 
 
Given the Legislature's deliberate choice to employ 
permissive but nonexclusive language in connection with the 
circumstances pursuant to which a contractual duty may be 
inferred and its use of mandatory, exclusive language in the 
 
 
12 The defendants mistakenly contend that this argument was 
waived. 
23 
 
same statute, we reject the defendants' proposed construction.  
See Commonwealth v. Dalton, 467 Mass. 555, 559 (2014) ("Where 
the Legislature grants discretion in some circumstances and 
denies it in others, the use of the word 'may' contrasted with 
the words 'may not' simply clarifies where discretion is granted 
and where it is forbidden . . ."); Fredericks v. Vartanian, 529 
F. Supp. 264, 268 (D. Mass. 1981), aff'd, 694 F.2d 891 (1st Cir. 
1982) (contrasting "may" in statute with "may . . . only if"). 
 
Moreover, the defendants' contention that the phrase 
"primary and substantial assistance" as used in the statute has 
the specific and distinct meaning prescribed to it in the health 
care industry is belied by the statute's use of the same phrase 
in connection with describing caretaker status arising from a 
familial relationship.  Specifically, in describing when 
"[r]esponsibility arising from a family relationship" may be 
inferred, the statute states that 
"a husband, wife, son, daughter, brother, sister, or other 
relative of an elder or person with a disability is a 
caretaker if the person has provided primary and 
substantial assistance for the care of the elder or person 
with a disability as would lead a reasonable person to 
believe that failure to provide such care would adversely 
affect the physical health of the elder or person with a 
disability" (emphasis added). 
 
G. L. c. 265, § 13K (a) (i).  Most such familial caretakers will 
not fall within the technical definition of primary care 
providers as that term is used in the health care industry; yet 
24 
 
the Legislature clearly intended to include familial caretakers 
within its scope. 
 
The defendants' reading of this phrase suffers from an 
additional flaw.  The statute provides that a contractual duty 
may arise where an individual is contractually obligated "to be 
responsible for providing primary and substantial assistance for 
the care of an elder or person with a disability," G. L. c. 265, 
§ 13K (a) (iii); it does not state that only those who 
contractually agree "to be directly responsible" for such care 
fall within its scope.  Reading such an additional limitation 
into the statutory language is improper.  See Commonwealth v. 
Newberry, 483 Mass. 186, 195-196 (2019), quoting Commissioner of 
Correction v. Superior Court Dep't of the Trial Court, 446 Mass. 
123, 126 (2006) ("Courts may not read into a statute a provision 
that the Legislature did not enact, nor 'add words that the 
Legislature had an option to, but chose not to include'").13 
 
13 Our interpretation is consistent with the meaning 
ascribed to "caretaker" in the Disabled Persons Protection 
Commission (DPPC) statute, G. L. c. 19C, which also addresses 
the consequences of abuse of persons with disabilities.  See 
Ciardi v. Hoffman-La Roche, Ltd., 436 Mass. 53, 62 (2002) 
("Statutes addressing the same subject matter clearly are to be 
construed harmoniously so as to give full effect to all of their 
provisions and give rise to a consistent body of law").  In that 
statute, "[c]aretaker" is defined as "a disabled person's 
parent, guardian or other person or agency responsible for a 
disabled person's health or welfare," G. L. c. 19C, § 1, which 
has been construed to "include not only direct care providers 
. . . but also those . . . responsible for arranging or 
supervising the provisions of care," DPPC Legal Advisory 
25 
 
 
Contrary to the defendants' suggestion, this does not mean 
that "caretaker" status applies to anyone in the State chain of 
command, no matter how attenuated their connection to the 
provision of care to an elder or person with a disability.  As 
discussed supra, whether an individual is a caretaker is limited 
by a rule of reasonableness.14  See G. L. c. 265, § 13K (a) ("A 
person may be found to be a caretaker under this section only if 
a reasonable person would believe that such person's failure to 
fulfill such responsibility would adversely affect the physical 
health of such elder or person with a disability" [emphasis 
added]). 
 
Given that the meaning of the term "caretaker" is not 
ambiguous, we need not examine the legislative history, which in 
any event does not appear to support the defendants' proposed 
construction.15  See Osborne-Trussell v. Children's Hosp. Corp., 
 
Memorandum, Definition of a Caretaker Under M.G.L. c. 19C (rev. 
Sept. 30, 2017). 
 
 
14 This rule, which applies to all "caretakers" under the 
statute, demonstrates that the defendants' concern that any 
volunteer or good Samaritan who provides "passing, secondary, or 
insubstantial assistance" to an elder would be considered a 
caretaker is unwarranted. 
 
 
15 As the Commonwealth notes, the then Attorney General 
proposed statutory language adding the elder neglect statute, 
St. 2004, c. 501, § 8, to "more effectively prosecute nursing 
home supervisors who allow a pattern of abuse and neglect to 
occur in the homes" (emphasis added).  Attorney General Reilly 
Commends Legislature for Passage of Bill to Protect Elderly, 
26 
 
488 Mass. 248, 254 (2021), quoting Doherty v. Civil Serv. 
Comm'n, 486 Mass. 487, 491 (2020) ("If the statutory language is 
clear, 'courts must give effect to its plain and ordinary 
meaning and need not look beyond the words of the statute 
itself'" [alteration omitted]). 
 
ii.  Caretaker analysis for the defendants.  The record 
before the grand jury supports probable cause that the 
defendants were caretakers within the meaning of G. L. c. 265, 
§ 13K (a).  Each is an individual who contractually is duty-
bound, answerable, or accountable for the health, well-being, 
and safety of an elder or person with a disability such that a 
reasonable person would believe that the defendants' failure in 
this regard would adversely affect the physical health of the 
elder or person with a disability. 
 
Walsh was the "administrative head of the home," with 
authority to "appoint . . . a medical director, a treasurer and 
an assistant treasurer."  G. L. c. 6, § 71.16  Clinton, as 
medical director, had "responsibility for the medical, surgical 
 
Disabled Citizens from Abuse, Neglect, U.S. State News (Jan. 4, 
2005). 
 
 
16 In support of his conclusion that the superintendent and 
medical director were not "caretakers," the judge mistakenly 
relied on a 1970 opinion by the then Attorney General 
interpreting certain language in G. L. c. 6, § 71, which was 
removed subsequently by amendment.  See St. 1971, c. 623, § 1.  
It has little bearing on the meaning of the version of the 
statute at issue in this case or the current statute. 
27 
 
and outpatient facilities and . . . [would] make recommendations 
to the superintendent regarding the appointments of all 
physicians, nurses and other medical staff."  Id.  Walsh had the 
authority to overrule Clinton's decisions.  Lauziere reported to 
both defendants, evidencing their authority to oversee and 
direct nursing decisions. 
 
Moreover, the defendants authorized the consolidation, 
indicating that they exercised the authority to control the 
veterans' care.  Walsh provided updates regarding the Soldiers' 
Home's COVID-19 response to Urena, talking with him daily to 
discuss COVID-19 protocols and conditions at the Soldiers' 
Home.17 
 
Clinton exercised caretaking authority by, inter alia, 
rejecting HMC's offers of assistance; participating in the 
decision to create a COVID-19 isolation space at the Soldiers' 
Home; deciding not to isolate HM when his COVID-19 test was 
pending, and then to isolate HM once he tested positive; and 
supervising doctors who cared for veterans.  On this record, the 
 
 
17 The steps that Liptak immediately took when she replaced 
Walsh -– assessing the state of the building, convening meetings 
with infection control experts, organizing a testing and COVID-
19 status cohorting regime for veterans, and sending veterans to 
HMC and BMC -- which were all steps that Walsh could have taken 
in the weeks and days leading to his replacement, also 
demonstrated the superintendent's caretaking authority. 
28 
 
grand jury could find that there was probable cause that both 
defendants were caretakers. 
 
c.  Substantial likelihood of harm.  The defendants also 
challenged the grand jury's finding of probable cause that they 
"create[d] a substantial likelihood of harm" by authorizing the 
consolidation.  General Laws c. 265, § 13K (d 1/2), provides 
that "[w]hoever, being a caretaker of an elder or person with a 
disability, wantonly or recklessly commits or permits another to 
commit abuse, neglect or mistreatment upon such elder or person 
with a disability, shall be punished."  The statute defines 
"[n]eglect" as "the failure to provide treatment or services 
necessary to maintain health and safety and which either harms 
or creates a substantial likelihood of harm" (emphasis added).  
G. L. c. 265, § 13K (a).  The theory presented to the grand jury 
focused on the evidence that the defendants "created a 
substantial likelihood of harm" to the named veterans by 
increasing the risk that the named veterans would contract 
COVID-19, and by causing the named veterans to become dehydrated 
and malnourished. 
 
Again, "our analysis begins with 'the "principal source of 
insight into legislative intent"' –- the plain language of the 
statute."  Patel, 489 Mass. at 362, quoting Tze-Kit Mui, 478 
Mass. at 712.  To "create" is "to bring into existence," to 
"cause," or "to produce or bring about by a course of action or 
29 
 
behavior."  Merriam-Webster Online Dictionary, https://www 
.merriam-webster.com/dictionary/create [https://perma.cc/N5B5 
-BSMM].  The common meaning of "substantial" is "considerable in 
quantity," or "significantly great."  Merriam-Webster Online 
Dictionary, https://www.merriam-webster.com/dictionary 
/substantial [https://perma.cc/RLV8-HHUV].  "Likelihood" refers 
to "the chance that something will happen," or "probability."  
Merriam-Webster Online Dictionary, https://www.merriam 
-webster.com/dictionary/likelihood [https://perma.cc/E6N5-CLMV].  
See Commonwealth v. Boucher, 438 Mass. 274, 276 (2002) ("As 
commonly used and understood, 'likely' is a word that 
encompasses a range of probabilities depending on the specific 
context in which it is used.  We conclude that something is 
'likely' if it is reasonably to be expected in the context of 
the particular facts and circumstances at hand").  Consequently, 
to "create[] a substantial likelihood of harm" means to engage 
in a course of behavior that produces a considerable chance or 
probability that harm will result. 
 
i.  Increased risk that the named veterans would contract 
COVID-19.  In the light most favorable to the Commonwealth, the 
Commonwealth presented "sufficient facts to warrant a person of 
reasonable caution in believing," Stirlacci, 483 Mass. at 780, 
quoting Commonwealth v. Levesque, 436 Mass. 443, 447 (2002), 
that the defendants' decision to consolidate more than forty 
30 
 
elderly veterans onto one floor designed for approximately one-
half that number, and particularly the decision to pack nine 
veterans into the dining room on that consolidated floor, 
produced a more considerable chance or probability that the 
named veterans would contract COVID-19.18 
 
Notably, Dr. Merchant testified that the decision to 
consolidate the floors violated basic infection control 
guidelines, which provided that patients who are symptomatic or 
who are suspected to be symptomatic should be separated from 
patients who are not showing symptoms.  Consolidation, Merchant 
testified, created a "recipe for a higher-risk situation" 
because each named veteran shared a room with more veterans than 
before the consolidation, their beds were much closer to one 
another, veterans wandered in and out of rooms on the floor, 
staff caring for COVID-19 positive patients came into the dining 
room, staff did not use PPE correctly, and the veterans on the 
consolidated floor -- whether they were COVID-19 positive, 
showed COVID-19 symptoms, or were asymptomatic -- all shared the 
same bathrooms. 
 
Moreover, Merchant reviewed the medical records of the nine 
veterans who were moved to the dining room on March 27, and 
 
18 Of course, the defendants should not be held to COVID-19 
infection control standards other than the standards applicable 
at the time they made the decision to consolidate. 
31 
 
opined that, on that day, at least three of the unnamed veterans 
were likely symptomatic.  Placing the named veterans into a 
closely packed dining room with the symptomatic veterans, Dr. 
Merchant opined, increased the risk of one or all of the named 
veterans contracting COVID-19.  Three of the named veterans -– 
GE, RT,19 and AP –- all tested positive on tests administered on 
March 31, four days after the consolidation; Merchant concluded 
that, given the incubation period for COVID-19, all three 
possibly contracted COVID-19 after being transferred to the 
dining room. 
 
Dr. Rosen also opined that three of the unnamed veterans 
were symptomatic before consolidation, and concluded that 
"cohort[ing]" them with the other veterans in the dining room –- 
including the named veterans -- went against "not only common 
sense but basic infection control practices where you try to 
separate and isolate those that are more likely to be contagious 
from those that [are not]";20 in Rosen's view, the consolidation 
 
19 RT was transferred to HMC on April 11 and passed away. 
 
20 Dr. Rosen testified: 
 
"[E]ven though all the veterans had been exposed it didn't 
mean that they had all already contracted COVID[-19].  In 
fact, we see that two of [the] veterans never tested 
positive for COVID[-19].  So at that time test results were 
not available for these veterans.  So it just goes against 
basic principles of infection control[, specifically,] that 
you have to cohort people based on their risks and your 
medical decision making." 
32 
 
increased the risk that the named veterans in the dining room 
would contract COVID-19.  Rosen concluded that the dining room 
was "almost an incubator for COVID[-19]"; beds were placed very 
close together without barriers between them, staff had 
insufficient knowledge of or poor access to PPE, doors were 
open, and residents comingled within the lounge area.  The 
consolidation, Rosen opined, made "a very high-risk situation 
. . . even more high-risk." 
 
Soldiers' Home staff also testified that consolidation 
violated known infection control practices and increased the 
risk that veterans would contract COVID-19.  For example, a 
certified nursing assistant testified that she was "extremely 
shocked and surprised that they would put more people" on 1 
North because it would result in veterans "on top of each other 
. . . shoulder to shoulder."  The state of the floor after 
consolidation "was the complete opposite of everything [she] 
learned" in nursing school.  Additionally, Liptak testified that 
she thought consolidation "increas[ed] the odds" that COVID-19 
negative veterans would contract COVID-19 by "exposing them to 
multiple people that were probably already COVID[-19] positive." 
The defendants contend that because the record also showed 
that the veterans housed on the consolidated floor already had 
been exposed to COVID-19 prior to consolidation, they did not 
"create" a substantial risk of harm; in their view, the risk of 
33 
 
harm already existed, and any increased risk caused by the 
consolidation is not covered by the statute.  As set forth 
supra, however, to "create a substantial risk of harm" requires 
that the caretaker engage in a course of behavior that produces 
a more considerable chance or probability that harm will result.  
This definition does not exclude situations where there is a 
preexisting risk; the baseline comparator is not limited to 
hypothetical, risk-free situations existing ex ante.21  The 
inquiry whether the defendants "created" a substantial risk of 
harm is focused on the defendants' conduct and whether that 
conduct produced a more considerable chance or probability that 
harm would result than would have existed in the absence of that 
conduct. 
Indeed, the defendants' construction makes little sense in 
the context of the provision of care, especially in connection 
with care for the elderly and patients with disabilities -- a 
population that is already at risk for multiple health 
 
21 Conduct may be criminalized where it increases an already 
present risk.  See, e.g., Commonwealth v. Carter, 481 Mass. 352, 
362-363 (2019), cert. denied, 140 S. Ct. 910 (2020) (affirming 
involuntary manslaughter conviction where defendant "creat[ed] a 
situation where there [was] a high degree of likelihood that 
substantial harm would result" to her boyfriend by encouraging 
him to get back into truck filled with carbon monoxide after he 
had saved himself from suicide attempt); Commonwealth v. Hadley, 
78 Mass. App. Ct. 405, 407-410 (2010) (defendant convicted of 
battery had "created a high degree of likelihood of substantial 
harm" to victim with serious preexisting medical conditions, 
including enlarged spleen, by kicking spleen). 
34 
 
conditions.  Here, the record supports probable cause that the 
defendants' decision to consolidate the veterans on one floor 
without adequate spacing between patients, which resulted in 
veterans coughing on each other, and housing symptomatic 
veterans with asymptomatic veterans, like the named veterans, 
produced a more considerable chance or probability that harm 
would result to the named veterans.22 
 
ii.  Dehydration and malnourishment.  The defendants' 
contention that the medical records for the named veterans do 
not support probable cause that the named veterans were 
dehydrated or malnourished fares no better.  The record showed 
that, following consolidation, the veterans' medical records 
were "incomplete and disorganized," containing only "sparse," 
"brief" information.  The grand jury were warranted in 
concluding that the medical records did not tell the complete 
story of the named veterans. 
 
22 We have recognized that "particularly [for] the elderly 
. . . , [COVID-19] poses a substantial likelihood of serious 
illness or death."  Foster v. Commissioner of Correction (No. 
1), 484 Mass. 698, 702, S.C., 484 Mass. 1059 (2020) and 488 
Mass. 643 (2021).  Clinton correctly asserts that prosecutors 
will need to show, at any subsequent trial, that the decision to 
consolidate resulted in an increased risk; at this stage, we 
conclude only that the record supported probable cause that the 
defendants' consolidation order created that increased risk. 
 
Clinton's contention that two of the named veterans were 
not harmed by the decision to consolidate is inapposite.  The 
statute requires only that the consolidation decision created a 
substantial risk of harm. 
35 
 
 
The grand jury could rely on the ample testimony that the 
veterans on the consolidated floor were underfed and dehydrated.  
One social worker testified that veterans on the consolidated 
floor were not receiving sufficient hydration or food and that 
the named veterans were dehydrated and malnourished.  When 
Liptak arrived, two veterans told her they were hungry, and she 
observed that there was insufficient staff to feed all the 
veterans on the floor.  Indeed, her first priority when she 
arrived was to "separate and hydrate" the veterans. 
 
Another witness testified that, when he visited his father 
on March 27, his father was so dehydrated that he did not think 
his father was receiving any hydration.  Together, the 
information before the grand jury warranted a finding of 
probable cause that the consolidation produced a more 
considerable chance or probability that the named veterans would 
become dehydrated and malnourished.  See Stirlacci, 483 Mass. at 
780, quoting O'Dell, 392 Mass. at 451 ("Probable cause is a 
'considerably less exacting' standard than that required to 
support a conviction at trial"). 
 
d.  Wantonly or recklessly.  Last, the Commonwealth 
presented sufficient evidence to support probable cause that, in 
consolidating the floors, the defendants did so "wantonly or 
recklessly."  G. L. c. 265, § 13K (d 1/2).  "Wanton or reckless 
conduct is 'intentional conduct, by way either of commission or 
36 
 
of omission where there is a duty to act, which conduct involves 
a high degree of likelihood that substantial harm will result to 
another.'"  Commonwealth v. Earle, 458 Mass. 341, 347 (2010), 
quoting Commonwealth v. Welansky, 316 Mass. 383, 399 (1944).  
"Wanton or reckless conduct amounts to what has been variously 
described as indifference to or disregard of probable 
consequences."  Commonwealth v. Godin, 374 Mass. 120, 129 
(1977), cert. denied, 436 U.S. 917 (1978), quoting Welansky, 
supra. 
 
The record before the grand jury showed that consolidation 
was inconsistent with infection control best practices known in 
March 2020.  Dr. Merchant testified that, although COVID-19 
infection control guidance has changed throughout the pandemic, 
even in March 2020 when the defendants decided to consolidate 
the veterans, the guidance was to separate patients suspected of 
having COVID-19 from asymptomatic patients; it was a standard 
component of "basic infection control guidelines for many 
diseases."  The grand jury also heard testimony that, according 
to an epidemiologist with the bureau of infectious disease at 
the Department of Public Health (DPH): 
"[A]s early as March 4[, 2020,] it was firmly accepted 
among the various guidances [sic] that residents of 
different COVID[-19] statuses should not be grouped 
together.  This has been firm and consistent guidance from 
the beginning and [has not] changed since the onset of the 
pandemic.  The guidance has been to create physical 
37 
 
separation between positive patients and asymptomatic 
patients." 
 
 
In fact, Clinton apparently recognized the significance of 
the exposure risk, exercising particular caution with respect to 
himself and the doctors at the Soldiers' Home; on the same day 
that HM tested positive for COVID-19, Clinton began quarantining 
at home for a week because he was in a high-risk population -- 
like the veterans in his care –- and he advised other doctors to 
minimize their time at the Soldier's Home as well.  Yet the 
grand jury heard testimony indicating that, despite protecting 
himself and fellow doctors against the risk of exposure, Clinton 
did not employ the same caution towards the veterans.  See 
Commonwealth v. Carter, 474 Mass. 624, 631 (2016), quoting 
Commonwealth v. Pugh, 462 Mass. 482, 497 (2012) (conduct was 
subjectively wanton or reckless if "grave danger to others" was 
apparent and "defendant . . . chose[] to run the risk rather 
than alter [his] conduct so as to avoid the act or omission 
which caused the harm"). 
The grand jury also heard that determining the available 
resource in the community was critical, even in March 2020, in 
planning for infection disease control.  Dr. Rosen testified 
that, in his opinion, when planning for a surge of the type 
anticipated in March 2020: 
"One of [the] things you do is you plan out and you go to 
the community and you utilize all the resources you could 
38 
 
have in the community.  That's what the [Centers for 
Disease Control] recommended.  So you would contact local 
hospitals and ask how they can help.  Can they –- do they 
have any extra [PPE], do they have any extra staff, can 
they –- can they take other residents[?]  You would contact 
all your other local nursing homes.  Do you have capacity 
to help us cohort[?]" 
 
The grand jury also heard testimony that the defendants had 
options that would have allowed them to conform the veterans' 
care to the then-existing infection control protocols.  Cameron, 
the chief operating officer of HMC, called Walsh twice during 
the week of March 23 and never received a response. 
Cameron also called Clinton directly, and over the course 
of two subsequent telephone calls, Cameron told Clinton that if 
the Soldiers' Home needed help, or if it wanted to hospitalize 
veterans, Clinton should contact Cameron.  According to Cameron, 
Clinton did not accept the offer of assistance; he did not 
indicate that COVID-19 was a problem at the Soldiers' Home, ask 
whether he could transfer veterans to HMC, or ask for additional 
resources from HMC such as nursing help or any PPE.  Moreover, 
according to the chief executive officer of HMC, if either 
defendant had indicated that he was experiencing staffing 
shortages or an outbreak, HMC would have been able to 
accommodate those veterans seven to eleven days before April 3.  
Moving veterans from the Soldiers' Home to HMC, the chief 
executive officer stated, would have required DPH's approval; 
that approval, the grand jury were told, was received on the 
39 
 
"same day" as it was requested.  BMC, too, had "plenty of 
capacity for COVID[-19] patients who needed admission to the 
hospital" during the week of March 23, but BMC did not receive 
any outreach from the Soldiers' Home before the consolidation.  
Rather, veterans were not sent to HMC or BMC until April 3.23 
The grand jury thus heard testimony that would warrant 
finding probable cause that the defendants had a duty to act in 
accordance with the infection control practices that the 
Commonwealth's experts testified to be known by medical 
professionals in March 2020, and that in declining to pursue 
available options and instead consolidate the two floors, the 
defendants engaged in intentional conduct of omission that 
involved a high degree of likelihood that substantial harm would 
result.  See Earle, 458 Mass. at 347.  See also Commonwealth v. 
Gallison, 383 Mass. 659, 665-666 (1981) (evidence of parent's 
"inaction in light of her child's vomiting, diarrhea, high 
 
23 The testimony regarding the available alternatives to 
consolidation, which the defendants did not pursue, was provided 
by an investigator who interviewed these witnesses.  This, of 
course, did not preclude the grand jury from relying on the 
investigator's report in issuing the indictments.  See 
Commonwealth v. Stevenson, 474 Mass. 372, 376 (2016), quoting 
O'Dell, 392 Mass. at 450-451 ("We have consistently and without 
notable exception held that 'an indictment may be based solely 
on hearsay'").  At this stage, we do not "inquire into the 
competency or sufficiency of the evidence before the grand 
jury," so long as the grand jury "hear[d] sufficient evidence to 
establish the identity of the accused . . . and probable cause 
to arrest him . . . for the crime charged" (quotation and 
citations omitted).  Stirlacci, 483 Mass. at 780. 
40 
 
fever, subsequent unconsciousness, and breathing failure," if 
believed, "would warrant the jury in concluding that the 
defendant should have been aware and indeed was aware of the 
increased risk of harm and thus [her] failure to remedy the 
situation was the kind of conduct which constitutes wanton and 
reckless conduct" [citation omitted]).24 
 
4.  Conclusion.  Based on the foregoing, we reverse the 
order allowing the defendants' motions to dismiss. 
 
 
 
 
 
 
 
So ordered. 
 
24 The dissent provides a rough roadmap for the defendants 
to follow as they marshal a defense that their conduct was not 
wanton or reckless, excusing the defendants' decisions and 
inactions as either uninformed or merely negligent conduct in 
the face of the chaotic realities of the early days of the 
pandemic.  In short, the dissent finds that the defendants did 
the best they could, given the situation with which they were 
faced.  This, of course, is not the question on appeal.  
Instead, we are tasked with the question whether the grand jury 
record supports their finding of probable cause.  In doing so, 
the grand jury were not required to "resolve[] all their doubts" 
or to weigh the evidence to assess whether it could "sustain a 
conviction" beyond a reasonable doubt (alteration omitted).  
Commonwealth v. Arias, 481 Mass. 604, 617-618 (2019), quoting 
Commonwealth v. Cartright, 478 Mass. 273, 283 (2017).  As set 
forth supra, viewed in the light most favorable to the 
Commonwealth, the record warrants a person of reasonable caution 
in believing that the defendants' actions, and inactions, 
involved a high degree of likelihood that substantial harm would 
result to the veterans under their care.  The record supports 
the grand jury's finding that the defendants acted in 
contravention of then-existing infectious disease control 
protocols and that they failed to pursue then-available options.  
At this stage, that is all that is required. 
 
LOWY, J. (dissenting, with whom Cypher, J., joins).  I 
agree with the court that that there was probable cause that the 
defendants were caretakers under the elder neglect statute and 
that there was sufficient evidence to support a finding of 
probable cause that the defendants' actions created a 
substantial likelihood of harm.  I dissent because -- even 
viewed in the light most favorable to the Commonwealth -- there 
was insufficient evidence before the grand jury to support a 
finding of probable cause that the defendants acted wantonly or 
recklessly, as required to support an indictment. 
As is often noted, hindsight is an exact science, but the 
protocols in the early days of the COVID-19 pandemic were 
anything but.  At its core, this prosecution is nothing more 
than an exercise in assigning blame with the benefit of 
hindsight.  A finding of probable cause that the defendants 
acted wantonly or recklessly in this case ignores the chaos, 
uncertainty, and unknowns present during the earliest days of 
the pandemic.  Such a finding also fails to recognize the 
untenable staffing challenges the Soldiers' Home in Holyoke 
(Soldiers' Home) faced during this time. 
Probable cause "exists where the facts and circumstances 
. . . [are] sufficient in themselves to warrant a [person] of 
reasonable caution in the belief that an offense has been . . . 
committed" (quotation and citation omitted).  Commonwealth v. 
2 
 
Coggeshall, 473 Mass. 665, 667 (2016).  Context is critical to 
the probable cause analysis because "[i]n dealing with probable 
cause . . . we deal with probabilities.  These are not 
technical; they are . . . practical considerations of everyday 
life, on which reasonable and prudent [people], not legal 
technicians, act" (emphasis added).  Commonwealth v. Arias, 481 
Mass. 604, 617 (2019), quoting Commonwealth v. Cartright, 478 
Mass. 273, 283 (2017).  In this case, we are tasked with 
evaluating probable cause as to whether the defendants were 
wanton or reckless while working with many patients whose 
conditions made isolation extremely difficult, and while 
simultaneously managing an extraordinarily reduced staff during 
the early days of a not yet fully understood pandemic. 
As noted by the court, "[w]anton or reckless conduct is 
'intentional conduct, by way either of commission or of omission 
where there is a duty to act, which conduct involves a high 
degree of likelihood that substantial harm will result to 
another.'"  Commonwealth v. Earle, 458 Mass. 341, 347 (2010), 
quoting Commonwealth v. Welansky, 316 Mass. 383, 399 (1944).  
"The standard of wanton or reckless conduct is at once 
subjective and objective . . . ."  Welansky, supra at 398.  
"Whether conduct is wanton or reckless is 'determined based 
either on the defendant's specific knowledge or on what a 
3 
 
reasonable person should have known in the circumstances.'"1  
Commonwealth v. Carter, 474 Mass. 624, 631 (2016), S.C., 481 
Mass. 352 (2019), cert. denied, 140 S. Ct. 910 (2020), quoting 
Commonwealth v. Pugh, 462 Mass. 482, 496 (2012).  "Proof of 
[wanton or reckless conduct] requires 'more than a mistake of 
judgment or even gross negligence.'"  Commonwealth v. Dragotta, 
476 Mass. 680, 686 (2017), quoting Commonwealth v. Michaud, 389 
Mass. 491, 499 (1983).  "[I]n all cases, not just those in which 
there is a horrific tragedy as there is here, we must look at 
the conduct that caused the result to determine whether it was 
wanton or reckless, not the resultant harm."  Commonwealth v. 
Hardy, 482 Mass. 416, 424 (2019). 
The court erroneously concludes that the defendants had 
safer options available to them other than consolidation and 
that the failure to pursue these options supported a finding of 
probable cause that the defendants' actions were wanton or 
reckless.  Ante at    .  This conclusion is not supported by the 
 
1 "If based on the objective measure of recklessness, the 
defendant's actions constitute wanton or reckless conduct . . . 
if an ordinary normal [person] under the same circumstances 
would have realized the gravity of the danger."  Commonwealth v. 
Carter, 474 Mass. 624, 631 (2016), S.C., 481 Mass. 352 (2019), 
cert. denied, 140 S. Ct. 910 (2020), quoting Commonwealth v. 
Pugh, 462 Mass. 482, 496-497 (2012).  "If based on the 
subjective measure, i.e., the defendant's own knowledge, grave 
danger to others must have been apparent and the defendant must 
have chosen to run the risk rather than alter [his or her] 
conduct so as to avoid the act or omission which caused the 
harm."  Carter, supra, quoting Pugh, supra at 497. 
4 
 
evidence.  "To constitute wanton or reckless conduct, as 
distinguished from mere negligence, grave danger to others must 
have been apparent, and the defendant must have chosen to run 
the risk rather than alter his conduct so as to avoid the act or 
omission which caused the harm."  Welansky, 316 Mass. at 398.  
Our cases demonstrate that "because wanton or reckless conduct 
requires a consideration of the likelihood of a result 
occurring, the inquiry is by its nature entirely fact-specific."  
Carter, 474 Mass. at 634.  It is "[t]he circumstances of the 
situation [that] dictate whether the conduct is or is not wanton 
or reckless."  Id. 
Because our inquiry is fact specific, the world as we knew 
it in March 2020 is an essential consideration in this case.  We 
have previously recognized the unknowns and absolute chaos 
created by the pandemic in the opinions that we issued in real 
time during what can only be described as a period of turmoil.  
See, e.g., Foster v. Commissioner of Correction (No. 1), 484 
Mass. 698, 702 (2020), S.C., 484 Mass. 1059 (2020) and 488 Mass. 
643 (2021) ("Despite a massive, concerted global containment 
effort, COVID-19 has continued to spread, both around the world 
and in Massachusetts.  Few inhabited places worldwide have been 
spared . . ." [footnote omitted]); Goldstein v. Secretary of the 
Commonwealth, 484 Mass. 516, 525-526 (2020) ("We need not dwell 
long on how dramatically conditions have changed in 
5 
 
Massachusetts since the Governor first announced a state of 
emergency arising from the COVID-19 pandemic on March 10.  All 
who presently live in the Commonwealth have seen it [and lived 
it] . . ."); Committee for Pub. Counsel Servs. v. Chief Justice 
of the Trial Court (No. 1), 484 Mass. 431, 433, S.C., 484 Mass. 
1029 (2020) ("The 2020 COVID-19 pandemic has created enormous 
challenges for every aspect of our communities. . . .  Health 
care workers on the frontlines of the epidemic are coming down 
with the virus in much higher percentages than others, while 
surgical masks and other basic protective equipment are in short 
supply, and hospitals with already close-to-capacity intensive 
care unit beds confront the possibility of inadequate resources 
to care for critically ill patients . . . .  Everyday life is 
heavily disrupted . . .").  A finding of probable cause in this 
case ignores the "practical considerations of everyday life" 
(citation omitted), Arias, 481 Mass. at 617, at an unprecedented 
time when in many ways life as we know it was falling apart.  
The grand jury minutes reviewed as a whole, in the context of 
the world as we knew it in March 2020, rather than with our 
current understanding of COVID-19, show that the Commonwealth 
has failed to demonstrate that the defendants acted with an 
"indifference to or disregard of [the] probable consequences," 
Welansky, 316 Mass. at 399, when responding to the outbreak 
6 
 
during the earliest stages of what we now know to be an 
unprecedented global pandemic. 
The court relies on the testimonies of Drs. Ronald Rosen 
and Asif Merchant and an epidemiologist with the bureau of 
infectious disease at the Department of Public Health (DPH) to 
support a finding of probable cause that the consolidation was 
wanton or reckless.  Ante at    .  Dr. Rosen testified that, in 
his opinion, when planning for an outbreak, such as the one that 
occurred at the Soldiers' Home, health care professionals go out 
into the community and "contact all your other local nursing 
homes" and "ask how they can help."  Dr. Merchant testified that 
separating symptomatic and asymptomatic patients constituted 
"basic infection control guidelines for many diseases."  And the 
epidemiologist testified that, from the beginning of the 
pandemic, the consistent guidance was that there should be 
"physical separation between positive patients and asymptomatic 
patients."  While all of this testimony is relevant, its 
application here, even in the light most favorable to the 
Commonwealth, is through the perfect lens of hindsight. 
At bottom, a finding of probable cause, based in large part 
on this testimony, disregards the specific "circumstances of the 
situation" at the Soldiers' Home, and it is those specific 
circumstances that ultimately dictate whether the consolidation 
was or was not wanton or reckless.  See Carter, 474 Mass. at 
7 
 
634.  For one, reliance on this evidence fails to recognize that 
an extraordinary number of staff members were sick or just 
refusing to work and that attempts to find more staff were made 
to no avail.  This testimony also discounts the real 
administrative obstacles to moving veterans to another facility.  
It further fails to take into account that the defendant David 
Clinton indicated that the Soldiers' Home was working to obtain 
additional personal protective equipment (PPE) prior to the 
consolidation and that the first request for assistance from the 
National Guard, which was made before the consolidation, was 
denied. 
Perhaps most concerning, this testimony overlooks the 
practical, ethical, and legal difficulties of treating the 
facility's dementia patients.  Many of the veterans at the 
Soldiers' Home were dementia patients, and it was common for 
these patients to wander throughout their respective unit and in 
and out of other veterans' rooms.  And according to the 
testimony before the grand jury, as a matter of medical ethics, 
these patients could not be "physically or chemically 
restrain[ed]."  As late as March 26, 2020, DPH confirmed to the 
Soldiers' Home that it was "not appropriate" to confine veterans 
with dementia to their rooms, even as an infection control 
measure.  All of these factors are critical to determining 
whether there was probable cause that under these particular 
8 
 
circumstances the consolidation was wanton or reckless.2  See 
Commonwealth v. Carrillo, 483 Mass. 269, 270 (2019) ("The 
Commonwealth must introduce evidence showing that, considering 
the totality of the particular circumstances, the defendant knew 
or should have known that his or her conduct created a high 
degree of likelihood of substantial harm . . ." [emphasis 
added]). 
The court also predicates its conclusion on the offer of 
help from Holyoke Medical Center (HMC), contending that as a 
result the defendants knew that they had safer options 
available.  Ante at    .  Review of the grand jury minutes 
reveals only scant evidence about the content of calls where 
help was purportedly offered to the Soldiers' Home.  The minimal 
evidence was presented through an investigator who was not a 
party to these calls, but nonetheless characterized the calls 
and pontificated about what would have happened if hypothetical 
questions had been asked on these calls. 
 
2 Moreover, specifically as to the defendant Bennett Walsh, 
reliance on this testimony to support a finding of probable 
cause that he was wanton or reckless ignores the fact that the 
function of his role was primarily that of an administrator.  He 
had no medical background or training, and ultimately the 
decision to consolidate patients was made during a discussion 
with medical professionals who worked at the Soldiers' Home.  In 
light of his nonmedical background and reliance on the medical 
professionals in the building, it is unlikely that Walsh or a 
reasonable person in his position would know that a high degree 
of likelihood of substantial harm would result from the merger. 
9 
 
According to the testifying investigator, she spoke to 
Spiros Hatiras, the chief executive officer of HMC, and Carl 
Cameron, the chief operating officer at HMC.  The investigator 
testified that Hatiras told her that in the days leading up to 
the consolidation, Hatiras asked Cameron to reach out to the 
Soldiers' Home to "prepare [HMC] for potential admissions from 
the Soldiers' Home."  The investigator said Hatiras told her 
that "he believed [Cameron] eventually did talk to [Clinton]" on 
"March 24th or March 25th, and the second time on March 26th."  
According to the investigator's testimony, "Hatiras'[s] 
understanding [was] that [Cameron] did not learn anything of 
significance other than that the Soldiers' Home had sick 
patients."  During her grand jury testimony, the investigator 
was also asked a number of hypothetical questions.  One question 
was whether "[it was] fair to say that" had Hatiras been asked 
to help accommodate residents before the consolidation, he 
"would have said, yes, and essentially would have reached out to 
[the proper authorities needed] to kind of coordinate the whole 
thing."  The investigator responded, "That's correct." 
The investigator also testified about her interview with 
Cameron.  She testified that Cameron told her that "he had 
contact with the Soldiers' Home between . . . March 23rd . . . 
and March 25th."  She stated that Cameron told her his initial 
telephone calls to both Bennett and Clinton were not immediately 
10 
 
returned, but Cameron said he ultimately spoke to Clinton twice.  
The investigator testified that Cameron said the first call 
between him and Clinton occurred around March 25.  The 
investigator –- who, again, was not on the call -- did not 
testify as to what anybody on the call told her was said.  
Rather, she characterized the first call as mainly about the 
Soldiers' Home employees who were becoming sick "as well as any 
PPE issues." 
The investigator then said that "Clinton then reached out 
to . . . Cameron [a second time] likely on March 26th."  The 
investigator, who was also not a party to this second call, 
testified that during this second call "Clinton told [Cameron] 
that the Soldiers' Home [was] having a tough time dealing with 
staff that was getting sick" and "that the Soldiers' Home was 
okay and that they were in the process of trying to secure 
additional PPE."  According to the investigator, who I emphasize 
again was not on the call,3 Cameron offered to help the Soldiers' 
Home.  However, to the extent that there was an offer for help, 
 
3 The court points out, in regard to the hearsay testimony 
concerning the telephone calls, that hearsay is admissible in 
grand jury proceedings.  I agree.  I point out that the grand 
jury witness was not on the telephone calls the witness 
describes, and that this witness pontificates on what the likely 
content to a hypothetical discussion would have been, as it 
relates to the weight of the evidence presented. 
11 
 
it was vague and not significantly elaborated upon before the 
grand jury. 
The only information the investigator gave about this offer 
was that, according to the investigator, Cameron told Clinton 
"that if the Soldiers' Home needed help or they wanted to 
hospitalize veterans, [Clinton] should reach out to [Cameron] so 
that he could help manage the Emergency Room" (emphasis added).  
In response to a question about how Clinton responded to this 
undefined offer of help, the investigator did not provide a 
direct answer.  Rather, she testified repeatedly about what 
Clinton did not say and questions he did not ask.  And although 
she was not a party to the call, the investigator testified that 
Cameron did not "sense any panic in [Clinton's] voice."  
Importantly, the investigator never elucidated whether there was 
a discussion between Cameron and Clinton regarding the actual 
extent of the help being offered or the relevant government 
agency approvals that would have been required to move veterans 
from the Soldiers' Home to HMC. 
Ultimately, these calls were, according to the testimony of 
the investigator, focused on PPE and preparing the HMC emergency 
room for potential admissions, respectively.  To the extent that 
any help was offered to the Soldiers' Home, it was narrow.  The 
investigator characterized the call as mainly a request for some 
warning so that Cameron could arrange logistics at the hospital 
12 
 
in the event that individuals were transferred.  Even in the 
light most favorable to the Commonwealth, this vague, undefined 
offer cannot be viewed as a readily available panacea to all the 
problems that the Soldiers' Home faced in the earliest days of 
the pandemic and, as such, the calls do not support a finding of 
probable cause that the defendants were wanton or reckless.  In 
the midst of such pandemonium, the action or lack thereof under 
these circumstances is a thin reed on which to build a finding 
of probable cause that the defendants acted wantonly or 
recklessly. 
To the extent that the court relies on the relevant agency 
approvals to move veterans being granted the "same day" it was 
requested and that another nearby hospital had the capacity to 
take veterans, in support of its conclusion, such reliance is 
misplaced.  Ante at    .  The approvals of which the court 
speaks were admittedly granted quickly but only after the 
cavalry had already arrived at the Soldiers' Home in response to 
the administration's involvement.  Nothing in the record 
indicates how long it would have taken to cut through the 
bureaucracy necessary to obtain such approvals were the National 
Guard not already present at the Soldiers' Home.  Reliance on 
speedy approval at that late stage also gives no credence to the 
critical fact that the consolidation only occurred after 
"reaching out to staffing agencies . . . [and] recent retirees" 
13 
 
to alleviate the staffing shortage had failed and an initial 
request for assistance from the National Guard on March 27, 
2020, was denied.  In other words, it is unconvincing to base a 
finding of probable cause on the capacity of another nearby 
hospital and the speed with which approvals were granted after 
the National Guard arrived especially where the record as a 
whole demonstrates that before the consolidation there were 
unsuccessful attempts to alleviate the staffing shortage and an 
initial request for National Guard assistance was both made and 
denied. 
I recognize that the burden on the Commonwealth at this 
stage is not an onerous one, and there is no denying that the 
events that occurred at the Soldiers' Home in March 2020 were a 
tragedy.  However, because I conclude that there was not 
sufficient evidence before the grand jury to support probable 
cause that the defendants acted wantonly or recklessly, the 
indictments lacked probable cause and were therefore properly 
dismissed.  See, e.g., Commonwealth v. Stirlacci, 483 Mass. 775, 
780 (2020).  This conclusion is evident when we properly 
consider the totality of the circumstances within the Soldiers' 
Home created by the avalanche of personnel who called out sick 
or refused to come to work, the practical difficulties created 
when dealing with dementia patients, the denial of an initial 
request for National Guard assistance, and the general 
14 
 
circumstances in the Commonwealth during March 2020.  See, e.g., 
Goldstein, 484 Mass. at 536 (Kafker, J., concurring) ("The 
COVID-19 pandemic has dramatically changed our current reality, 
not only in the Commonwealth, but across the globe, and not 
simply for a month or two"). 
We owe our best to our soldiers who, now in old age and 
frail health, face the twilight of their journey.  Their service 
to our nation and the cause of liberty has passed.  Their 
service, however, entitles them to the opportunity to live out 
their days in comfort and safety.  There can be no doubt that 
what occurred at the Soldiers' Home in March 2020 was a tragedy.  
And in the face of such tragedy, perhaps hurling blame and 
subjecting the defendants to imprisonment might salve our 
conscience.  But criminalizing blame will do nothing to prevent 
further tragedy or help unravel the complex reasons why the 
responses of the Soldiers' Home and so many nursing homes proved 
inadequate in the nascent days of the pandemic.  Since the 
testimony in the grand jury failed to constitute probable cause 
to criminalize such blame, I respectfully dissent.