Court Opinion

ID: 9390249
Source: CourtListenerOpinion
Date Created: 2023-04-27 14:06:23.951597+00
Date Added: 2024-06-11T17:18:32.608622
License: Public Domain

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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

     10The 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.

     11Our 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

     13Our 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).

     14This 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.

     15As 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

     17The 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

     18Of 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

     21Conduct 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.

     22We 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

     23The 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.

     24The 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.