A patient was confirmed dead at WellSpan York Hospital’s emergency department after being left unattended for more than an hour on Aug. 16, WDAF-TV reported.

According to the report by the Department of Health, the patient arrived by ambulance and was brought into the Emergency Department at 9:59 a.m. with nausea and dizziness. Staff members screened and triaged him upon his arrival. 

EMS personnel spoke with the pivot nurse but the patient wasn’t taken to the pivot nurse’s desk, and the nurse was not seen speaking or examining the patient, the report read.

Emergency staff were seen on video walking past a patient in a wheelchair about 12 times, York Daily Record reported. However, after three unsuccessful attempts of identifying the patient in the ER between 10:25 a.m. and 12:05 p.m they marked him as “left without being seen.” Staff members then found him unresponsive in a wheelchair around 12:25 p.m, according to the report. After resuscitation efforts were unsuccessful, the patient was pronounced dead at 1:31 p.m.

WellSpan York Hospital’s Vice President of Medical Affairs Allan Birenberg M.D., wrote in a statement:

“This was a rare event that occurred in our emergency department at WellSpan York Hospital. We take seriously our commitment to provide safe, timely, compassionate care to everyone who walks through our doors. In this instance, we did not meet the high standards to which we hold ourselves every day.”

“We have reviewed what happened and taken immediate steps to correct any issues which contributed to this event.  We are committed to doing our very best, every day, for every patient, and we will continue to work hard to make sure that happens. To that end, we continue to redesign our processes to ensure access to high-quality, timely care for all,” the statement continued.

After a special monitoring visits were made by the Department of Health on Aug. 22, 23, and 30, WellSpan York Hospital was determined to be out of compliance with Pennsylvania’s Medical Care Availability and Reduction of Error Act.

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