An internal review of a patient death at the Buffalo V-A Medical center found an embarrassing series of medical errors.
The report from the Veterans Affairs Office of Inspector General was released on Monday and detail the mistakes made.
Among them, that two nurses in charge of monitoring patient vital signs failed to notice the patients deteriorating heart beat rhythm.
Another nurse later found the patient without a pulse, but did not "call a code" or signal for emergency help.
That same nurse and a respiratory therapist declared the patient dead, even though they were not authorized to do so. That's a duty given to doctors.
And later, hospital administrators failed to remove the medical staff involved from performing patient care while an internal review was conducted.
A spokeswoman for the facility offered 2 On Your Side a statement which reads in part, "VAWNYHS wants to assure veterans and their family members that our facility is a safe environment and our employees remain dedicated to providing quality health care."
But Senator Kristen Gillibrand says the report proves to her there are lapse in the quality of car at the medical center.