A veteran died 10 minutes after being baptized in a pool at the Department of Veterans Affairs Medical Center in Dallas, a government watchdog has found.

The VA inspector general said the death was one of several examples of untimely deaths and poor quality of care at the facility from 2011 to 2013.

The unnamed veteran in his 60s checked into the medical center for cancer treatment in 2011, and asked to be placed on “do not resuscitate” status. He requested a full-immersion baptism, a request that was referred to the facility’s chaplain.

The chaplain’s office indicated it could take several days to arrange the baptism. The next day, a staff member and a nurse manager who had training as a minister performed a full-immersion baptism for the patient in the facility’s spinal-cord injury pool without notifying the chaplain’s service.

“Following the baptism, [the patient] returned to his wheelchair,” the report said. “Staff spoke with [the patient] and took photographs with him, and then [he] became unresponsive “less than 5 minutes later.”

The staff did not perform resuscitation or clear the patient’s airway because of the DNR status, and pronounced the patient dead 10 minutes after the baptism.

The facility’s management conducted a review of the incident, and an ethics consultant made several recommendations, including that baptisms “should be thoroughly assessed by all relevant parties,” and that religious activities should remain under the chaplain’s service.

As a result of the case, staff at the facility received more than a year’s worth of “sensitivity to diversity” training.

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