RICHMOND, Va. (AP) — The hospital that initially treated a man who later died while being admitted to a Virginia psychiatric hospital failed to meet care standards while he was in a mental health crisis, a state investigation found.

The state Department of Health led the investigation of Parham Doctors’ Hospital, where Irvo Otieno was briefly held, the Richmond Times-Dispatch reported.

Otieno, a 28-year-old Black man, died in March after being pressed to the floor of Central State Hospital for about 11 minutes by a group of Henrico County sheriff’s deputies and hospital employees. Surveillance video that captured how Otieno was treated at the facility where he was set to receive care sparked outrage across the U.S. and calls for mental health and policing reforms.

Parham staff were “not in compliance” with health guidelines for hospitals that treat mental health crisis patients, two inspectors said. The report also said a psychiatrist did not examine Otieno during his six hours in the emergency department.

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“The facility staff failed to provide stabilizing treatment for one of twenty-five patients after the patient presented to the emergency department with an emergency medical condition,” the report said.

Parham Doctors’ Hospital is working with the Department of Health and has submitted an action plan requested by the agency, said Pryor Green, a spokesperson for Hospital Corporations of America, which owns the facility.

“We strive to always provide compassionate, high-quality care to all patients,” Green said.

Otieno was experiencing mental distress at the time of his initial encounter with law enforcement in suburban Richmond in early March, days before he was taken to the state hospital, his family has said.

He was first taken into police custody March 3, when he was transported to the local hospital for mental health treatment under an emergency custody order.

Police have said that while at the local hospital, he “became physically assaultive toward officers,” at which point they arrested him and took him to a local jail, a transfer Otieno’s family has said should never have happened.

Mark Krudys, an attorney for the Otieno family, described his treatment at Parham as “non-care.”

“The very reason that lrvo was brought to the hospital was to stabilize his condition, but that effort was effectively abandoned,” Krudys said Tuesday afternoon in a statement.

Otieno’s death has led to legal charges and a wrongful death settlement in addition to a pledge from the governor to seek reforms for mental health care.

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