A patient at a Department of Veterans Affairs (VA) hospital in Queens, New York died last year after being fed a too-large piece of chicken that got stuck in their esophagus, according to a new report from the VA Office of Inspector General. Staff at St. Albans Community Living Center first thought the unidentified patient, who showed signs of a fever, cough, lethargy, and low oxygen levels, had COVID-19, the report says. The patient stopped breathing after being intubated at the Brooklyn VA Medical Center, where a “large piece of chicken was found deep in the patient’s airway.” The facility’s acute care team determined the cause of death to have been “the aspiration of proteinaceous material”—that is, chicken that “looked to be formed with no signs of gastric juices.”

Staff members gave wildly different approximations about the size of the chicken chunk, the OIG report says. Still, while the OIG was unable to determine its exact size, “the piece of chicken was larger than was appropriate to feed the patient.” The OIG criticized the VA facility for lax training standards, improper feeding procedures, inaccurate record keeping, and a failure to inform the patient’s spouse about what exactly had happened.