A report by the Delaware Division of Professional Regulation states that a state prison inmate serving six months in jail for a probation violation died after what it calls “incompetent” actions by a contracted nurse.

The report says the nurse took nearly 20 minutes to call 9-1-1 after the inmate became unresponsive at the Sussex Community Corrections Center. By the time authorities arrived, the inmate had no pulse.

The now-ex-Connections Community Support Programs nurse didn’t comply with “legal and acceptable standards of nursing” prior to James Daniels’ 2016 death, according to the state report.

The nurse’s attorney has said the delayed call was due to prison policy requiring approval before calling 9-1-1. The report calls the policy problematic, and it has been changed following Daniels’ death.