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A lawsuit filed against the Children’s Hospital of Philadelphia (CHOP) alleges that a contaminated eye examination that sickened 23 infants in the hospital’s neonatal intensive care unit led to the death of at least one child.

The family of baby Melanie Sanders, who was born weighing just over 1 pound in May 2016, claims that she was diagnosed with an eye condition and transferred to CHOP in July, where she underwent a series of eye examinations.

According to a Philly.com report, 23 infants in the neonatal intensive care unit contracted adenovirus infections after eye exams.

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Melanie Sanders’ family claims in the lawsuit that she began to experience respiratory symptoms in mid-August, and tested positive for adenovirus type 3. The Centers for Disease Control and Prevention (CDC) said adenovirus type 3, 4 and 7 are most commonly associated with acute respiratory disease or conjunctivitis. Patients with weakened immune symptoms or existing respiratory or cardiac disease are at higher risk of developing severe illness from an adenovirus infection.

According to the family, the baby went into chronic respiratory failure and required a drainage tube placed in her chest on four separate occasions. She then developed a bacterial infection on top of the viral illness and died on Sept. 11, 2016.

The hospital acknowledged the outbreak in a medical journal in June 2017, and attributed the illnesses to a lack in equipment cleanliness and a failure by staff to wear gloves.

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“It’s hard to believe that can happen in 2016, but it did,” Shanin Specter, the family’s attorney, told CBS Philadelphia. “It’s shocking that at CHOP they would not be cleaning their instrumentation and they would not have been wearing gloves during an eye examine.”

Lawyers for the hospital contend that survival of babies born prematurely is uncertain for numerous reasons, and that once the outbreak was identified, staff moved quickly to determine the source and warn those at risk.

In addition to the 23 babies, nine adults – six nurses and three parents – were sickened. Of the babies diagnosed, five developed pneumonia and 11 had eye-related symptoms.

Specter filed a second lawsuit on behalf of another family whose child died after becoming infected at the hospital, but he told Philly.com he was investigating what role the virus had played in her death.

The Associated Press contributed to this report.