(ABC News) -- It was exactly midnight when Caroline Burns eerily opened her eyes and looked at the operating lights above her, shocking doctors who believed she was dead and were about to remove her organs and donate them to patients on the transplant waiting list.
The Syracuse Post-Standard unearthed a report from the U.S. Department of Health and Human Services that chronicled the series of errors that led to the near-organ removal on a living patient at St. Joseph's Hospital Health Center in Syracuse, N.Y., in 2009.
"The patient did not suffer a cardiopulmonary arrest (as documented) and did not have irreversible brain damage," the HHS report concluded. "The patient did not meet criteria for withdrawal of care."
According to the report, doctors had inaccurately diagnosed Burns with irreversible brain damage and ignored nurses who'd noticed signs that Burns was improving: She curled her toes when touched, flared her nostrils and moved her mouth and tongue. She was also breathing on her own even though she was on a respirator.
Burns, who was 41 at the time, was initially found unresponsive and surrounded by empty bottles of Xanax, Benadryl, a muscle relaxant and an anti-inflammatory drug on Oct.16, 2009, according to the report. She was hypothermic and had a weak pulse, but she was alive.
In the St. Josephs emergency room, doctors performed toxicology tests and determined Burns was suffering from a multi-drug overdose, according to the report. She was unresponsive and put on a ventilator.
Poison control specialists recommended using activated charcoal to stop Burns' body from absorbing the drugs, but it never happened, according to the report. Doctors couldn't get the tubes into her body. As a result, the HHS report concluded, it's possible Burns continued to absorb the pills she'd ingested, but doctors never did more toxicology testing to find out.
Read about organ donation in other countries.
Soon, Burns was having seizures, but subsequent head CT scans on Oct. 17 and Oct. 18 appeared normal.
Still, the EEG brain scans indicated "poor prognosis" on Oct. 18, so doctors planned to "wait and see" whether Burns would improve over the next few days, they told HHS investigators in August 2010, according to the report. That same day, however, doctors told the family that Burns' brain damage was irreversible and that she'd undergone "cardiorespiratory arrest."
The family made the decision to take Burns off life support and donate her organs the next day.
Although Burns opened her eyes at the last minute, saving herself from the organ harvest procedure, she committed suicide in 2011. The family never sued, and family members told the Syracuse Post-Standard that Burns was too depressed to be upset about what happened to her at St. Joseph's.
Hospital officials eventually concluded it's possible that the drugs resulted in the unresponsive state doctors mistook for irreversible brain damage, according to the HHS document.
Drug overdoses can mimic brain death, but American Academy of Neurology guidelines should keep doctors from failing to recognize the difference, said Dr. Eelco Wijdicks, a member of the American Academy of Neurology who was the senior author on its list of guidelines for determining brain death. Wijdicks did not treat Burns and said he could not comment on her case.
The hospital determined that it had followed protocols, according to its reviews sent to the state Department of Health. HHS disagreed, and said the investigation of Burns' near death was inadequate. St. Joseph's didn't conduct a review until the state Department of Health asked it to nearly five months after the near-organ removal.
"It consisted of a one-page document that was labeled 'File Notes:… (Patient A),'" HHS officials wrote of the St. Joseph's review. "The document contained a reference to 'perception differences' but lacked any analysis or resolution of the issue."
Still, the nightmare is "exceedingly rare," Wijdicks said. The American Academy of Neurology guidelines consist of about 25 tests for doctors to perform to be absolutely sure a patient won't get better, he said.
"When that is done, there should be no errors made," Wijdicks said.
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