Doctors at St. Joseph's Hospital Health Center told the family of Colleen Burns that she was dead following a drug overdose, and the family agreed to remove Burns from life support and move forward with organ donation.
But Burns opened her eyes in the operating room just as she was being prepped for surgery.
The Syracuse Post-Standard obtained state health department records under freedom of information laws and found that the hospital made a series of troubling mistakes.
The report found that after Burns arrived in the emergency room, staff skipped a recommended treatment of activated charcoal to prevent absorption of the drugs. Not enough testing was done to see if she was free of all drugs, and not enough brain scans were performed.
Doctors also ignored a nurse's warnings that Burns was responding to stimuli and breathing on her own. She curled her toes when touched, flared her nostrils, and moved her mouth and tongue, signs her condition was improving.
Twenty minutes after those observations were made, Burns was given the sedative Ativan and prepped for surgery, according to state records.
The state Health Department review found St. Joe's care of Burns unacceptable and the U.S. Department of Health and Human Services (HHS) criticized the hospital for not investigating the cause until prompted by the state.
"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."
Although Burns, 41 at the time, opened her eyes at the last minute, she ultimately committed suicide in 2011. The family never sued, according to her mother, Lucille Kuss. "She was so depressed that it really didn't make any difference to her," Kuss said.
St. Joe's was fined $6,000 last September for its mishandling of the Burns case, along with $16,000 for an unrelated case. The hospital also was ordered to hire a consulting neurologist to teach staff how to accurately diagnose brain death.