Doctors at a central New York hospital nearly harvested organs from a woman in 2009 despite warning signs she wasn't dead, and the hospital has been fined, according to state records.
Colleen Burns, 41, opened her eyes as she was being prepared for surgery by St. Joseph's Hospital Health Center, the Syracuse Post-Standard reported Sunday
. Doctors had told her family she was dead after a drug overdose, and relatives agreed to take her off life support and allow the donation.
Records the newspaper obtained under state freedom of information laws document a series of missteps, including doctors ignoring nurses' observations that Burns was responding to stimuli and trying to breathe on her own. The surgery was called off when she opened her eyes in the operating room.
The North Syracuse mother of three was released from the hospital after two weeks recovering from an overdose of Xanax, Benadryl and a muscle relaxant, but killed herself 16 months later, her mother, Lucille Kuss, told the newspaper.
She said her daughter wasn't upset by the near-miss and it wasn't a cause of her suicide.
"She was so depressed that it really didn't make any difference to her," Kuss said.
The family didn't sue the hospital, despite doctors' failure to explain what happened, she said.
"They were just kind of shocked themselves," she said. "It came as a surprise to them as well."
The state health department fined the hospital $6,000 after finding its care of Burns was unacceptable. And the federal Centers for Medicare and Medicaid Services criticized its failure to investigate.
"The hospital did not undertake an intensive and critical review of the near-catastrophic event in this case," the federal agency said, and did not "identify the inadequate physician evaluations of (Burns) that occurred when nursing staff questioned possible signs of improving neurological function."
The overdose had put Burns in a deep coma, but hospital staff interpreted that as irreversible brain damage without doing enough evaluation, the state health department found.
It said the hospital: skipped a recommended treatment to prevent the drugs the patient took from being absorbed by her stomach and intestines, failed to do enough testing to determine whether she was free of drugs, didn't do enough brain scans and that doctors ignored a nurse's view that Burns was alive and improving.
A day before surgery, Burns reacted to a reflex test performed by a nurse. Outside the operating room, staff reported her nostrils flared, she appeared to be breathing on her own despite being on a respirator, and her lips and tongue moved.
There's no mention in doctors' notes that they were aware she was improving, according to the report.
The organ-harvesting procedure continued until Burns opened her eyes under the operating room lights.
Hospital spokeswoman Kerri Howell said it follows organ donation policies and procedures through the Finger Lakes Donor Recovery Network.
"These policies were followed in this case, which was complicated in terms of care and diagnosis," Howell said. "We've learned from this experience and have modified our policies to include the type of unusual circumstance presented in this case."
The hospital submitted a plan to correct the problems to the state health department, which ordered it to hire a consulting neurologist to teach staff how to diagnose brain death and a consultant to review the hospital's quality assurance program.