A New York patient awoke on the operating table just as doctors were about to remove her organs for donor transplantation, according to a report from the US Department of Health and Human Services (DHHS).

The report, detailed in the Syracuse Post-Standard , says that doctors believed the patient, 41-year-old Caroline Burns, was deceased before carrying out the operation at St. Joseph’s Hospital Health Center in Syracuse, NY, in 2009

According to the DHSS report , doctors incorrectly diagnosed the patient with anoxic (irreversible) brain damage, classifying her as brain dead.

The report states that Burns was found unresponsive on October 16, 2009, surrounded by bottles of Benadryl (an antihistamine), Xanax (an anti-anxiety drug), Nabumetone (an anti-inflammatory), and Baclofen (a muscle relaxant). Although she was alive, she was hypothermic with a weak pulse.

A toxicology test was carried out shortly after, shows the report, which determined that the patient was suffering from a drug overdose. She was deemed unresponsive and was connected to a ventilator.

The report states that Burns began to have seizures, although the results of head CT scans that were carried out on October 17 and 18 were normal.

According to the DHHS report, EEG scans revealed a “poor prognosis” on October 18. Doctors passed on information to Burns’ family that the brain damage was irreversible and that she had undergone “cardiorespiratory arrest,” which led them to the decision to withdraw the patient from life support and proceed with organ donation.

But nurses reported the next day that the patient showed signs of recovery.

The report states: “Nurse number 1 documented: ‘toes curled when foot stimulated, tachycardic, hypertensive, flaring nostrils, mouthing with lips and moving tongue, breathing above the ventilator.’

The DHHS report continues by stating that the patient was evaluated in response to Nurse number 1’s observations by a resident’ and neurologist, but they “did not indicate appreciation that the neurological condition was improving.”

At midnight on October 20, the report shows the patient was moved to the operating room for donation after cardiac death (DCD). It continues: “Patient A opened her eyes and looked at the lights; pursuit of DCD was subsequently halted.

According to the report, findings from the interviews and document reviews showed the hospital:

“did not undertake an intensive and critical review of the near catastrophic event in this case, did not identify the significant lapses in medical care that resulted in inappropriate pursuits of brain and cardiac death determinations, and did not identify the the inadequate physician evaluations of Patient A (Burns) that occurred when nursing staff questioned possible signs of improving neurological function.”

The DHHS report states that hospital officials did conclude after the events that the drug overdoses that Caroline Burns had come into hospital with might have put her into an unresponsive state – which the doctors could mistakenly have diagnosed as irreversible brain damage.

Previous studies have shown that overdoses of particular drugs could potentially mimic brain death. For example, a study featured in Clinical Toxicology reported two cases of Baclofen intoxication, in which brain death was presented as an explanation for a prolonged coma.

Other research published in the Oxford Journals revealed that the diagnosis of brain death may be difficult when factors such drugs, hypothermia or metabolic disturbances interfere with clinical examinations or tests.

However, the DHHS report on Caroline Burns concludes that “the patient did not meet criteria for withdrawal of care” and that “insufficient time had elapsed and insufficient testing was done to make sure all the drugs were out of the patient’s system before withdrawal of life-sustaining treatment was discussed.”