It was like something out of a B horror movie. Caroline Burns opened her eyes and looked around. The first thing she saw were the operating room lights above her. Doctors were busy — busy on her. Someone noticed that Caroline Burns had opened her eyes, which was disconcerting for everyone involved. Caroline Burns was not under anesthesia in this operating room. Because everyone in that room thought that Caroline Burns was dead. In this room, doctors were harvesting her organs to give to other patients on the organ donor waiting list.

But it turned out that Caroline Burns wasn’t done with them.

This nightmarish tale happened in 2009. But the details of it are only now being discovered since the Syracuse Post-Standard in Syracuse, New York found the details in a report from the U.S. Department of Health and Human Services. That report outlines how Burns came to be in St. Joseph’s Hospital Health Center in the first place, and gives some clues about how such an embarrassing mistake could have been made.

Caroline Burns, it appears, had attempted suicide. She had been found unresponsive and apparently taken many Xanax and Benadryl pills. She was brought in to the hospital, and doctors performed toxicology tests. She was put on a ventilator. After a few days, doctors declared that she had suffered cardiopulmonary arrest and ordered her removed from the ventilator.

However, some nurses had noticed what they believed to be improvement from Burns. When she had first arrived, they noticed that she curled her toes when touched. She moved her mouth and tongue. She was also breathing on her own, even though she was on a respirator.

But after the doctors declared her as having suffered the cardiopulmonary arrest, her family made the decision to remove her from life support and to donate her organs.

And that is where we came in.

The HHS report concluded that, “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.”

Caroline Burns left the hospital. But she again committed suicide in 2011.