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.
St. Joseph's CEO Kathryn Ruscitto released a statement as a result of the Post-Standard story, saying that the hospital is not discussing the case at the family's request.
"Things are never as simple as one newspaper article might make them seem," she said.
Ruscitto said the hospital had made changes over the past four years and continued to improve.
"St. Joseph's provides compassionate care to more than 2,000 people every day throughout our system," she said. "Anytime something doesn't go right, we take it extremely seriously."
Editor's note: An earlier version of this story incorrectly referred to the patient as Caroline Burns. Her name is Colleen Burns.