This is the full CMS report on St. Joseph Hospital's handling of patient Colleen Burns.
Back in time this patients was taken to the operating room for organ recovery according to the donation after circulatory death pathway. However when the patients showed signs of 'waking up' in the anaesthetic bay organ donation was immediately abandoned.
Despite a preliminary internal investigation revealing no concerns, the external investigation undertaken by CMS revealed that there were a number of issues.
As a result a number of recommendations were made plus the hospital was fined. The full report can be accessed by clicking on the banner headline.