LEXINGTON, Ky. (WDKY) A Kentucky family’s nightmare is leading to major changes in the nation’s organ transplant system.

Donna Rhorer has spent years caring for her brother, TJ Hoover, but what happened to him in 2021 still haunts her.

Rhorer told affiliate WDKY she doesn’t believe it’s safe to be an organ donor in Kentucky.

In October 2021, Hoover was admitted to Baptist Health’s emergency room after an overdose. He remained unresponsive for two days, and his family agreed to honor his wishes and donate his organs. But just as he was being prepped for surgery, the unthinkable happened.

“He was thrashing around, crying, trying to pull his tube out,” Nyckoletta Martin, who witnessed the moments before the scheduled procedure, told WDKY in October 2024. “He was pushing everybody’s hands away who were trying to prep and drape him for surgery.”

Hoover’s case sparked a federal investigation and multiple congressional hearings. The U.S. Department of Health and Human Services announced it will begin reforming the organ transplant system following the findings.

“They looked at just three months of data from earlier this year and found that it happened 20% of the time when someone was wheeled into the OR to be an organ donor in Kentucky,” said Jennifer Erickson, a senior fellow with the Federation of American Scientists. “And it was stopped because it turns out they were still alive, that they never should have been wheeled in the first place.”

For Rhorer, those numbers are heartbreaking.

“It makes me sad TJ is not a one-off case,” Rhorer added. “But at the same time, it just goes to prove that it is happening and it is a problem.”

Dr. Raymond Lynch, chief of the organ transplant branch with the Health Resources and Services Administration (HRSA), apologized for the failures in care. He outlined plans for sweeping changes at Tuesday’s committee meeting.

“It’s unacceptable and it’s not something that HRSA is going to let stand. This was the impetus for our corrective action plan to make sure that this did not continue in Kentucky and that other OPOs could learn by example,” Lynch explained. “This is HESA’s responsibility. HRSA has this authority delegated by the secretary, and we intend to make sure that the OPTN and its contractors are able to fulfill this role.”

“What we heard from very irate members of Congress was, It’s like watching a bad horror movie,” said Erickson. “So it’s the federal government’s job to fix that because they need to make it safe in Kentucky.”

Now, Hoover is improving, though his recovery remains unpredictable due to the nature of his brain injury.

“Every recovery is different, but I put it in God’s hands,” Rhorer added. “He’s here because God has a bigger plan for him, and his recovery is going to look like what God has for him.”

Network for Hope CEO Barry Massa, the organ procurement organization involved in TJ’s case.

“The July 22 Congressional Committee hearing on our nation’s organ procurement organizations was an important step toward increasing transparency for the millions of people who choose to register to be organ donors across the country. It also offered a valuable opportunity to clarify the role OPOs play and to highlight the life-saving work being done by organizations like Network for Hope.

We hold ourselves to the highest standards and are committed to ongoing improvement as we carry out the sacred responsibility of honoring each individual’s decision to become an organ donor. We remain focused on our mission and dedicated to earning and maintaining the public’s trust in the donation and transplant system,” the statement read.