Beginning in 2006, Teleflex, the manufacturer of the clips, sent warning letters alerting hospitals that the clips were "contraindicated" -- or unsafe for use -- in laparoscopic kidney donor surgeries. Hospitals received at least three letters, and some received as many as six.
Officials at University Medical Center, where Gotcher had her surgery, said they received the 2006 letters, but at the time they weren't purchasing the clip. Years later, when they did start purchasing the clips, the letter had been forgotten -- it was one of dozens of letters about various devices and other safety issues the hospital gets every year.
Friedman says the letters didn't go far enough to alert doctors not to use them on kidney donors. For example, they didn't mention that kidney donors had actually died when the clips were used on them.
"It's shocking that it doesn't say that even a single donor died. It's meaningless without saying that," Friedman says.
According to documents obtained by Dr. Friedman through the Freedom of Information Act, in 2007 the FDA called these letters "effective" and "adequate to prevent a reoccurrence of the problem" even though only about half the hospitals acknowledged getting the notification, according to a 2007 audit by the FDA.
After Gotcher's death, the FDA issued a safety notification reminding surgeons that the clips are contraindicated for kidney donor surgeries.
"It comes back to me all at once."
In a statement to CNN, the FDA said the clips, when used correctly, can effectively control bleeding. The agency added that while most transplant surgeons heeded the agency's warning, "despite repeated efforts to communicate this important safety information, some transplant surgeons continue to improperly use these clips. While the FDA can warn against the unsafe use of a medical device, doctors are not prohibited from using cleared or approved devices for an unapproved use within their practice of medicine."
Teleflex, the company that makes these clips, said surgeons have safely and successfully used them in millions of surgical procedures, and that the company believes the transplant community is "well aware" of the warning not to use them in kidney donors.
"A contraindication is a clear, well understood and accepted concept in the medical community that says, 'do not use this device for this purpose.'" Teleflex wrote in a statement to CNN.
University Medical Center, where Gotcher died, says it wasn't using the clips when it received the warning letter in 2006, and that its system to track warnings was insufficient to alert the hospital when they later purchased clips. They've since put corrective actions in place by hiring an outside company to track and document warnings and recalls.
The hospital settled a lawsuit filed by Gotcher's family for an unspecified sum.
None of this brings back Florinda Gotcher.
"Every time I go to the cemetery it hits me," her daughter. "It comes back to me all at once."