1 00:00:03,252 --> 00:00:05,812 Let's start on a Friday morning with this sad news, 2 00:00:05,812 --> 00:00:07,332 the death of Joan Rivers. 3 00:00:08,452 --> 00:00:11,812 NARRATOR: Joan Rivers was the undisputed queen of stand-up comedy. 4 00:00:12,812 --> 00:00:16,372 I found this dress on the chair next to my husband's bed. 5 00:00:16,372 --> 00:00:17,932 -Isn't that lucky? -(AUDIENCE LAUGHING) 6 00:00:17,932 --> 00:00:22,572 NARRATOR: Renowned for her unique brand of fast talking and sexually charged wit, 7 00:00:22,572 --> 00:00:26,852 she was a fixture on stage and television for nearly five decades. 8 00:00:26,852 --> 00:00:29,212 I was the one who told David Beckham, 9 00:00:29,212 --> 00:00:33,252 -"Make your life easier, hire a personal secretary." -(AUDIENCE LAUGHING) 10 00:00:33,252 --> 00:00:39,292 Joan spawned so many women that are in comedy today. She led the way. 11 00:00:39,292 --> 00:00:42,412 Without her, they couldn't talk about the stuff they talk about. 12 00:00:42,412 --> 00:00:44,732 Joan made it possible. 13 00:00:44,732 --> 00:00:48,772 NARRATOR: Even in her 80s Joan was connecting with a much younger audience, 14 00:00:48,772 --> 00:00:50,812 with her show Fashion Police. 15 00:00:52,092 --> 00:00:56,532 But at 1:17pm on 4 September 2014, 16 00:00:56,532 --> 00:00:59,292 at New York's Mount Sinai Hospital 17 00:00:59,292 --> 00:01:03,692 following an earlier simple exploratory examination of her throat, 18 00:01:03,692 --> 00:01:05,932 Joan Rivers was pronounced dead. 19 00:01:06,972 --> 00:01:10,012 MALE NEWS ANCHOR: The 81-year-old died after going into cardiac arrest 20 00:01:10,012 --> 00:01:11,652 and losing consciousness. 21 00:01:12,772 --> 00:01:17,412 It was a seemingly routine procedure that was to go tragically wrong. 22 00:01:18,772 --> 00:01:19,972 The challenge for me 23 00:01:19,972 --> 00:01:23,132 is to find out just how and why this happened. 24 00:01:32,012 --> 00:01:36,052 NARRATOR: Dr Jason Payne-James is an internationally recognised specialist 25 00:01:36,052 --> 00:01:38,692 in forensic and legal medicine, 26 00:01:38,692 --> 00:01:40,972 called on by the National Crime Agency, 27 00:01:40,972 --> 00:01:45,092 the Metropolitan Police, and government task forces in the US and the UK. 28 00:01:48,212 --> 00:01:51,532 He provided evidence in the Soham murders and Baby P cases. 29 00:01:54,012 --> 00:01:56,732 These are the medical papers related to Joan Rivers' death 30 00:01:56,732 --> 00:01:59,532 and together with other information I have gathered, 31 00:01:59,532 --> 00:02:03,092 they will provide clues as to how she lived her life. 32 00:02:03,092 --> 00:02:06,972 And ultimately to pinpoint the reason for her untimely death. 33 00:02:16,452 --> 00:02:18,532 NARRATOR: Times Square, New York. 34 00:02:18,532 --> 00:02:20,372 Eight days before her death. 35 00:02:24,012 --> 00:02:26,692 Joan is on stage at the Laurie Beechman Theatre, 36 00:02:26,692 --> 00:02:28,532 one of her favourite comedy venues. 37 00:02:28,532 --> 00:02:30,852 (AUDIENCE CHEERING) 38 00:02:30,852 --> 00:02:33,732 At 81, Joan Rivers is busier than ever. 39 00:02:34,732 --> 00:02:36,212 I love you too! 40 00:02:36,212 --> 00:02:40,572 Her hectic work schedule means flying from LA to New York several times a week. 41 00:02:41,812 --> 00:02:47,252 Joan was always the most ambitious, driven woman I've known. 42 00:02:48,532 --> 00:02:51,212 Throughout her career, it was work, work, work. 43 00:02:52,252 --> 00:02:54,412 Work and Melissa. 44 00:02:54,412 --> 00:02:55,772 NARRATOR: Her daughter, Melissa, and Joan 45 00:02:55,772 --> 00:02:58,812 have worked together for years in the entertainment industry. 46 00:02:58,812 --> 00:03:00,652 Sometimes even as co-presenters. 47 00:03:01,772 --> 00:03:03,212 (INDISTINCT TALKING) 48 00:03:03,212 --> 00:03:04,892 8:40pm 49 00:03:06,172 --> 00:03:09,172 On stage, Joan is as vibrant and acerbic as ever. 50 00:03:09,172 --> 00:03:10,212 (AUDIENCE LAUGHING) 51 00:03:10,212 --> 00:03:11,412 (INAUDIBLE) 52 00:03:14,372 --> 00:03:17,732 Lifelong Joan fan, Shade Rupe, was in the audience that night. 53 00:03:19,212 --> 00:03:21,372 RUPE: I was so happy to get to go see her again. 54 00:03:21,372 --> 00:03:23,892 It was a birthday present to myself 55 00:03:23,892 --> 00:03:27,452 and I am so glad that I made that choice. 56 00:03:28,492 --> 00:03:32,052 NARRATOR: During the show Joan jokes about everything, even her own death. 57 00:03:33,732 --> 00:03:36,012 And at one point she starts telling this joke. 58 00:03:36,012 --> 00:03:37,492 RIVERS: It's no joke getting old. 59 00:03:37,492 --> 00:03:40,052 And she goes, "You know, I'm 81!" 60 00:03:40,052 --> 00:03:41,732 RIVERS: I could die tomorrow. 61 00:03:41,732 --> 00:03:46,292 I could just go over, I could go over right now, right just... (CHOKING) 62 00:03:48,172 --> 00:03:49,812 RUPE: But I was really shocked. 63 00:03:49,812 --> 00:03:53,332 That was like how can this woman be 81 years old. 64 00:03:53,332 --> 00:03:54,412 (AUDIENCE CHEERING) 65 00:03:54,412 --> 00:03:59,252 She was more like a 40-year-old running back and forth on that stage. 66 00:03:59,252 --> 00:04:05,212 I have never seen so much life in a human being as I had that evening. 67 00:04:05,212 --> 00:04:07,332 (AUDIENCE APPLAUSE) 68 00:04:10,612 --> 00:04:16,612 Accidentally running into her afterwards, she was so kind and cool. 69 00:04:16,612 --> 00:04:18,372 There was no rushing. 70 00:04:18,372 --> 00:04:21,492 She was, like, so happy to say hello to a fan. 71 00:04:22,972 --> 00:04:26,092 NARRATOR: He asked her to pose for a photograph with him. 72 00:04:26,092 --> 00:04:28,332 It was to be the last photo that would be taken of Joan 73 00:04:28,332 --> 00:04:29,532 as we remember her. 74 00:04:34,132 --> 00:04:38,772 PAYNE-JAMES: I can see from the medical papers that Joan's daughter, Melissa Rivers, 75 00:04:38,772 --> 00:04:42,892 objected to autopsy on the grounds of Joan's religious faith. 76 00:04:42,892 --> 00:04:44,732 She was Jewish. 77 00:04:44,732 --> 00:04:49,212 But the medical examiner did complete a full external examination. 78 00:04:50,532 --> 00:04:53,612 The first things I noticed from the medical examiner's report are that 79 00:04:53,612 --> 00:05:00,772 Joan was 5'2" tall, she had dyed blonde hair with black roots, 80 00:05:00,772 --> 00:05:05,532 she had thick make-up on her face and brown eye shadow. 81 00:05:05,532 --> 00:05:08,812 Of course this is the look we all associate with Joan Rivers. 82 00:05:12,212 --> 00:05:17,652 NARRATOR: In the 1960s, after a decade of hawking her act around the clubs of New York, 83 00:05:17,652 --> 00:05:21,412 Joan won herself a slot on The Tonight Show Starring Johnny Carson. 84 00:05:21,412 --> 00:05:23,532 One of America's most popular shows. 85 00:05:25,612 --> 00:05:29,732 DENIS MARKELL: When Joan Rivers was on Johnny Carson, she was an immediate hit. 86 00:05:29,732 --> 00:05:31,412 Because that it was something new. 87 00:05:31,412 --> 00:05:33,252 And something that people hadn't really seen before. 88 00:05:34,532 --> 00:05:36,852 NARRATOR: Joan's popularity was based on her willingness 89 00:05:36,852 --> 00:05:40,772 to joke about subjects not widely spoken about on network TV. 90 00:05:42,772 --> 00:05:45,692 Joan became a pioneer for female comedians. 91 00:05:45,692 --> 00:05:47,532 Forging a 50-year career 92 00:05:47,532 --> 00:05:50,412 in the previously male-dominated industry of stand-up. 93 00:05:51,692 --> 00:05:56,652 I think that Joan will always be regarded as the originator 94 00:05:56,652 --> 00:05:58,372 of the type of material she did. 95 00:05:58,372 --> 00:06:03,052 She spawned so many women that are in comedy today. 96 00:06:12,172 --> 00:06:14,532 NARRATOR: Joan is enjoying dinner with Jay Redack, 97 00:06:14,532 --> 00:06:17,692 her close friend and writing partner for the past 40 years. 98 00:06:19,412 --> 00:06:22,532 REDACK: That night she was typical Joan. 99 00:06:22,532 --> 00:06:26,532 Pleased with everything, pleased with the way things were going with her career. 100 00:06:27,532 --> 00:06:31,972 She was up and happy. Didn't seem to have a concern in the world. 101 00:06:34,132 --> 00:06:37,412 I have a memory of talking about our age together. 102 00:06:38,372 --> 00:06:40,372 And I'd say, "Gee, if I go first, 103 00:06:40,372 --> 00:06:44,412 "I collect art, and I think I'll leave you a beautiful painting. 104 00:06:44,412 --> 00:06:46,332 "What will you leave me?" 105 00:06:46,332 --> 00:06:49,132 And I think she said, "Melissa and some of my shoes." 106 00:06:50,572 --> 00:06:52,692 NARRATOR: But something's playing on Joan's mind. 107 00:06:53,972 --> 00:06:55,132 REDACK: Joan did mention 108 00:06:55,132 --> 00:06:57,852 that she was going to have some type of a procedure in the morning. 109 00:06:57,852 --> 00:07:00,692 She said, "My voice has been a little bit raspy." 110 00:07:00,692 --> 00:07:02,332 Little throat thing, it's nothing. 111 00:07:02,332 --> 00:07:05,932 She showed absolutely no worry or concern 112 00:07:05,932 --> 00:07:08,892 about what was going to be done the next day at all. 113 00:07:13,332 --> 00:07:17,012 NARRATOR: Joan's medical history suggests she had little to worry about. 114 00:07:17,012 --> 00:07:21,452 She was a non-smoker and only admitted to the occasional glass of wine. 115 00:07:23,252 --> 00:07:27,252 She took large amounts of vitamins and minerals to supplement her diet. 116 00:07:28,772 --> 00:07:32,652 So overall, despite her age, she's in pretty good physical shape. 117 00:07:33,892 --> 00:07:35,932 NARRATOR: But Dr Payne-James has identified 118 00:07:35,932 --> 00:07:38,452 a possible warning sign in her medical notes. 119 00:07:40,252 --> 00:07:45,772 I can see that Joan is taking a daily dose of the drug bisoprolol fumarate. 120 00:07:46,972 --> 00:07:49,892 This is a beta blocker used to treat high blood pressure. 121 00:07:50,892 --> 00:07:54,052 This is significant because at operation, 122 00:07:54,052 --> 00:07:58,212 I would expect her doctors to be keeping a close eye on her blood pressure. 123 00:07:58,212 --> 00:08:02,052 Because if it goes too high or too low there is a risk of stroke or collapse. 124 00:08:09,520 --> 00:08:11,520 NARRATOR: New York's Upper East Side. 125 00:08:12,560 --> 00:08:16,720 Seven days before her death, Rivers arrives at Yorkville Endoscopy 126 00:08:16,720 --> 00:08:20,120 with her personal physician and friend Dr Gwen Korovin 127 00:08:20,120 --> 00:08:22,240 for what should have been a routine examination. 128 00:08:25,240 --> 00:08:27,800 But Joan wasn't unduly worried. 129 00:08:27,800 --> 00:08:31,920 She had suffered from throat problems before but had always made light of them. 130 00:08:31,920 --> 00:08:34,360 -BUTTERWORTH: Morning, Joan. How are you? -Good morning. 131 00:08:34,360 --> 00:08:35,480 (STRAINING) No voice. 132 00:08:35,480 --> 00:08:37,920 BUTTERWORTH: No voice! Are you kidding me? 133 00:08:37,920 --> 00:08:41,800 No voice. And we're doing Fashion Police tomorrow night, 134 00:08:41,800 --> 00:08:44,360 so I've had a cider. 135 00:08:45,520 --> 00:08:48,000 -Do you want to see the sign for orgasm? -Sure. 136 00:08:48,000 --> 00:08:50,560 -Okay. -(LAUGHING) 137 00:08:50,560 --> 00:08:51,800 (CROWD LAUGHING) 138 00:08:51,800 --> 00:08:54,000 -Do you want to see faking orgasm? -Sure. 139 00:08:54,000 --> 00:08:57,040 (CROWD LAUGHING) 140 00:08:59,120 --> 00:09:01,360 NARRATOR: When journalist Benjamin Butterworth spoke with Joan 141 00:09:01,360 --> 00:09:05,040 a few days before she checked into the clinic, she could barely speak. 142 00:09:07,080 --> 00:09:09,000 She was coughing a lot, she was hoarse, 143 00:09:09,000 --> 00:09:13,840 she was croaky and it was evident that something wasn't right. 144 00:09:13,840 --> 00:09:17,960 NARRATOR: Joan's voice was her life. Without it she couldn't work. 145 00:09:17,960 --> 00:09:21,600 And even at the age of 81, work meant everything to Joan. 146 00:09:22,960 --> 00:09:26,400 Joan was always very ambitious and very driven. 147 00:09:27,400 --> 00:09:30,920 If she didn't have a booking the next weekend or the next week, 148 00:09:30,920 --> 00:09:33,720 she thought she was in trouble throughout her career. 149 00:09:34,720 --> 00:09:38,920 Through the highs, lows, and the big success she still... "I have to work." 150 00:09:38,920 --> 00:09:41,240 "If I'm not working, something's wrong." 151 00:09:43,040 --> 00:09:45,400 NARRATOR: Joan was always career-driven. 152 00:09:45,400 --> 00:09:49,360 But a devastating personal tragedy 27 years earlier 153 00:09:49,360 --> 00:09:51,200 had made her even more work-focused. 154 00:09:53,600 --> 00:09:57,600 In 1986, she was given her own late-night talk show by Fox. 155 00:09:58,720 --> 00:10:00,560 Her husband, Edgar, was the producer. 156 00:10:01,640 --> 00:10:05,760 At first it was a dream come true, but things soon started to unravel. 157 00:10:06,880 --> 00:10:09,920 This was something she was going to pour her energies into, 158 00:10:09,920 --> 00:10:13,560 and she was working with her husband. 159 00:10:13,560 --> 00:10:17,160 And, for whatever reason, there was friction with Fox. 160 00:10:17,160 --> 00:10:20,280 And ultimately they took her off the air. 161 00:10:21,280 --> 00:10:23,000 NARRATOR: Joan's husband, Edgar, blamed himself 162 00:10:23,000 --> 00:10:24,640 for the loss of the show. 163 00:10:25,840 --> 00:10:31,200 On August 14, 1987, whilst suffering from clinical depression, 164 00:10:31,200 --> 00:10:35,120 he took a fatal overdose of prescription pills in a hotel room. 165 00:10:40,360 --> 00:10:42,280 Joan is at home with her daughter, Melissa. 166 00:10:43,280 --> 00:10:45,680 They've been handed two envelopes from her husband, Edgar. 167 00:10:46,800 --> 00:10:49,280 They contained details of the family finances 168 00:10:49,280 --> 00:10:52,320 and cassette tapes, containing personal messages. 169 00:10:52,320 --> 00:10:53,560 (SOBBING) 170 00:10:53,560 --> 00:10:56,160 Effectively Edgar's suicide note. 171 00:11:00,120 --> 00:11:02,000 (CRYING) 172 00:11:06,680 --> 00:11:09,800 Joan and her teenage daughter, Melissa, were devastated. 173 00:11:10,960 --> 00:11:14,600 BUTTERWORTH: Joan had lost her show, she'd lost her career, she'd lost her husband. 174 00:11:15,640 --> 00:11:17,880 All in a close succession. 175 00:11:17,880 --> 00:11:22,160 And I asked her on the phone what she did in reaction to that. 176 00:11:22,160 --> 00:11:25,040 And she told me, "I was at home. 177 00:11:25,040 --> 00:11:28,880 "I was sat in a chair and I had a gun" on her lap. 178 00:11:28,880 --> 00:11:32,200 She had her hand on the gun and she was going to shoot herself. 179 00:11:33,760 --> 00:11:37,520 NARRATOR: She was only 54 years old, but Joan had hit rock bottom. 180 00:11:40,760 --> 00:11:42,480 What a horrible tragedy for anyone, 181 00:11:42,480 --> 00:11:45,640 but to have these two things happen at the same time 182 00:11:45,640 --> 00:11:50,040 meant that Joan then, as she herself would say, was dead in the business. 183 00:11:53,080 --> 00:11:57,320 She could have at that point, I think she had the money, simply retired. 184 00:11:58,360 --> 00:12:00,560 Done something else. 185 00:12:00,560 --> 00:12:02,520 That wasn't Joan. As she said, "This is my life". 186 00:12:04,480 --> 00:12:06,600 Working on stage, working in front of a camera... 187 00:12:08,240 --> 00:12:10,880 NARRATOR: Joan's response was to work harder than ever. 188 00:12:10,880 --> 00:12:14,360 To remain in the public eye through her stand-up and TV cameos. 189 00:12:18,160 --> 00:12:22,040 That work addiction would have helped her avoid, 190 00:12:22,040 --> 00:12:25,720 I think, the deep pain that she may have been feeling at that time. 191 00:12:27,000 --> 00:12:31,920 I think, also, it masks a great deal of emotional sensitivity 192 00:12:31,920 --> 00:12:34,440 that they are staying away from. 193 00:12:34,440 --> 00:12:36,840 And so all these behaviours 194 00:12:36,840 --> 00:12:39,680 act as a distraction from what's really going on. 195 00:12:39,680 --> 00:12:41,560 That inner turmoil. 196 00:12:43,080 --> 00:12:46,560 NARRATOR: Over the next 10 years, she steadily rebuilt her career. 197 00:12:46,560 --> 00:12:50,680 With an Emmy-award-winning daytime talk show and a hit Broadway play. 198 00:12:52,640 --> 00:12:55,600 She built up a jewellery business and launched her own perfume. 199 00:12:57,120 --> 00:13:00,440 Then in 2010, she was reborn to a new generation 200 00:13:00,440 --> 00:13:02,880 with her bitchy hit format, Fashion Police. 201 00:13:05,120 --> 00:13:09,080 Joan was always the strongest woman I have ever known. 202 00:13:09,080 --> 00:13:10,880 The drive was amazing. 203 00:13:10,880 --> 00:13:14,160 She would fly back and forth in the United States. 204 00:13:14,160 --> 00:13:17,440 She'd fly to Europe constantly. 205 00:13:17,440 --> 00:13:21,200 Her schedule was hectic and yet she never complained. 206 00:13:21,200 --> 00:13:23,240 It seemed to energise her. 207 00:13:23,240 --> 00:13:26,320 The more she would work, the happier she seemed to be. 208 00:13:36,110 --> 00:13:38,910 NARRATOR: Joan signs the papers consenting to a routine procedure 209 00:13:38,910 --> 00:13:40,590 called an endoscopy. 210 00:13:42,870 --> 00:13:46,630 In an endoscopy, a tiny camera is passed down the throat 211 00:13:46,630 --> 00:13:49,550 so doctors can see their patient's oesophagus and stomach. 212 00:13:51,470 --> 00:13:54,950 PAYNE-JAMES: An endoscopy is generally considered a pretty low-risk procedure 213 00:13:54,950 --> 00:13:57,030 with very few complications. 214 00:13:58,070 --> 00:13:59,310 So in a specialist unit 215 00:13:59,310 --> 00:14:02,310 like Yorkville Endoscopy where the gastroenterologists 216 00:14:02,310 --> 00:14:04,830 were doing over a thousand procedures a month, 217 00:14:04,830 --> 00:14:07,470 there's no reason to expect anything would go wrong. 218 00:14:08,670 --> 00:14:12,270 NARRATOR: The endoscopy will reveal whether acid from Joan's stomach 219 00:14:12,270 --> 00:14:15,950 has moved up the oesophagus and damaged her vocal cords. 220 00:14:15,950 --> 00:14:17,830 This may be the source of her hoarseness. 221 00:14:22,910 --> 00:14:24,950 A nurse checks Joan's vital signs. 222 00:14:27,790 --> 00:14:29,270 (INDISTINCT TALKING) 223 00:14:29,270 --> 00:14:30,950 I can see from the medical records 224 00:14:30,950 --> 00:14:33,910 that as she's about to be transferred to the procedure room, 225 00:14:33,910 --> 00:14:38,230 her blood pressure is 118 over 80, pulse rate 62, 226 00:14:38,230 --> 00:14:42,870 respiratory rate 16 and her oxygen saturation is 100%. 227 00:14:43,990 --> 00:14:46,950 So there's no reason to suspect there may be problems ahead. 228 00:14:50,230 --> 00:14:53,070 NARRATOR: Joan is transferred to the procedure room. 229 00:14:53,070 --> 00:14:56,310 With her is her personal physician, Dr Gwen Korovin, 230 00:14:56,310 --> 00:14:58,550 an ear, nose, and throat specialist. 231 00:14:58,550 --> 00:15:00,510 (MONITORS BEEPING) 232 00:15:00,510 --> 00:15:02,630 (INDISTINCT DISCUSSIONS) 233 00:15:02,630 --> 00:15:05,070 Dr Korovin has referred Joan to the clinic. 234 00:15:06,830 --> 00:15:10,190 However gastroenterologist Dr Lawrence Cohen, 235 00:15:10,190 --> 00:15:13,350 the clinic's medical director, will perform the procedure. 236 00:15:15,670 --> 00:15:17,870 You got me on my best side? 237 00:15:17,870 --> 00:15:21,350 NARRATOR: What happened in the next 47 minutes is disputed. 238 00:15:21,350 --> 00:15:23,390 And is known only to the people that were in the room. 239 00:15:24,430 --> 00:15:26,110 Their accounts differ greatly. 240 00:15:28,750 --> 00:15:31,430 Joan is given propofol, an anaesthetic. 241 00:15:31,430 --> 00:15:35,350 But in a sedative dose that will put her in a semi-conscious state. 242 00:15:35,350 --> 00:15:37,430 Like all anaesthetics, propofol carries a risk. 243 00:15:39,350 --> 00:15:41,310 Propofol affects brain activity 244 00:15:41,310 --> 00:15:43,950 and can cause the heart to beat abnormally. 245 00:15:43,950 --> 00:15:46,310 This can cause reduced blood pressure, 246 00:15:46,310 --> 00:15:48,710 decreasing the amount of oxygen going round the body. 247 00:15:49,710 --> 00:15:52,350 NARRATOR: Within minutes, the propofol takes effect 248 00:15:52,350 --> 00:15:56,550 and Joan is positioned ready for Dr Cohen to perform the endoscopy. 249 00:15:56,550 --> 00:16:00,190 But at 9:09am, the anaesthetist later told investigators, 250 00:16:00,190 --> 00:16:02,950 there was apparently a change of plan. 251 00:16:02,950 --> 00:16:05,790 PAYNE-JAMES: According to anaesthetist, Dr Renee Bankulla, 252 00:16:05,790 --> 00:16:12,270 instead of Dr Cohen proceeding with the scheduled upper gastrointestinal endoscopy, 253 00:16:12,270 --> 00:16:16,710 Dr Gwen Korovin started a trans-nasal laryngoscopy. 254 00:16:18,110 --> 00:16:21,190 NARRATOR: If true, it's a significant breach of protocol. 255 00:16:22,470 --> 00:16:25,550 Joan hasn't given written consent to this new procedure. 256 00:16:25,550 --> 00:16:27,110 It hasn't been planned for, 257 00:16:27,110 --> 00:16:30,990 and Dr Korovin is not authorised to perform any procedures at the clinic. 258 00:16:35,230 --> 00:16:36,470 In legal papers, 259 00:16:36,470 --> 00:16:40,390 Dr Korovin has formally denied the unscheduled procedure occurred, 260 00:16:40,390 --> 00:16:43,950 but Dr Cohen told the medical examiner it did happen. 261 00:16:43,950 --> 00:16:46,270 It's recorded in the clinic's medical notes. 262 00:16:46,270 --> 00:16:49,150 And Mariella Sabillon, the endoscopy technician, 263 00:16:49,150 --> 00:16:52,790 also told investigators a laryngoscopy is performed. 264 00:16:56,670 --> 00:17:00,990 A laryngoscopy might give a better view of what was causing Joan's raspy throat. 265 00:17:05,470 --> 00:17:10,710 A trans-nasal laryngoscopy is a procedure whereby a small flexible telescope 266 00:17:10,710 --> 00:17:14,990 is passed backwards through the nose to directly view the larynx or voice box. 267 00:17:16,830 --> 00:17:21,190 The vocal cords can be directly viewed and any abnormality assessed. 268 00:17:22,550 --> 00:17:25,190 NARRATOR: Dr Cohen later tells the medical examiner 269 00:17:25,190 --> 00:17:28,750 Dr Korovin could not properly see Joan's vocal cords because of mucus. 270 00:17:29,750 --> 00:17:33,510 Just minutes after Dr Korovin allegedly begins the laryngoscopy, 271 00:17:33,510 --> 00:17:37,630 Joan's vital signs, measurements of the body's basic functions, deteriorate. 272 00:17:39,310 --> 00:17:42,950 I know from the clinical medical records that at 9:12, 273 00:17:42,950 --> 00:17:47,950 her oxygen saturation levels are recorded as 92%. 274 00:17:47,950 --> 00:17:52,390 That's dropped from 100% at 8:44, about half an hour earlier. 275 00:17:54,350 --> 00:17:58,110 NARRATOR: Anything less than 95% is a cause for concern. 276 00:17:58,110 --> 00:18:01,670 So Joan is given more oxygen to raise her saturation levels. 277 00:18:04,630 --> 00:18:06,550 Joan's oxygen level improves. 278 00:18:14,910 --> 00:18:17,110 Now the scheduled endoscopy begins. 279 00:18:20,550 --> 00:18:24,750 Dr Cohen starts the procedure by inserting his scope into Joan's oesophagus. 280 00:18:30,590 --> 00:18:32,430 But the anaesthetist now notices 281 00:18:32,430 --> 00:18:35,910 Joan's oxygen saturation levels are still low 282 00:18:35,910 --> 00:18:39,990 and requests the endoscope is withdrawn to free up Joan's airways. 283 00:18:42,270 --> 00:18:48,030 PAYNE-JAMES: At 9:16, the blood pressure has dropped to 92 over 54, 284 00:18:48,030 --> 00:18:53,670 the pulse rate has dropped to 56 and her oxygen saturation levels remain low. 285 00:18:56,030 --> 00:18:57,830 The reason that the anaesthetist has intervened 286 00:18:57,830 --> 00:18:59,630 is that there's a very real risk 287 00:18:59,630 --> 00:19:02,190 that Joan may suffer a respiratory arrest, 288 00:19:02,190 --> 00:19:04,910 circulatory collapse, and cardiac arrest. 289 00:19:05,950 --> 00:19:08,190 This is a very serious situation. 290 00:19:08,190 --> 00:19:11,310 Because the outcome without intervention 291 00:19:11,310 --> 00:19:12,550 may be death. 292 00:19:16,550 --> 00:19:18,510 NARRATOR: Every time someone goes into surgery, 293 00:19:18,510 --> 00:19:21,310 there is a risk that something might go wrong. 294 00:19:21,310 --> 00:19:24,390 But this is a risk that Joan has taken many times before. 295 00:19:26,310 --> 00:19:27,710 Over the last 50 years, 296 00:19:27,710 --> 00:19:31,550 she's been in and out of the operating theatre many, many times. 297 00:19:31,550 --> 00:19:33,110 But not because of illness. 298 00:19:34,790 --> 00:19:38,030 Famously, Joan Rivers loved plastic surgery. 299 00:19:38,030 --> 00:19:41,270 Her obsession with her body image stretched back to childhood. 300 00:19:44,630 --> 00:19:46,190 I asked her about her plastic surgery 301 00:19:46,190 --> 00:19:48,150 because my God, she'd had so much of it, 302 00:19:48,150 --> 00:19:50,990 and she said, "Look, when you're the fat, ugly kid, 303 00:19:50,990 --> 00:19:54,110 "you need to have the plastic surgery as an adult to overcome that." 304 00:19:56,470 --> 00:20:00,910 I wonder about the internal picture that Joan carried in her own head 305 00:20:00,910 --> 00:20:06,350 about how she looked to other people, and it seems to me she created 306 00:20:06,350 --> 00:20:11,590 a body image and an image of herself that wasn't attractive. 307 00:20:14,470 --> 00:20:18,470 NARRATOR: Joan had her first cosmetic enhancement aged 32 in 1965. 308 00:20:19,990 --> 00:20:22,750 An operation to remove the bags from under her eyes. 309 00:20:24,270 --> 00:20:28,750 In 1977, at the age of 44, she had her first facelift. 310 00:20:30,630 --> 00:20:34,390 The more popular Joan became and the more she was photographed, 311 00:20:34,390 --> 00:20:37,070 the more she saw her imperfections. 312 00:20:37,070 --> 00:20:39,070 She responded with more surgery. 313 00:20:40,430 --> 00:20:44,910 In the entertainment industry people do need to look their best. 314 00:20:44,910 --> 00:20:48,350 In Hollywood, perhaps, a lot of people do go and have nips and tucks. 315 00:20:48,350 --> 00:20:50,230 And it's not even thought about. 316 00:20:51,350 --> 00:20:56,350 And then I wonder if Joan would have just seen cosmetic surgery 317 00:20:56,350 --> 00:20:59,070 as part and parcel of that package. 318 00:20:59,070 --> 00:21:01,630 So in order to beat off the competition, 319 00:21:01,630 --> 00:21:04,950 in order to stand out, I need to go in for maintenance. 320 00:21:06,030 --> 00:21:08,630 NARRATOR: In the 80s she had several nose jobs, 321 00:21:08,630 --> 00:21:11,030 a set of cheek implants, and a tummy tuck, 322 00:21:12,270 --> 00:21:16,070 becoming as famous for her cosmetically enhanced looks as her humour. 323 00:21:17,350 --> 00:21:23,030 I think Joan Rivers is one of the first people to be so open 324 00:21:23,030 --> 00:21:28,110 with the plastic surgery, who never made that hidden at all. 325 00:21:28,110 --> 00:21:29,470 Uh, plastic surgery... 326 00:21:29,470 --> 00:21:31,910 And I haven't done as much as everyone thinks I've done. 327 00:21:31,910 --> 00:21:34,550 But that's fine, think what you want, you know. 328 00:21:34,550 --> 00:21:39,110 Um, you have to know how much to do, when to do it. 329 00:21:39,110 --> 00:21:41,910 And I always recommend doing a little at a time. 330 00:21:41,910 --> 00:21:44,990 A little bit at a time. Otherwise you're gonna look like 331 00:21:44,990 --> 00:21:46,550 you've been through a wind tunnel or... 332 00:21:46,550 --> 00:21:50,390 Robert Redford looks like he's in the witness protection programme. 333 00:21:50,390 --> 00:21:54,230 You go, "Who's that?" (GASPING AND LAUGHING) 334 00:21:54,230 --> 00:21:56,510 He could actually kill a man and get away with it now. 335 00:21:58,750 --> 00:22:00,910 NARRATOR: Despite a growing fear of surgery, 336 00:22:00,910 --> 00:22:03,390 she continued to have various nips and tucks 337 00:22:03,390 --> 00:22:05,230 until five years before her death. 338 00:22:11,510 --> 00:22:15,070 Joan's oxygen saturation levels are still below a safe limit. 339 00:22:16,230 --> 00:22:20,670 The anaesthetist intervenes, gives her more oxygen, and Joan appears stable. 340 00:22:22,870 --> 00:22:26,590 But the anaesthetist said she now notices Joan's hand move. 341 00:22:26,590 --> 00:22:29,870 So gives her another shot of propofol to keep her sedated. 342 00:22:33,430 --> 00:22:38,190 PAYNE-JAMES: I can see from the medical notes that the dose given to Joan was 300 mg. 343 00:22:39,830 --> 00:22:43,950 If Joan had been given 300 mg, a massive dose, 344 00:22:43,950 --> 00:22:45,310 this could well have led 345 00:22:45,310 --> 00:22:47,950 to either a respiratory or cardiac arrest. 346 00:22:47,950 --> 00:22:49,830 (MONITORS BEEPING) 347 00:22:49,830 --> 00:22:52,710 So could this be the cause of Joan's death? 348 00:22:56,590 --> 00:22:59,950 I can see from a report provided to the medical examiner 349 00:22:59,950 --> 00:23:05,950 that this was a recording error and in fact she only received 120 mgs. 350 00:23:05,950 --> 00:23:08,870 This brings it within therapeutic guidelines, 351 00:23:08,870 --> 00:23:13,910 and so I don't think that this is a cause for Joan's tragic and unexpected death. 352 00:23:26,510 --> 00:23:29,790 NARRATOR: Dr Lawrence Cohen continues with an endoscopy, 353 00:23:29,790 --> 00:23:33,350 a procedure allowing him to view Joan Rivers' oesophagus and stomach 354 00:23:33,350 --> 00:23:36,190 in an attempt to find the cause of her raspy throat. 355 00:23:37,390 --> 00:23:40,630 The several time-stamped images are recorded on the endoscopy notes, 356 00:23:40,630 --> 00:23:43,470 and one reveals a large hiatus hernia. 357 00:23:46,310 --> 00:23:48,510 Hiatus hernia is a common condition 358 00:23:48,510 --> 00:23:51,070 whereby the upper part of the stomach, 359 00:23:51,070 --> 00:23:53,910 due to a relative weakness in the diaphragm, 360 00:23:53,910 --> 00:23:56,030 passes into the chest 361 00:23:56,030 --> 00:24:00,910 and allows acid and other stomach contents to reflux into the gullet. 362 00:24:05,030 --> 00:24:07,670 NARRATOR: If acid has been refluxing into her gullet, 363 00:24:07,670 --> 00:24:11,230 then this could easily be the cause of her raspy throat. 364 00:24:11,230 --> 00:24:14,630 It could also be the indication of something much more serious. 365 00:24:17,590 --> 00:24:21,830 PAYNE-JAMES: Prolonged exposure to acid can have damaging effects, 366 00:24:21,830 --> 00:24:24,070 which, if left untreated, 367 00:24:24,070 --> 00:24:26,990 can be associated with oesophageal cancer. 368 00:24:28,390 --> 00:24:31,590 NARRATOR: However, there's no sign of any cancerous tissue. 369 00:24:31,590 --> 00:24:33,590 But there is swelling in Joan's throat. 370 00:24:38,150 --> 00:24:40,470 And as they're withdrawing the endoscope, 371 00:24:40,470 --> 00:24:44,550 I note that they record a retinoid oedema. 372 00:24:44,550 --> 00:24:48,510 And that is swelling near the vocal cords. 373 00:24:50,150 --> 00:24:53,870 But whether this is the cause of her raspy throat is unclear. 374 00:24:55,470 --> 00:24:57,510 NARRATOR: With the endoscopy completed, 375 00:24:57,510 --> 00:25:00,110 that should have signalled the end of the procedure. 376 00:25:01,190 --> 00:25:04,710 Around this time, Joan's vital signs start to fall sharply. 377 00:25:09,070 --> 00:25:14,510 Her blood pressure has dramatically dropped to 84 over 40, her pulse is 47, 378 00:25:14,510 --> 00:25:18,190 and her oxygen sats remain low at 92%. 379 00:25:19,390 --> 00:25:20,910 This is a critical situation. 380 00:25:24,150 --> 00:25:27,270 NARRATOR: However, according to the testimony of the anaesthetist 381 00:25:27,270 --> 00:25:28,990 and endoscopy technician, 382 00:25:28,990 --> 00:25:31,470 Joan's physician Dr Gwen Korovin, 383 00:25:31,470 --> 00:25:33,790 though unauthorised to operate at the clinic, 384 00:25:33,790 --> 00:25:36,430 decides she wants another look at Joan's vocal cords. 385 00:25:40,030 --> 00:25:41,350 The anaesthetist says 386 00:25:41,350 --> 00:25:45,390 she expresses her concerns about this second unscheduled procedure 387 00:25:45,390 --> 00:25:47,630 due to the swelling in Joan's throat. 388 00:25:47,630 --> 00:25:49,310 But Dr Cohen overrules her. 389 00:25:50,630 --> 00:25:54,630 In legal papers, Dr Korovin denies any laryngoscopy is performed. 390 00:25:57,750 --> 00:25:58,910 At this point, 391 00:25:58,910 --> 00:26:03,230 again according to the testimony of the anaesthetist and the technician, 392 00:26:03,230 --> 00:26:06,390 Dr Cohen takes out his mobile phone and takes a picture. 393 00:26:06,390 --> 00:26:10,550 Saying, "Maybe Joan would like to see this in the recovery area." 394 00:26:10,550 --> 00:26:12,870 Dr Cohen denies that this took place. 395 00:26:16,350 --> 00:26:19,110 This obviously distracts from the procedure being undertaken 396 00:26:19,110 --> 00:26:22,150 and is ethically inappropriate. 397 00:26:22,150 --> 00:26:25,830 NARRATOR: Then according to the testimony of both the anaesthetist and technician, 398 00:26:25,830 --> 00:26:29,390 Dr Korovin starts her second laryngoscopy. 399 00:26:29,390 --> 00:26:31,630 But Joan's vital signs are still falling. 400 00:26:34,070 --> 00:26:36,990 If not treated, then she's at very real risk 401 00:26:36,990 --> 00:26:40,190 of a serious complication like a stroke, 402 00:26:40,190 --> 00:26:43,350 or worse, a cardiac or respiratory arrest. 403 00:26:44,390 --> 00:26:46,990 NARRATOR: Now according to the anaesthetist's records, 404 00:26:46,990 --> 00:26:51,670 Dr Korovin removes her scope so Joan can be given the air she critically needs. 405 00:26:53,430 --> 00:26:56,270 She needs to use a mask but it's not working. 406 00:26:56,270 --> 00:26:59,110 Something is stopping the oxygen reaching Joan's lungs. 407 00:27:02,070 --> 00:27:04,910 PAYNE-JAMES: This is where things are becoming dangerous. 408 00:27:04,910 --> 00:27:08,270 I can see that according to Dr Bankulla's written account of the procedure, 409 00:27:08,270 --> 00:27:12,630 she says she was finding it difficult to get oxygen into Joan's lungs 410 00:27:12,630 --> 00:27:14,510 by using the Ambu bag mask. 411 00:27:18,470 --> 00:27:20,310 Unless the airway is re-established, 412 00:27:20,310 --> 00:27:24,950 there is a risk of slowing of the heart beat and a reduction in oxygen levels 413 00:27:24,950 --> 00:27:27,150 to a point at which they become fatal. 414 00:27:32,190 --> 00:27:35,590 NARRATOR: While the doctors fight to get air into Joan, there's another problem. 415 00:27:36,910 --> 00:27:40,070 Dr Cohen expresses concern that he can't feel a pulse. 416 00:27:41,950 --> 00:27:45,430 PAYNE-JAMES: Failure to be able to feel a pulse means one of two things. 417 00:27:45,430 --> 00:27:49,950 Either the blood pressure is so low that the finger tips can't feel it, 418 00:27:49,950 --> 00:27:52,070 or the heart has actually stopped. 419 00:27:58,630 --> 00:28:02,550 NARRATOR: According to Yorkville's records, Joan is now in cardiac arrest. 420 00:28:03,790 --> 00:28:05,590 Dr Cohen goes for help. 421 00:28:07,430 --> 00:28:10,230 And returns a minute later with another anaesthetist. 422 00:28:14,830 --> 00:28:20,390 At 9:30 he starts CPR to keep blood and oxygen circulating to the vital organs. 423 00:28:24,270 --> 00:28:27,550 PAYNE-JAMES: The brain is dependent on oxygenated blood. 424 00:28:27,550 --> 00:28:29,070 If it doesn't get enough, 425 00:28:29,070 --> 00:28:31,750 then irreversible brain damage can occur. 426 00:28:32,950 --> 00:28:34,230 (INDISTINCT TALKING) 427 00:28:34,230 --> 00:28:36,350 NARRATOR: They need to restart Joan's heart. 428 00:28:38,630 --> 00:28:40,790 And they give her an adrenalin shot. 429 00:28:40,790 --> 00:28:42,950 (AIR PUMPING) 430 00:28:42,950 --> 00:28:45,590 It works. Her pulse returns. 431 00:28:48,550 --> 00:28:52,270 But Ambu bagging isn't working, and she's still not getting enough oxygen. 432 00:28:59,470 --> 00:29:03,910 Joan's oxygen levels have been well below safe for five minutes. 433 00:29:03,910 --> 00:29:07,430 And the medical team are struggling to insert a tube into Joan's throat 434 00:29:07,430 --> 00:29:10,710 so she can breathe through a ventilator, known as intubation. 435 00:29:13,950 --> 00:29:18,110 At 9:40am, staff call 911 for emergency assistance. 436 00:29:24,350 --> 00:29:28,630 At 9:47am, Joan is finally intubated. 437 00:29:28,630 --> 00:29:32,390 Paramedics arrive but Joan is still not out of danger. 438 00:29:35,150 --> 00:29:41,230 PAYNE-JAMES: From the medical notes, we see at 9:48 that her blood pressure's 184 over 132. 439 00:29:41,230 --> 00:29:45,030 With a pulse rate of 142. That's very fast. 440 00:29:45,030 --> 00:29:47,950 This is putting a big strain on the heart of an elderly lady. 441 00:29:49,070 --> 00:29:52,070 In addition, her oxygen level is at 87. 442 00:29:52,070 --> 00:29:53,790 They've actually been lower, 443 00:29:53,790 --> 00:29:56,950 but that's still low enough for me to be very concerned 444 00:29:56,950 --> 00:29:59,390 about the amount of oxygen getting to her brain. 445 00:30:01,990 --> 00:30:05,550 NARRATOR: The paramedics rush Joan to the nearby hospital, Mount Sinai. 446 00:30:05,550 --> 00:30:07,350 (SIREN WAILING) 447 00:30:09,750 --> 00:30:11,550 By now the story was out. 448 00:30:13,110 --> 00:30:14,550 We are back with breaking news. 449 00:30:14,550 --> 00:30:16,910 We're learning now that comedian Joan Rivers 450 00:30:16,910 --> 00:30:20,110 has been rushed to a New York City hospital, Mount Sinai. 451 00:30:20,110 --> 00:30:23,750 Those are the only details we have at this point. 452 00:30:25,270 --> 00:30:27,470 REDACK: I had a phone call from my wife. 453 00:30:27,470 --> 00:30:30,030 She said, "Have you heard the news?" I said, "What news?" 454 00:30:30,030 --> 00:30:33,110 She says, "They rushed Joan to the hospital." 455 00:30:35,590 --> 00:30:38,830 We just had dinner literally hours before. 456 00:30:38,830 --> 00:30:42,390 All I could think was, "My God, what happened?" 457 00:30:43,510 --> 00:30:45,710 The emails started coming in. 458 00:30:45,710 --> 00:30:48,350 You know they're like, "Did you just hear about Joan Rivers? 459 00:30:48,350 --> 00:30:49,630 "Did you hear about Joan Rivers?" 460 00:30:49,630 --> 00:30:51,110 And I was like, "What are you talking about? 461 00:30:51,110 --> 00:30:53,070 "I just saw her on stage. What are you..." 462 00:30:53,070 --> 00:30:55,310 And I'm just like, "Oh, she's fine, she's fine. 463 00:30:55,310 --> 00:30:57,030 "I mean, I just saw her last night." 464 00:30:57,030 --> 00:30:59,830 There's... This is... This is... No, she'll be out in an hour. 465 00:31:13,310 --> 00:31:16,550 NARRATOR: Joan is now in intensive care but is in a stable condition. 466 00:31:19,430 --> 00:31:21,750 Her daughter, Melissa, has flown in from LA 467 00:31:21,750 --> 00:31:24,110 and keeps a constant vigil by her side. 468 00:31:25,510 --> 00:31:28,390 Joan's close friends wait for positive news. 469 00:31:29,670 --> 00:31:33,270 REDACK: I really had no sense of how serious it was. 470 00:31:33,270 --> 00:31:37,030 It was very confusing and depressing. 471 00:31:37,030 --> 00:31:39,430 It was unbelievable. Tragic. 472 00:31:39,430 --> 00:31:40,950 How could something like this happen? 473 00:31:47,700 --> 00:31:49,100 NARRATOR: Three days later, 474 00:31:49,100 --> 00:31:52,940 Melissa is told that her mother is highly unlikely to regain consciousness. 475 00:31:56,900 --> 00:31:59,700 Melissa is faced with a heart-rending decision 476 00:31:59,700 --> 00:32:02,260 whether to switch off her mother's life support. 477 00:32:04,420 --> 00:32:05,820 Melissa's decision was guided 478 00:32:05,820 --> 00:32:09,700 by Joan's definition of quality of life as outlined in her will. 479 00:32:11,500 --> 00:32:14,740 Days before Joan checked in for her endoscopy, 480 00:32:14,740 --> 00:32:18,380 journalist Benjamin Butterworth asked whether she ever worried 481 00:32:18,380 --> 00:32:20,540 something might go wrong during surgery. 482 00:32:22,220 --> 00:32:24,860 I said to Joan, "What would you do if there was a health problem? 483 00:32:24,860 --> 00:32:26,380 "If something went wrong?" 484 00:32:26,380 --> 00:32:29,340 'Cause obviously I was interviewing her, and she was 81 years old. 485 00:32:29,340 --> 00:32:31,820 It was a plausible thing to happen. 486 00:32:31,820 --> 00:32:33,660 Though I didn't think it really would. 487 00:32:33,660 --> 00:32:37,060 And Joan said, "Look, if something went wrong with my health, 488 00:32:37,060 --> 00:32:40,140 I'd kill myself. I would not want to go on." 489 00:32:40,140 --> 00:32:42,100 (AIR PUMPING) 490 00:32:44,620 --> 00:32:46,100 (MONITORS BEEPING) 491 00:32:46,100 --> 00:32:47,300 NARRATOR: 12:00pm 492 00:32:49,820 --> 00:32:52,780 Melissa decides to turn off the life support machine. 493 00:32:55,260 --> 00:32:57,060 (BUTTON CLICKING) 494 00:33:06,260 --> 00:33:09,700 At 1:17pm, Joan Rivers is pronounced dead. 495 00:33:17,460 --> 00:33:20,900 When I heard the news, I didn't know how to react. It was just stunning. 496 00:33:22,060 --> 00:33:24,620 Stunning that she was gone. 497 00:33:24,620 --> 00:33:27,500 MARKELL: My first thought was she went out on top. 498 00:33:27,500 --> 00:33:30,900 She was the top story of the national news. 499 00:33:31,900 --> 00:33:34,020 And so to me, wherever she was, 500 00:33:34,020 --> 00:33:36,380 I knew that would make her incredibly happy. 501 00:33:38,020 --> 00:33:42,300 NARRATOR: Hundreds of endoscopies are performed every day all over the world. 502 00:33:42,300 --> 00:33:47,100 For such a routine procedure to have such a devastating conclusion is extremely rare. 503 00:33:49,740 --> 00:33:53,900 The question is, in the case of Joan Rivers, what exactly went wrong? 504 00:33:54,940 --> 00:33:59,300 Looking at her medical notes, though she's 81 she's in good physical shape. 505 00:34:00,820 --> 00:34:02,260 She's got no heart problems 506 00:34:02,260 --> 00:34:05,020 and no other underlying health conditions. 507 00:34:06,580 --> 00:34:10,500 NARRATOR: What happened in the critical 47 minutes is in dispute. 508 00:34:10,500 --> 00:34:14,580 But why did Joan Rivers die after a seemingly routine procedure? 509 00:34:19,820 --> 00:34:22,380 Two medical professionals told investigators 510 00:34:22,380 --> 00:34:25,380 that in addition to Joan's planned endoscopy, 511 00:34:25,380 --> 00:34:27,860 Joan's personal doctor, Gwen Korovin, 512 00:34:27,860 --> 00:34:32,060 performed two unscheduled and unauthorised laryngoscopies. 513 00:34:32,060 --> 00:34:35,860 And that around the time of the second laryngoscopy things went wrong. 514 00:34:38,540 --> 00:34:41,900 At 9:28 her oxygen levels appear to go into free fall. 515 00:34:44,340 --> 00:34:46,500 Down to 50. 516 00:34:46,500 --> 00:34:51,180 NARRATOR: According to Dr Payne-James this sharp fall in Joan's oxygen levels 517 00:34:51,180 --> 00:34:54,780 could be the result of a condition known as laryngospasm. 518 00:34:56,540 --> 00:35:00,060 PAYNE-JAMES: Laryngospasm is a sustained closure of the vocal cords, 519 00:35:00,060 --> 00:35:03,980 which results in partial or complete loss of the patient's airway. 520 00:35:05,100 --> 00:35:07,900 It can be caused by direct contact trauma. 521 00:35:10,100 --> 00:35:14,540 NARRATOR: It's possible that a laryngoscope touching Joan's vocal cords 522 00:35:14,540 --> 00:35:17,180 may have caused them to close over her airway. 523 00:35:19,460 --> 00:35:22,380 Joan had only been given a sedative dose of anaesthetic 524 00:35:22,380 --> 00:35:24,580 so her reflexes were functioning. 525 00:35:28,660 --> 00:35:33,740 The report to the medical examiner states the timing and size of the doses 526 00:35:33,740 --> 00:35:38,380 are consistent with making a patient susceptible to laryngospasm 527 00:35:38,380 --> 00:35:43,140 from the stimulus of a fibre-optic scope irritating the vocal cords. 528 00:35:44,580 --> 00:35:46,500 But based on the evidence in front of me, 529 00:35:46,500 --> 00:35:47,820 it's impossible to establish 530 00:35:47,820 --> 00:35:50,580 whether she did or didn't have laryngospasm. 531 00:35:52,260 --> 00:35:57,220 NARRATOR: What is certain is by 9:30am on August 27, 2014, 532 00:35:57,220 --> 00:35:59,180 Joan's life was under threat. 533 00:36:00,540 --> 00:36:03,140 The doctors in the room were faced with falling oxygen levels, 534 00:36:05,580 --> 00:36:06,780 falling blood pressure, 535 00:36:09,140 --> 00:36:10,740 leading to cardiac arrest. 536 00:36:14,380 --> 00:36:16,580 Cardiopulmonary resuscitation was started. 537 00:36:19,260 --> 00:36:21,780 But oxygen levels remained very low. 538 00:36:22,980 --> 00:36:28,020 At these levels, unless rapidly corrected, vital organ damage will ensue. 539 00:36:30,020 --> 00:36:31,540 (FRANTIC ORDERING) 540 00:36:32,780 --> 00:36:36,900 NARRATOR: With every second vital, doctors were struggling to get air into Joan's lungs. 541 00:36:38,940 --> 00:36:42,500 This appears to be due to problems with maintaining an airway. 542 00:36:42,500 --> 00:36:44,700 And this might be due to airway obstruction. 543 00:36:46,420 --> 00:36:49,500 NARRATOR: There is conflicting evidence of the extent of any obstruction. 544 00:36:51,860 --> 00:36:55,260 Endoscopic images show that the airway was open, 545 00:36:55,260 --> 00:36:59,140 and yet the anaesthetist reports swelling preventing intubation. 546 00:37:00,220 --> 00:37:02,580 Now this could be for two reasons, mainly. 547 00:37:03,620 --> 00:37:05,900 Swelling around the vocal cords 548 00:37:05,900 --> 00:37:09,860 or closure of the vocal cords due to a laryngospasm. 549 00:37:09,860 --> 00:37:11,860 We don't know which of those two contributed. 550 00:37:12,980 --> 00:37:14,540 NARRATOR: The precise cause of the difficulties 551 00:37:14,540 --> 00:37:17,260 with ventilation is impossible to establish. 552 00:37:19,180 --> 00:37:20,660 PAYNE-JAMES: But whatever the reason, 553 00:37:20,660 --> 00:37:23,700 the anaesthetist was unable to intubate. 554 00:37:25,020 --> 00:37:28,980 NARRATOR: Dr Payne-James believes there was a potential solution 555 00:37:28,980 --> 00:37:32,020 to the apparent blockage, an emergency tracheostomy. 556 00:37:33,820 --> 00:37:38,460 It's a rare procedure, but it's a very effective way of getting air into the lungs. 557 00:37:40,300 --> 00:37:44,900 A tracheostomy is simply a surgically created hole in the front of the windpipe 558 00:37:44,900 --> 00:37:49,420 below an obstruction that allows air to move in and out of the lungs. 559 00:37:51,540 --> 00:37:53,180 An emergency tracheostomy 560 00:37:53,180 --> 00:37:56,100 is a procedure that should be within the capabilities 561 00:37:56,100 --> 00:37:58,540 of any anaesthetist or surgeon. 562 00:38:00,020 --> 00:38:02,220 NARRATOR: Dr Bankulla, the anaesthetist, 563 00:38:02,220 --> 00:38:05,180 states that she considered performing a tracheostomy 564 00:38:05,180 --> 00:38:09,700 but as she eventually successfully intubated, she deemed it unnecessary. 565 00:38:11,340 --> 00:38:14,900 However, intubation was not achieved until 19 minutes 566 00:38:14,900 --> 00:38:17,060 after Joan went into cardiac arrest. 567 00:38:19,460 --> 00:38:21,260 Dr Payne-James believes 568 00:38:21,260 --> 00:38:26,020 this delay in intubating resulted in irreparable damage to Joan's brain. 569 00:38:28,820 --> 00:38:30,820 If there was complete airway obstruction, 570 00:38:30,820 --> 00:38:33,180 then it's possible that an emergency tracheostomy 571 00:38:33,180 --> 00:38:34,460 could have saved her life. 572 00:38:46,180 --> 00:38:49,460 NARRATOR: Joan was transferred to Mount Sinai Hospital 573 00:38:49,460 --> 00:38:51,980 where she was put into a medically-induced coma 574 00:38:51,980 --> 00:38:54,060 in the hope that her brain would recover. 575 00:38:56,060 --> 00:39:00,140 PAYNE-JAMES: The report to the medical examiner says Joan never awakened 576 00:39:00,140 --> 00:39:02,740 and remained comatose until her death. 577 00:39:02,740 --> 00:39:06,980 The cerebral scans were consistent with global anoxic injury. 578 00:39:06,980 --> 00:39:12,540 This means that the brain has been deprived of oxygen for a significant period of time. 579 00:39:16,740 --> 00:39:20,660 The office of the chief medical examiner completed its investigation 580 00:39:20,660 --> 00:39:22,900 and concluded, and I quote, 581 00:39:22,900 --> 00:39:28,420 "That the cause of Ms Rivers' death is anoxic encephalopathy due to hypoxic arrest." 582 00:39:29,580 --> 00:39:34,500 And what that simply means is that she died from lack of oxygen to the brain. 583 00:39:35,740 --> 00:39:40,580 So for me, the 19 minutes between the loss of her pulse 584 00:39:40,580 --> 00:39:44,700 and Joan's successful intubation is crucial. 585 00:39:46,060 --> 00:39:48,740 Her oxygen saturations were already marginal 586 00:39:48,740 --> 00:39:53,220 and in that critical period of time her brain was starved of oxygen, 587 00:39:53,220 --> 00:39:56,060 which resulted in the irreversible brain damage 588 00:39:56,060 --> 00:39:57,860 from which she could not recover. 589 00:40:01,660 --> 00:40:04,900 NARRATOR: Joan's daughter Melissa has begun a medical negligence action 590 00:40:04,900 --> 00:40:06,940 against the doctors and the clinic. 591 00:40:09,620 --> 00:40:11,420 The defendants deny negligence. 592 00:40:12,700 --> 00:40:14,060 (MONITOR BEEPING) 593 00:40:14,060 --> 00:40:15,780 (BUTTON CLICKING) 594 00:40:21,020 --> 00:40:23,020 (BAGPIPES PLAYING) 595 00:40:25,620 --> 00:40:27,580 Three days after her death, 596 00:40:27,580 --> 00:40:30,140 Joan's memorial service was held in New York. 597 00:40:31,380 --> 00:40:37,340 Her send-off was attended by her family, close friends, and hundreds of adoring fans. 598 00:40:37,340 --> 00:40:42,740 She cared so much about the audience, she cared so much about her craft, 599 00:40:42,740 --> 00:40:44,500 and she cared so much about the community. 600 00:40:45,740 --> 00:40:48,020 MARKELL: Relevance was very important to Joan. 601 00:40:48,020 --> 00:40:52,180 It was important to her that people remember that she was around 602 00:40:52,180 --> 00:40:54,580 and that she was still part of the public eye. 603 00:40:56,660 --> 00:41:00,860 Joan Rivers is at the forefront. There is no one else. 604 00:41:00,860 --> 00:41:03,540 She is Mount Rushmore of comedy. 605 00:41:06,260 --> 00:41:09,740 MARKELL: I thought, "This is exactly what she would have wanted." 606 00:41:09,740 --> 00:41:13,180 I think she would have loved every single minute of it. 607 00:41:16,460 --> 00:41:21,220 I think the world will miss a very bold, 608 00:41:21,220 --> 00:41:26,260 a very funny, a very wonderful lady. 609 00:41:26,260 --> 00:41:29,900 And for those that knew her intimately, generous to a fault. 610 00:41:31,140 --> 00:41:34,140 I will miss Joan more than I can describe, 611 00:41:34,140 --> 00:41:36,620 more than anyone I've ever known in my life. 612 00:41:36,620 --> 00:41:39,020 Captions edited by Ai Media ai-media.tv