Let's start on a Friday morning with this sad news ` the death of Joan Rivers. Joan Rivers was the undisputed queen of stand-up comedy. I found this dress on the chair next to my husband's bed. Isn't that lucky? Renowned for her unique brand of fast-talking and sexually charged wit, she was a fixture on stage and television for nearly five decades. I was the one who told David Beckham, 'Make your life easier. Hire a personal secretary.' LAUGHTER Joan spawned so many women that are in comedy today. She led the way. Without her, they couldn't talk about the stuff they talk about. Joan made it possible. Even in her 80s, Joan was connecting with a much younger audience with her show 'Fashion Police'. SIREN WAILS But at 1.17pm on the 4th of September 2014 at New York's Mt Sinai Hospital, following an earlier simple exploratory examination of her throat, Joan Rivers was pronounced dead. REPORTER: The 81-year-old died after going into cardiac arrest and losing consciousness. It was a seemingly routine procedure that was to go tragically wrong. The challenge for me is to find out just how and why this happened. Dr Jason Payne-James is an internationally recognised specialist in forensic and legal medicine; called on by the National Crime Agency, Metropolitan Police and government task forces in the US and the UK. He provided evidence in the Soham murders and Baby P cases. These are the medical papers related to Joan Rivers' death, and together with other information I have gathered, they will provide clues as to how she lived her life and ultimately to pinpoint the reason for her untimely death. Times Square, New York, eight days before her death. AUDIENCE CHEERS Joan is on stage at the Laurie Beechman Theatre, one of her favourite comedy venues. At 81, Joan Rivers is busier than ever. MAN: I love you, Joan. I love you too. Her hectic work schedule means flying from LA to New York several times a week. Joan was always the most ambitious, driven woman I've known. Throughout her career, it was work, work, work. Work and Melissa. Her daughter Melissa and Joan have worked together for years in the entertainment industry, sometimes even as co-presenters. 8.40pm. On stage, Joan is as vibrant and acerbic as ever. Lifelong Joan fan Shade Rupe was in the audience that night. I was so happy to get to go see her again. It was a birthday present to myself, and I'm so glad that I made that choice. During the show, Joan jokes about everything, even her own death. And at one point she starts telling this joke, and she goes, 'You know, I'm 81. I could just go over. I could go over right now, right, just.... yaaaaaack.' But I was really shocked. I was like, 'How can this woman be 81 years old?' She was more like a 40-year-old; running back and forth on that stage. I have never seen so much life in a human being as I had that evening. Accidently running into her afterwards, she was so kind and cool. There was no rushing. She was, like, so happy to say hello to a fan. He asked her to pose for a photograph with him. It was to be the last photo that would be taken of Joan as we remember her. I can see from the medical papers that Joan's daughter, Melissa Rivers, objected to autopsy on the grounds of Joan's religious faith. She was Jewish. But the medical examiner did complete a full external examination. The first things I noticed from the medical examiner's report was that Joan was 5'2" tall. She had dyed blonde hair with black roots. She had thick make-up on her face and brown eyeshadow. Of course, this is the look we all associate with Joan Rivers. In the 1960s, after a decade of hawking her act around the clubs of New York, Joan won herself a slot on The Tonight Show, starring Johnny Carson, one of America's most popular shows. When Joan Rivers was on Johnny Carson, she was an immediate hit because it was something new and something that people hadn't really seen before. Joan's popularity was based on her willingness to joke about subjects not widely spoken about on network TV. Joan became a pioneer for female comedians, forging a 50-year career in a previously male-dominated industry of stand-up. I think that Joan will always be regarded as the originator of the type of material she did; she spawned so many women that are in comedy today. Joan is enjoying dinner with Jay Redack, her close friend and writing partner for the past 40 years. That night she was typical Joan. Pleased with everything. Pleased with the way things were going with her career. She was up and happy. Didn't seem to have a concern in the world. I have a memory of talking about our age together, and I'd say, 'Gee, if I go first, I collect art, and I think I'll leave you a beautiful painting. 'What will you leave me?' And I think she said, 'Melissa and some of my shoes.' But something's playing on Joan's mind. Joan did mention that she was going to have some type of a procedure. She said, 'My voice has been a little bit raspy.' She showed absolutely no worry or concern about what was going to be done the next day at all. Joan's medical history suggests she had little to worry about. She was a non-smoker and only admitted to the occasional glass of wine. She took large amounts of vitamins and minerals to supplement her diet. So, overall, despite her age, she's in pretty good physical shape. But Dr Payne-James has identified a possible warning sign in her medical notes. I can see that Joan is taking a daily dose of the drug bisoprolol fumarate. This is a beta blocker used to treat high blood pressure. This is significant because at operation, I would expect her doctors to be keeping a close eye on her blood pressure because if it goes too high or too low, there is a risk of stroke or collapse. Seven days before her death, Rivers arrives at Yorkville Endoscopy with her personal physician and friend, Dr Gwen Korovin, for what should have been a routine examination. But Joan wasn't unduly worried. She had suffered from throat problems before but had always made light of them. MAN: Morning, Joan. How are you? > (MOUTHS) No voice? Are you kidding me? Nope. WHISPERS: I am doing Fashion Police tomorrow night, so I've got to sign. Do you want to see the sign for orgasm? Sure. OK. (LAUGHS) Do you want to see 13 orgasms? Sure. PEOPLE LAUGH When journalist Benjamin Butterworth spoke with Joan a few days before she checked into the clinic, she could barely speak. But she was coughing a lot. She was hoarse. She was croaky, and it was evident that something wasn't right. Joan's voice was her life. Without it, she couldn't work. And even at the age of 81, work meant everything to Joan. Joan was always very ambitious and very driven. If she didn't have a booking the next weekend or the next week, she thought she was in trouble. Throughout her career, through the highs, lows and the big success, she still, 'I have to work. 'If I'm not working, something's wrong.' Joan was always career-driven, but a devastating personal tragedy 27 years earlier had made her even more work-focused. In 1986, she was given her own late-night talk show by Fox. Her husband, Edgar, was the producer. At first it was a dream come true, but things soon started to unravel. And this was something that she was going to pour any energies into. And she was working with her husband, and for whatever reason, there was friction with Fox, and ultimately they took her off the air. Joan's husband, Edgar, blamed himself for the loss of the show. On August 14th 1987, whilst suffering from clinical depression, he took a fatal overdose of prescription pills in a hotel room. Joan is at home with her daughter, Melissa. They've been handed two envelopes from her husband, Edgar. They contain details of the family finances and cassette tapes containing personal messages; BOTH CRY effectively Edgar's suicide note. Joan and her teenage daughter, Melissa, were devastated. Joan had lost her show, she'd lost her career, she'd lost her husband all in a close succession. And I asked her on the phone what she did in reaction to that, and she told me, 'I was at home. I was sat in a chair and I had a gun...' on her lap. She had her hand on the gun and she was going to shoot herself. She was only 54 years old but Joan had hit rock bottom. What a horrible tragedy for anyone, but to have these two things happen at the same time meant that Joan then, as she herself would say, was dead in the business. She could have at that point ` I think she had the money ` simply retired. Done something else. That wasn't Joan. As she said, 'This is my life ` working on stage, working in front of a camera.' Joan's response was to work harder than ever to remain in the public eye through her stand-up and TV cameos. That work addiction would have helped her avoid, I think, the deep pain that she may have been feeling at that time. I think it also masks a great deal of emotional sensitivity that they are staying away from, and so all these behaviours act as a distraction from what's really going on, that inner turmoil. Over the next 10 years, she steadily rebuilt her career with an Emmy award-winning daytime talk show and a hit Broadway play. She built up a jewellery business and launched her own perfume. Then in 2010, she was reborn to a new generation with her bitchy hit format, Fashion Police. Joan was always the strongest woman I've ever known. The drive was amazing. She would fly back and forth the United States. She would fly to Europe constantly. Her schedule was hectic, and yet she never complained, and it seemed to energise her. The more she would work, the happier she seemed to be. 5 Joan signs the papers consenting to a routine procedure called an endoscopy. In an endoscopy, a tiny camera is passed down the throat so doctors can see their patient's oesophagus and stomach. Endoscopies, generally, are considered a pretty low-risk procedure with very few complications. So in a specialist unit like Yorkville Endoscopy where the gastroenterologists were doing over 1000 procedures a month, there's no reason to expect anything would go wrong. The endoscopy will reveal whether acid from Joan's stomach has moved up the oesophagus and damaged her vocal chords. This may be the source of her hoarseness. A nurse checks Joan's vital signs. I can see from the medical records that as she's about to be transferred to the procedure room her blood pressure is 118/80, pulse rate 62, respiratory rate 16 and her oxygen saturation is 100%. So there's no reason to suspect there may be problems ahead. Joan is transferred to the procedure room. With her is her personal physician, Dr Gwen Korovin, an ear, nose and throat specialist. Dr Korovin has referred Joan to the clinic. However, gastroenterologist Dr Lawrence Cohen, the clinic's medical director, will perform the procedure. Have you got me on my best side? What happened in the next 47 minutes is disputed and is known only to the people that were in the room. Their accounts differ greatly. Joan is given propofol, an anaesthetic, but in a sedative dose that will put her in a semi-conscious state. Like all anaesthetics, propofol carries a risk. Propofol affects brain activity and can cause the heart to beat abnormally. This can cause reduced blood pressure, decreasing the amount of oxygen going around the body. Within minutes, the propofol takes effect, and Joan is positioned ready for Dr Cohen to perform the endoscopy. But at 9.09am, the anaesthetist later told investigators there was, apparently, a change of plan. According to anaesthetist Dr Reddy Bankulla, instead of Dr Cohen proceeding with the scheduled upper gastrointestinal endoscopy, Dr Gwen Korovin started a transnasal laryngoscopy. If true, it's a significant breach of protocol. Joan hasn't given written consent to this new procedure. It hasn't been planned for, and Dr Korovin is not authorised to perform any procedures at the clinic. In legal papers, Dr Korovin has formally denied the unscheduled procedure occurred, but Dr Cohen told the medical examiner it did happen. It's recorded in the clinic's medical notes, and Mariela Sauvignon, the endoscopy technician, also told investigators a laryngoscopy is performed. A laryngoscopy might give a better view of what was causing Joan's raspy throat. A transnasal laryngoscopy is a procedure whereby a small, flexible telescope is passed backwards through the nose to directly view the larynx or voice box. The vocal chords can be directly viewed and any abnormality assessed. Dr Cohen later tells the medical examiner Dr Korovin could not properly see Joan's vocal chords because of mucus. Just minutes after Dr Korovin allegedly begins the laryngoscopy, Joan's vital signs, measurements of the body's basic functions, deteriorate. I know from the clinical medical records that at 9.12 her oxygen saturation levels are recorded as 92%. That's dropped from 100% at 8.44, a half an hour earlier. Anything less than 95% is a cause for concern, so Joan is given more oxygen to raise her saturation level. Joan's oxygen level improves. 9.16am. Now the scheduled endoscopy begins. Dr Cohen starts the procedure by inserting his scope into Joan's oesophagus. But the anaesthetist now notices Joan's oxygen saturation levels are still low and requests the endoscope is withdrawn to free up Joan's airways. At 9.16, the blood pressure has dropped to 92/54. The pulse rate has dropped to 56 and her oxygen saturation levels remain low. The reason the anaesthetist has intervened is that there is a very real risk that Joan may suffer a respiratory arrest, circulatory collapse and cardiac arrest. This is a very serious situation because the outcome without intervention may be death. Every time someone goes into surgery, there is a risk that something might go wrong. But this is a risk that Joan has taken many times before. Over the last 50 years, she's been in and out of the operating theatre many many times, but not because of illness. Famously, Joan Rivers loved plastic surgery. Her obsession with her body image stretched back to childhood. I asked her about her plastic surgery cos, my God, she had so much of it, and she said, 'Look, when you're the fat, ugly kid, you need to have the plastic surgery as an adult 'to overcome that.' I wonder about the internal picture that Joan carried in her own head about how she looked to other people, and it seems to me she created a body image and an image of herself that wasn't attractive. Joan had her first cosmetic enhancement aged 32 in 1965 ` an operation to remove the bags from under her eyes. In 1977 at the age of 44, she had her first facelift. The more popular Joan became and the more she was photographed, the more she saw her imperfections. She responded with more surgery. In the entertainment industry, people do need to look their best. In Hollywood, perhaps, a lot of people do go and have nips and tucks, and it's not even thought about. And then I wonder if Joan would have just seen cosmetic surgery as part and parcel of that package. So in order to beat off the competition, in order to stand out, 'I need to go in for maintenance.' In the '80s, she had several nose jobs, a set of cheek implants and a tummy tuck; becoming as famous for her cosmetically enhanced looks as her humour. I think Joan Rivers is one of the first people to be so open with the plastic surgery, who never made that hidden at all. Uh, plastic surgery... I haven't done as much as everyone thinks I've done, but that's fine. Think what you want, you know. You have to know how much to do, when to do it, and I always recommend doing a little at a time. A little bit at a time, otherwise you're going to look like you've been through a wind tunnel. Uh, Robert Redford looks like he's in the witness protection programme. You go, 'Who's that?' (GASPS) Oh. He can actually kill a man and get away with it now. Despite her growing fear of surgery, she continued to have various nips and tucks until five years before her death. Joan's oxygen saturation levels are still below safe limits. The anaesthetist intervenes, gives her more oxygen and Joan appears stable. But the anaesthetist said she now notices Joan's hand move, so gives her another shot of propofol to keep her sedated. I can see from the medical notes that the dose given to Joan was 300mg. If Joan had been given 300mg, a massive dose, this could well have led to either a respiratory or cardiac arrest. So could this be the cause of Joan's death? But I can see from a report provided to the medical examiner that this was a recording error and, in fact, she only received 120mg. This brings it within therapeutic guidelines, and so I don't think that this is a cause for Joan's tragic and unexpected death. 6 Yorkville Endoscopy clinic, New York. Dr Lawrence Cohen continues with an endoscopy, a procedure allowing him to view Joan Rivers' oesophagus and stomach in an attempt to find the cause of her raspy throat. Several time stamped images are recorded on the endoscopy notes and one reveals a large hiatus hernia. Hiatus hernia is a common condition whereby the upper part of the stomach, due to a relative weakness in the diaphragm, passes into chest and allows acid and other stomach contents to reflux into the gullet. If acid has been refluxing into her gullet, then this could easily be the cause of her raspy throat. It could also be the indication of something much more serious. Prolonged exposure to acid can have damaging effects, which, if left untreated, can be associated with oesophageal cancer. However, there's no sign of any cancerous tissue but there is swelling in Joan's throat. And as they're withdrawing the endoscope, I note that they record arytenoid oedema, and that is swelling near the vocal chords. But whether this is the cause of her raspy throat is unclear. With the endoscopy completed, that should have signalled the end of the procedure. Around this time, Joan's vital signs start to fall sharply. Her blood pressure has dramatically dropped. 84/40. Her pulse is 47 and her oxygen sats remain low at 92%. This is a critical situation. However, according to the testimony of the anaesthetist and endoscopy technician, Joan's physician, Dr Gwen Korovin, though unauthorised to operate at the clinic, decides she wants another look at Joan's vocal chords. The anaesthetist says she expresses her concerns about this second unscheduled procedure due to the swelling in Joan's throat. But Dr Cohen overrules her. In legal papers, Dr Korovin denies any laryngoscopy is performed. At this point, again, according to the testimony of the anaesthetist and the technician, Dr Cohen takes out his mobile phone and takes a picture, saying, 'Maybe Joan would like to see this in the recovery area.' Dr Cohen denies that this took place. This obviously distracts from the procedure being undertaken and is ethically inappropriate. Then according to the testimony of both anaesthetist and technician, Dr Korovin starts her second laryngoscopy, but Joan's vital signs are still falling. If not treated, then she's at very real risk of a serious complication, like a stroke, or worse, a cardiac or respiratory arrest. Now, according to the anaesthetist's record, Dr Korovin removes her scope so that Joan can be given the air she critically needs. She needs to use a mask but it's not working. Something is stopping the oxygen reaching Joan's lungs. This is where things are becoming dangerous. I can see that according to Dr Bankulla's written account of the procedure, she says she was finding it difficult to get oxygen into Joan's lungs by using the ambu bag mask. Unless the airway is re-established, there is a risk of slowing of the heartbeat and a reduction in oxygen levels to a point at which they become fatal. While the doctors fight to get air into Joan, there's another problem. Dr Cohen expresses concern that he can't feel a pulse. Failure to be able to feel a pulse means one of two things ` either the blood pressure is so low that the fingertips can't feel it or the heart has actually stopped. According to Yorkville's records, Joan is now in cardiac arrest. Dr Cohen goes for help and returns a minute later with another anaesthetist. At 9.30 he starts CPR to keep blood and oxygen circulating to the vital organs. The brain is dependant on oxygenated blood. If it doesn't get enough, then irreversible brain damage can occur. They need to restart Joan's heart and they give her an adrenaline shot. It works. Her pulse returns. But ambu bagging isn't working and she's still not getting enough oxygen. Joan's oxygen levels have been well below safe for five minutes, and the medical team are struggling to insert a tube into Joan's throat so she can breathe through a ventilator, known as intubation. At 9.40am, staff call 911 for emergency assistance. At 9.47am, Joan is finally intubated. Paramedics arrive. But Joan is still not out of danger. From the medical notes, we see at 9.48 that her blood pressure is 184/132 with a pulse rate of 142. That's very fast. This is putting a big strain on the heart of an elderly lady. In addition, her oxygen levels are at 87. They've actually been lower, but that's still low enough for me to be very concerned about the amount of oxygen getting to her brain. The paramedics rush Joan to the nearby hospital Mt Sinai. SIREN WAILS By now the story was out. We are back with breaking news. We're learning now that comedian Joan Rivers has been rushed to a New York City hospital, Mt Sinai. Those are the only details we have at this point. I had a phone call from my wife. She said, 'Have you heard the news?' 'What news?' She said, 'They rushed Joan to the hospital.' We just had dinner literally hours before. All I could think was, 'Oh my God. What happened?' The emails started coming in. They were like, 'Did you just hear about Joan Rivers?' 'Did you hear about Joan Rivers?' And I was like, 'What are you talking about? 'I just saw her on stage. What are`?' And I was like, 'Oh, she's fine. She's fine. I mean, I just saw her last night. 'This is... This is... No, she'll be out in an hour.' Joan is now in intensive care but is in a stable condition. Her daughter Melissa has flown in from LA and keeps a constant vigil by her side. Joan's close friends wait for positive news. I really had no sense of how serious it was. It was very confusing and depressing. It was unbelievable. Tragic. How could something like this happen? Three days later, Melissa is told that her mother is highly unlikely to regain consciousness. Melissa is faced with the heart-rending decision whether to switch off her mother's life support. Melissa's decision was guided by Joan's definition of quality of life as outlined in her will. Days before Joan checked in for her endoscopy, journalist Benjamin Butterworth asked whether she ever worried something might go wrong during surgery. I said to Joan, 'What would you do if there was a health problem if something went wrong?' Because I was interviewing her. She was 81 years old. It was a plausible thing to happen, though I didn't think it really would. And Joan said, 'Look, if something went wrong with my health, I'd kill myself. 'I would not want to go on.' 12pm. Melissa decides to turn off the life support machine. MACHINE BEEPS At 1.17pm, Joan Rivers is pronounced dead. When I heard the news, I didn't know how to react. It was just stunning. Stunning that she was gone. My first thought was, 'She went out on top.' She was the top story of the national news. And so to me wherever she was, I knew that would make her incredibly happy. 4 Hundreds of endoscopies are performed every day all over the world. For such a routine procedure to have such a devastating conclusion is extremely rare. The question is, in the case of Joan Rivers, what exactly went wrong? Looking at her medical notes, though she's 81, she's in good physical shape. She's got no heart problems and no other underlying health conditions. What happened in the critical 47 minutes is in dispute, but why did Joan Rivers die after a seemingly routine procedure? Two medical professionals told investigators that in addition to Joan's planned endoscopy, Joan's personal doctor, Gwen Korovin, performed two unscheduled and unauthorised laryngoscopies, and that around the time of the second laryngoscopy, things went wrong. At 9.28, her oxygen levels appear to go into freefall. Down to 50. According to Dr Payne-James, this sharp fall in Joan's oxygen levels could be the result of a condition known as laryngospasm. Laryngospasm is a sustained closure of the vocal chords which results in partial or complete loss of the patient's airway. It can be caused by direct contact trauma. It's possible that a laryngoscope touching Joan's vocal chords may have caused them to close over her airway. Joan had only been given a sedative dose of anaesthetic so her reflexes were functioning. The report to the medical examiner states (READS) 'The timing and size of the dosage 'are consistent with making a patient susceptible to laryngospasm from the stimulus 'of a fibre-optic scope irritating the vocal chords.' But based on the evidence in front of me, it's impossible to establish whether she did or didn't have laryngospasm. What is certain is that by 9.30am on August 27th 2014, Joan's life was under threat. The doctors in the room were faced with falling oxygen levels, falling blood pressure leading to cardiac arrest. Cardiopulmonary resuscitation was started but oxygen levels remained very low. At these levels, unless rapidly corrected, vital organ damage will ensue. With every second vital, doctors were struggling to get air into Joan's lungs. This appears to be due to problems with maintaining an airway, and this might be due to airway obstruction. There is conflicting evidence of the extent of any obstruction. Endoscopic images show that the airway was open and yet the anaesthetist reports swelling preventing intubation. Now this could be for two reasons mainly ` swelling around the vocal chords or closure of the vocal chords due to laryngospasm. We don't know which of those two contributed. The precise cause of the difficulties with ventilation is impossible to establish. But whatever the reason, the anaesthetist was unable to intubate. Dr Payne-James believes there was a potential solution to the apparent blockage ` an emergency tracheostomy. It's a rare procedure but it's a very effective way of getting air into the lungs. A tracheostomy is simply a surgically created hole in the front of the windpipe, below an obstruction, that allows air to move in and out of the lungs. An emergency tracheostomy is a procedure that should be within the capabilities of any anaesthetist or surgeon. Dr Bankulla, the anaesthetist, states that she considered performing a tracheostomy, but as she eventually successfully intubated, she deemed it unnecessary. However, intubation was not achieved until 19 minutes after Joan went into cardiac arrest. Dr Payne-James believes this delay in intubating resulted in irreparable damage to Joan's brain. If there was complete airway obstruction, then it's possible that an emergency tracheostomy could have saved her life. 5 Joan was transferred to Mt Sinai Hospital where she was put into a medically induced coma in the hope that her brain would recover. The report to the medical examiner says Joan never awakened and remained comatose until her death. The cerebral scans were consistent with global anoxic injury. This means that the brain has been deprived of oxygen for a significant period of time. The office of the chief medical examiner completed its investigation and concluded, and I quote, 'That the cause of Miss Rivers' death is anoxic encephalopathy 'due to hypoxic arrest.' And what that simply means is that she died from a lack of oxygen to the brain. So for me, the 19 minutes between the loss of her pulse and Joan's successful intubation is crucial. Her oxygen saturations were already marginal, and in that critical period of time, her brain was starved of oxygen, which resulted in the irreversible brain damage from which she could not recover. Joan's daughter, Melissa, has begun a medical negligence action against the doctors and the clinic. The defendants deny negligence. MACHINE BEEPS BAGPIPES PLAY Three days after her death, Joan's memorial service was held in New York. Her send-off was attended by her family, close friends and hundreds of adoring fans. She cared so much about the audience. She cared so much about her craft, and she cared so much about the community. Relevance was very important to Joan. It was important to her that the people remember her, that she was still around and that she was still part of the public eye. Joan Rivers is at the forefront... There is no one else. She is Mt Rushmore of comedy. I thought this is exactly what she would have liked. I think she would have loved every single minute of it. I think the world will miss a very bold, a very funny, a very wonderful lady, and for those that knew her intimately, generous to a fault. I will miss Joan more than I can describe, more than anyone I've ever known in my life.