What went wrong with Joan Rivers' last procedure

The late comedian, Joan Rivers.

Melissa Rivers has filed a malpractice suit against Yorkville Endoscopy, the New York City clinic that treated her mother, Joan, for a minor throat surgery last August. The procedure had complications and Joan Rivers went into cardiac arrest; she died a week later.

While the New York medical examiner determined that Rivers died from brain damage due to lack of oxygen, many questions remained about what exactly went wrong during what was supposed to be a routine procedure. (Rivers went in complaining of hoarseness in her voice.) The suit against the clinic alleges that the doctors at the clinic were "reckless, grossly negligent and wanton" and abandoned the 81-year-old comedian "when emergency procedures were necessary to save her life."

"What ultimately guided me was my unwavering belief that no family should ever have to go through what my mother, Cooper and I have been through," Melissa Rivers told the AP about her decision to file the lawsuit, which seeks an unnamed amount in damages. "The level of medical mismanagement, incompetency, disrespect and outrageous behavior is shocking and frankly, almost incomprehensible."

Here's what the complaint says happened.

Before the procedure:

Before she went under anesthesia, Rivers signed a written consent form allowing for surgical procedures, including an upper endoscopy (which examines the digestive tract) and possible biopsy. In the procedure room were Lawrence Cohen, then the medical director of the clinic, and Renuka Bankulla, an anesthesiologist. Rivers's personal doctor, Gwen Korovin (an ear, nose and throat specialist) was also in the room.

That is a key point in the complaint: That Korovin a) should not have been allowed into the room while the procedure was taking place and b) was not allowed or licensed to perform any medical procedures at the clinic. But clinic staff did not stop her, the complaint alleges.

During the procedure:

Korovin took the lead and performed a transnasal laryngoscopy on Rivers (which examines the back of someone's throat and vocal box), even though that wasn't initially discussed. The complaint says Bankulla raised questions given that Rivers had not authorized the additional procedure - but Cohen ignored the objections and allowed Korovin to go on with the laryngoscopy.

The complaint notes that during the laryngoscopy, Bankulla had trouble keeping Rivers's oxygen saturation at a safe level, and her oxygen dipped again during the endoscopy. The doctors "failed to properly observe and monitor Joan Rivers's vital signs which were deteriorating," it states, adding that her blood pressure and pulse were also dropping.

When the endoscopy was done, Korovin wanted to do another laryngoscopy. Again, a concerned Bankulla raised objections. The complaint says that Cohen told Bankulla that she was "being paranoid." And even though Rivers was sedated at a lighter level after the endoscopy - which left her vocal cords at greater risk of irritation from the medical instruments - Korovin went on to do the procedure one more time.

The suspicious selfie:

One bit of gossip that circulated after Rivers' death was that one of the doctors snapped photos of Rivers while she was under anesthesia. The complaint alleges that Cohen, in fact, took out his phone and took pictures of Rivers with Korovin. He said that Rivers possibly "will like to see these in the recovery area."

After the procedure:

Rivers began suffering from bradycardia (when the heart rate slows down to dangerous levels) and a "code blue" was called. The doctors also noticed her oxygen levels were dropping, but that none of them "ordered, performed or recommended the appropriate emergency treatment." Also, the complaint says, when Cohen finally looked to Korovin to perform an emergency procedure to help the oxygen flow, Korovin had already left the room and "abandoned her patient." Twelve minutes after the doctors called "code blue," someone dialed 911 for an ambulance.

Ultimately, the complaint states, "None of the medical personnel at Yorkville Endoscopy who were present during the procedures performed on Joan Rivers possessed the knowledge, training and ability to handle the medical emergency." Rivers died a week later at a Manhattan hospital.

The complaint echoes what federal investigators for the Centers for Medicare and Medicaid Services outlined in a report last fall. As a result, Yorkville Endoscopy is scheduled to lose its federal accreditation.