The 22 page detailed report is graciously plastered on the NY Daily News website for all to see. I highly recommend reading it.
The report explains who the federal investigators spoke to and what they reviewed in order to reach their conclusions...
The endoscopy center failed to have procedures in place to ensure that only authorized and credentialed doctors and staff are permitted on site and in the procedure room.
The endoscopy center failed to have procedures in place to ensure that only authorized and credentialed doctors are permitted to perform procedures.
The endoscopy center failed to have procedures in place to ensure that proper informed consent is obtained for all procedures performed.
As a result of these signficant findings, the federal investigators determined that these compromised patient safety and "an immediate jeopardy" was declared on 9/3/14. In response to these scathing violations, the endoscopy center has confirmed their intention to correct and fix these glaring problems.
Without actually naming who patient #1 is, we know that it's Joan Rivers based on her age, 81 and the date she had her endoscopy procedure at this endoscopy center.
It means that she was supposed to have a fiber-optic tube inserted down her throat into her stomach. However, a different procedure was done compared to the one she was supposed to have. This is because Joan's ear nose and throat doctor was brought into the edoscopy center to perform a look-see.
There was only one big problem...
Joan's ear nose and throat doctor was not credentialed to do any procedure at this facility. Nor did she obtain any written consent from Joan to actually do this procedure. These are two big violations from the standards of care that were referred to earlier by this federal investigation.
Here's the wording in the report...
In the next sentence, the report indicates that this uncredentialed ENT doctor was the one actually performing the nasal procedure in the presence of the medical director (Joan Rivers' gastroenterologist) an anesthesiologist and a technician.
Here's another violation of protocol...
Does that violation mean that the doctors were careless and violated the basic standards of medical care that resulted in Joan's injuries and untimely death? That's not what this section of this report means. In fact, you will notice that nowhere in the report do the federal investigators connect the dots and explain why and how Joan Rivers suffered the injuries she did.
Did you know that in a medical malpractice case in New York, we must only show that we are more likely right than wrong that what we are claiming is true?
Legally, that's known as the preponderance of evidence. Put another way, in order to be successful at trial, a jury must determine that we are only more likely right than wrong that the doctors and staff violated the basic standards of medical care and that those violations were a cause of Joan's injuries and her untimely death.
The jurors do NOT have to sit there for days and weeks on end trying to decide with 100% certainty whether the doctors actions caused and contributed to her respiratory arrest, cardiac arrest, massive brain damage and her death.
Here's another critical observation that is not reflecting kindly upon the doctors and staff at the endoscopy center...
Here is a detailed sequence of events, looking at it from Joan's vital signs of what was happening...
You should know that in an emergency situation, the doctors and staff are not busy writing and records the events as they're happening. Instead, they are (hopefully) attending to the patient. It's only after the crisis has ended do they begin to document the details of the emergency.
As a result, there are often subtle inconsistencies between the timing of the events. Sometimes, there are glaring inconsistencies between team members. This creates often dramatic testimony between the medical caregivers that contradict eachother.
Here's the problem I have with what happened in these fateful minutes...
If Joan went into cardiac arrest at 9:28 a.m. and an anesthesiologist is in the room, why did it take ten minutes to administer basic crash cart emergency life-saving medications? That makes no sense whatsoever. One reason is that the crash cart was nowhere to be found. Either that or it was in an area far away from where this procedure was happening.
Maybe the crash cart (a cart designed to carry life-saving medications) was locked and nobody had the key.
Regardless of the actual reason, the question is why these medications were not administered quickly and immediately.
We would have a field day questioning the anesthesiologist during pre-trial testimony to get to the heart of why these critical life-saving medications were not administered immediately.
"Doctor, would you agree that in an ambulatory surgery facility you must have a crash cart available at all times?
Would you agree that the crash cart must be fully stocked?
Would you agree that a crash cart must be readily available?
Would you agree that the following medications must be contained within a crash cart: Epinephrine, atropine and succinycholine?
Tell me what epinephrine is and when it's used.
Tell me what atropine is and when it's used.
Tell me what succinycholine is and when you'd use it.
Would you agree that if a crash cart was not readily available at the ambulatory surgery facility that would be a departure from good care?
Would you agree that if a crash cart was not full stocked, that would be a departure from good care?
Would you agree that if a crash cart did not containe (1) epinephrine (2) atropine and (3) succinylcholine that would be a departure from good care?
In addition to those departures, they would also be violations from the protocol established by the endoscopy center.
In addition to those departures, they would also be violations from good, basic anesthesia practice."
and on, and on...
Here's just one inconsistency in the timing of when life-saving medication was given...
Here's another two violations observed by federal investigators...
There is a requirement that the patient consent in writing to every procedure being performed. According to the investigation, here's what they said...
That of course refers to the procedure done by Joan's private ear nose and throat doctor.
These inconsistencies create an abundance of issues that will be addressed during any lawsuit that's brought by Melissa Rivers during the depositions of the endoscopy center staff and anesthesiologist.
To forcefully bring home the point, the investigators point out a glaring lack of informed consent for the laryngoscopy that was done by the ENT...
To add fuel to the fire, we have indications that a staff member took a photo using a cell phone while Joan Rivers was sedated which clearly violated the endoscopy facility's cell phone policy. Take a look...