A case of respiratory arrest turned fatal for Joan Rivers when it resulted in brain damage, according to the New York City medical examiner, which described the incident as "a predictable complication of medical therapy."

The medical examiner's report on the comedian's Sept. 4 death, released on Thursday afternoon, "did not cite medical error as a cause of death, but left open the possibility of malpractice," notes the New York Times. Nor did it assess the adequacy of any rescue attempts during the incident.

An ENT specialist quoted in the Times remarked, however, that as a cause of death, anoxic encephalopathy due to hypoxic arrest generally results from a series of mistakes. "It's not easy to kill a patient," says Jamie Koufman, MD. "It takes several errors."

Ms. Rivers, 81, underwent a laryngoscopy and upper GI endoscopy under propofol at Yorkville Endoscopy on August 28. The routine procedure was intended to probe a recent bout of hoarseness and the possibility of acid reflux.

David Bernard