The New York Department of Health and Human Services has examined the office where Joan Rivers stopped breathing and a disturbing number of mistakes were found.

According to a report obtained by TMZ, the Yorkville Endoscopy Center did more than a few things wrong on that fateful day.

First and maybe foremost was the fact that no one at the office weighed Joan before her procedure. Since she was going to be sedated for the endoscopy they would have needed to know her weight in order to administer the correct amount of anesthesia.

And according to the computer they actually gave Rivers TWICE the necessary dose of Propofol to put her under. Though a staff member had told the Health and Human Services people that she made a computer mistake and the dosage entered in their computer was more than was actually administered.

Still the report's list of questionable things continues.

Apparently Joan's personal doctor, Dr Gwen Korovin, came into the operating room without authorization and announced that she would do the procedure first on Joan. But the procedure Dr. Korovin performed was a laryngoscopy, even though Joan had only consented to an upper endoscopy procedure.

Dr. Korovin is also the doctor who took that now famous selfie photo in the operating room. She reportedly asked the staff to take that photo of her doing the procedure saying Joan wanted it.

And finally, and perhaps the worst part of all this, The Department's reports says the staff didn't even notice that Rivers was dying on the table. The were apparently oblivious as her oxygen levels plummeted.

Very sad report indeed.