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How do you do a death audit?

On July 3, 2011, Ken Devoney living at 5042 N Winthrop Ave., Chicago, passed away.
He is survived by his two sisters and their children.

What was the cause of death?
He had a cardiac problem.
He died of cardiac arrest.
These were the available facts.

What questions need to be answered?

What were the symptoms, signs, or complaints he had prior to death?

To whom did he complaint prior to death?

Did he have any diagnosis prior to death?

What was the diagnosis?

Who has his medical records?

What is contained in his medical records?

When were the medical records last updated?

Did his symptoms and signs correlate with the diagnosis?

How old was he?

What is the contact information of his relatives?

Did he die in his sleep or was he awake when the problems occurred?

Who knows more about this case?

What was the exact location and circumstances of the death?

Who verified the death?

Who witnessed the funeral?

What type of burial did he have?

Was there a religious burial?

Where is his burial site?

Did he have any other health problems?

Did he die in the hospital or at home?

Who first reported his death?

What were the circumstances under which he or she reported his death?

Who was his treating medical doctor?

What was his treating medical doctor’s reponse to his premature death?

What issues need to be deliberated?

The system did not provide proper health care services.
The system did not utilize already existing heath care services within the building.

Who should be held responsible for this premature death?

How could this have been prevented?

By properly educating health care workers, including medical doctors.

By properly utilizing health care resources existing in the building.