Healthcare Inspection Review of an Unexpected Death North Chicago VA Medical Center North Chicago, Illinois

The purpose of this inspection was to determine the validity of allegations regarding the care provided to a patient who died within 24 hours of admission to the North Chicago VA Medical Center (VAMC), North Chicago, Illinois. The complainant suggested that a medical trainee may have been inadequately supervised. We found the quality of care reviews conducted by the VAMC to be thorough. Although we found deficiencies in the quality of care provided for this patient, we did not demonstrate a connection with the patient’s death. We recommended that managers evaluate this case with Regional Counsel for possible disclosure to the patient’s family. We also recommended that staff comply with the VAMC’s policy for rapid intervention in patients with deteriorating clinical conditions. Management submitted appropriate implementation plans.