She pronounced at 5:11.

And then four things happened, none of which is a scandal on its own.

The family produced a physician. Fernando Vance told the night doctor that his daughter was under the care of Dr.

Sergio Reyes and that Dr.

Reyes was on his way and would complete the certificate.

That is a normal thing.

A treating physician certifying a death is the standard route and it exists precisely so that a night-shift doctor who has never met a patient does not have to.

Nobody called the medical examiner. This is the failure and it is the only one.