Background Mortality statistics are key inputs for evidence based health policy at national level. However mortality statistics alone does not provide necessary information for further identification of improvement opportunities which could be manageable in local health systems in the place where vital registration system is not established. This study intends to disclose the profile of death events among the urban poor, with aim to identify improvement opportunities from the view of quality management of local health system. Methods Eleven communities in Ancol, Jakarta, were selected for the survey, and the information of death events were collected from community leaders of rukun warga (RW), village office, health centers, hospitals, and public cemeteries. The families or co-habitants of the deceased cases under 55 years old were interviewed. Results Two hundred and twenty four of death events were identified. The number reported in the demography statistics was 114 in 24 months during the same period, while 67 cases less than 55 years old were investigated by interview regarding history prior to death. . Thirty-eight percent died at healthcare facilities while 59% died at home. Private services were consulted as frequently as public services. Case studies based on history review revealed “improvement opportunities” in local health systems, and some of those critically contributed to eventual deaths which would be prevented by improvement in quality management of local health systems. Conclusion Community death events were good tracer for assessment of actual performance of local health systems as well as for identifying improvement opportunities.