In April 2010, the Council of Australian Governments (COAG) agreed on health and hospitals reform, with the establishment of the National Health and Hospitals Network. The aims of the network include “helping patients receive more seamless care across sectors of the health system” and “improving the quality of care” with “high-performance standards”.1 As a key component of the reforms and a funding condition, health facilities will be required to regularly report performance data to the federal government. Data will be based on national performance indicators that are already agreed to by COAG and address “access to services, quality of service delivery, financial responsibility, patient outcomes and/or patient experience”.2

Disappointingly, the COAG reforms appear to neglect clinical patient outcome data that are reported for the purpose of monitoring and improving patient safety, not least of which are mortality data.

In Australia, pooled data on anaesthesia-related and surgery-related perioperative mortality are routinely analysed by the Australian and New Zealand College of Anaesthetists Mortality Working Group and the Royal Australasian College of Surgeons’ Australia and New Zealand Audit of Surgical Mortality, respectively.3 The practice of anaesthesia is highly regarded for its patient-safety record, and mortality reporting is considered an important tool in monitoring safety by informing standards of care with respect to equipment, techniques and classification of patients’ fitness.4 This year will see the first national public reports on surgical mortality in Australia, with early reports from Western Australia supporting the argument that clinician participation and leadership in mortality audits produce changes and improvements in patient care. Data from WA show that the proportion of deaths associated with deficiencies of care has fallen, and 73% of participating surgeons have changed their practice in at least one way.5

Clinician-led mortality reporting can contribute meaningfully to health reform but, sadly, there are few other instances of peer review of treatment-associated mortality and centralised public reporting in Australian health systems. Closer examination reveals that even the national anaesthesia dataset is incomplete because several states do not participate in mortality audits.3 Cooper and Gaba, in an appraisal of international anaesthesia-related mortality reporting, explain the limitations of, and possible reluctance to participate in, mortality reporting, which they claim is “plagued by confounding variation in definitions, relatively small sample sizes from selected institutions, and the lack of large population studies”.4

The Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) in New South Wales — the longest-serving committee of its sort in Australia — is an excellent model of clinician-led mortality reporting.6 Appointed by the NSW Minister for Health and administered by the Clinical Excellence Commission (CEC), SCIDUA reviews all deaths occurring within 24 hours of anaesthesia or sedation. Data analyses by SCIDUA, which this year is celebrating its 50th anniversary, have substantially contributed to mortality reporting internationally.3,7,8 The Australia and New Zealand Audit of Surgical Mortality developed from the SCIDUA model via the NSW Special Committee Investigating Deaths Associated With Surgery (established in 1993, the latter is now the Collaborating Hospitals Audit of Surgical Mortality, and it too is administered by the CEC).

SCIDUA’s terms of reference provide solutions to several of the limitations described by Cooper and Gaba4 and are useful starting points for other groups establishing mortality registers.6 Important starting points include a clearly defined preoperative period and phrasing of degrees of contribution to death. SCIDUA’s registry includes both expected and unexpected deaths, enabling identification of unanticipated emerging threats to safety, such as those associated with new drugs and procedures. Patients are classified according to their risk of death from comorbidities. This classification allows data about expected and unexpected deaths to be analysed separately, an essential requirement for trend analysis when concomitant increases in patient and surgical complexity could confound mortality rates.

All sources of data obtained by SCIDUA are protected by qualified privilege under section 23 of the Health Administration Act 1982 (NSW). Of historical interest, SCIDUA was responsible for this section of the Act, which ensures qualified privilege to peer-review committees across all clinical disciplines within NSW.

Recent changes to the NSW Public Health Act 1991 and Public Health (General) Regulation 2002 have led to a modified procedure for reporting deaths occurring within 24 hours of anaesthesia or sedation (now classified as a Category 1 scheduled medical condition). However, the new procedure retains not only mandatory notification of perioperative death but protection by privilege of anaesthetists who voluntarily submit information and analyses. These provisions encourage frank and comprehensive reporting, evidenced by the breadth of information available for analysis.3

Lessons in maintaining patient safety generated through SCIDUA are communicated widely. SCIDUA sends a confidential report outlining its conclusions about the circumstances contributing to death to the notifying anaesthetist. Pooled de-identified data are incorporated into the Australian and New Zealand College of Anaesthetists’ national triennial mortality report.3 The health care community is alerted to perceived safety risks through an annual report provided to the NSW Minister for Health and through periodic reports published in national and international journals.9,10

All deaths in all health facilities should be subject to clinical scrutiny. De-identified and pooled data should be systematically analysed for the purpose of continually monitoring patient safety as therapies change. The models provided by SCIDUA and, more recently, the Australia and New Zealand Audit of Surgical Mortality are there to be applied by all health care providers. Food for thought!