Anaesthesia Mortality Committee (Western Australia)
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This is a Committee appointed by the Minister of Health as per the 1978 Amendment of the Health Act 1911: Part XIIIC: Section 340B. The first meeting was held on September 21, 1979 under the Chairmanship of Dr T. M. McAuliffe.
OF THE COMMITTEE
investigate deaths that occur within 48 hours of administration of an anaesthetic OR are
considered to be due to the effects of an anaesthetic and to determine 'whether in the
opinion of the committee the death might have been avoided'. The Committee ' may add to such determination such
constructive comments as the committee deems advisable for the future assistance and
guidance of medical practitioners, dental practitioners, and nurses'. The medical or dental practitioner involved is
notified in writing and in confidence about the determination of the Committee.
A confidential summary of the cases
investigated by the investigator and considered by the Committee during each year is
forwarded to the Commissioner.
The Committee may impart or cause to
be imparted to medical practitioners and others such education and instruction in
anaesthetic theory and practice as it may deem necessary or advisable from time to time so
to do for their assistance and guidance in avoiding and preventing anaesthetic morbidity
or mortality. The Committee is an advisory
NOT a disciplinary body.
TO ANAESTHESIA AND THE COMMUNITY
The Anaesthetic Mortality Committee is protected
by the Health Services (Quality Improvement) Bill 1994 which has effect despite the Freedom of Information Act 1992.
Confidentiality is a fundamental concern for the
Committee. The Committee will not discuss or report on any case unless complete
confidentiality can be assured.
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Only the Chairman, Investigator, and Executive
Director, Public Health are aware of the identities of any parties in any reports made to
the Committee. All identifying information is
removed from all information that is provided to other members of the Committee.
No member of the Committee other than the
Chairman or Investigator shall communicate with the person referred to in any report.
No information, record, report, statement,
memorandum or particulars is admissable in any court or before any tribunal board or
person in any action or inquiry of any kind whatsoever.
However, nothing in the Act shall prejudice or otherwise affect any of the
provisions of the Coroner's Act so far as it relates to prosecutions for indictable and
Therefore, Coroner's cases are not discussed by
the Committee until the Coroner has given his verdict on that case.
The Committee may publish a summary of its
investigations so long as this does not involve disclosure or identification of any of the
OF THE COMMITTEE
All members of the Committee are appointed by the
Minister of Health
Five permanent members (including
deputies) who are nominated by
Regional Committee of the Australian and New Zealand College of Anaesthetists (this
nominee will be chairman of the committee).
(c) Senate of the University of Western Australia (Professor
of Anaesthesia or his/her nominee)
branch of the Australian Society of Anaesthetists
(e) State branch of the Australian Medical Association
Investigator and a deputy investigator
provisional members (including deputies)who are nominated by
(a) State branch of the Royal Australasian College of
Obstetricians and Gynaecologists
(b) State branch of the Royal Australasian College of General
(c) State branch of the Royal Australasian College of Surgeons
(d) Royal Australasian Nursing Federation (A registered
(e) State branch of the Australian Dental Association (A
(f) University of Western Australia (Professor of Clinical
Other medical practitioners or nurses with
specialised knowledge may be co-opted to the Committee
The current committee may be obtained by contacting Anaesthesia WA Secretariat.
All reports to the Executive
Director, Public Health are forwarded to the Investigator.
If the Investigator makes a determination from a report that anaesthesia played no
part in the death of the patient, this will be communicated to the Executive Director,
Public Health who will communicate this in writing to the practitioner making the
report. If there is insufficient information
in the report for the Investigator to make a determination, the Investigator will examine
the patient's medical records. If the Investigator makes a determination from the
patient's records that anaesthesia played no part in the death of the patient, this will
be communicated to the Executive Director, Public Health the practitioner making the
If the Investigator is unable to
make a determination of the cause of death, or has an opinion that the death was wholly or
partly attributable to anaesthesia, the Investigator will report this determination to the
Chairman of the Committee. From time to time
the Chairman of the Committee will convene a meeting of the Committee to discuss such
determinations. This will usually involve all
permanent members of the Committee (or their deputies) and at least two provisional
members (or their deputies). The Committee
then considers the Investigator's report and the patient's records and makes an
determination (in their opinion) about the contribution of anaesthesia, if any, to the
death of the patient .
The Committee classifies all deaths using the
NH&MRC Primary Classification of Peri-operative Deaths:-
NH&MRC PRIMARY CLASSIFICATION OF PERI-OPERATIVE DEATHS
Where it is reasonably certain that death was caused by the
anaesthetic agent or technique of administration, or in other ways coming directly within
the anaesthetist's province
Similar cases, but in which there is some element of doubt as to
whether the agent or the technique was entirely responsible for the fatal result.
Cases in which the patient's death was caused by both the
anaesthetic and surgical technique
Death entirely referable to surgical technique
Inevitable deaths, such as death due to severe general peritonitis,
but in which anaesthetic and surgical techniques were apparently satisfactory
Fortuitous death, such as death due to pulmonary embolism
Death which cannot be assessed despite considerable data
Death on which an opinion could not be formed because of inadequacy
CLASSIFICATION OF ANAESTHESIA RELATED FACTORS AND CAUSES OF DEATH
B. Anaesthetic Technique
C. Anaesthetic Drugs
D. Anaesthetic Management
CASES TO REPORT
Section 336B of the Act states:-
Whenever any person should die within a period of 48 hours following the
administration of an anaesthetic agent or as a result of any complications arising from
the administration of an anaesthetic, the fact of such death shall be reported forthwith
to the Executive Director, Public Health by the person who administers the anaesthetic to
a medical practitioner who attended a person prior to the death of that person is of the
opinion that anaesthesia or the administration of an anaesthetic may reasonably be
suspected as the cause of death or as contributing to the cause of death of that person ,
that medical practitioner shall forthwith report to the Executive Director, Public Health
that he has formed such an opinion.
Deaths reportable to the Maternal Mortality
Committee are not reportable to the Anaesthetic Mortality Committee.
Reports of deaths to the Coroner are completely
separate from reports under the 'Anaesthetic Mortality ' Act.
It is noted that only the FACT OF DEATH must
be reported to the Executive Director, Public Health.
However, a summary assists the Investigator to make a determination about whether
anaesthesia may have contributed to the death. If
no details are provided to the Investigator, the Investigator MUST examine the patient's
The following is an example of the minimum
data required by the Investigator. This is
usually accompanied by a short narrative summary of the circumstances of the death.
Executive Director, Public Health
Health Department of Western Australia
P. O. Box 8172
PERTH WA 6849
CONFIDENTIAL REPORT TO THE STATE INVESTIGATOR
ANAESTHETIC MORTALITY COMMITTEE
PATIENT NAME: XXXX
DATE OF BIRTH: XXXX URN: XXXX
OPERATION: XXXX HOSPITAL: XXXX
DATE: XXXX ASA: XXX
DATE DECEASED: XXXX TIME DECEASED: XXXX
ANAESTHETIST/S: XXXX SURGEON: XXXX
BEGAN: XXXX ENDED: XXXX
TO DEATH: XXXX
PRESUMED CAUSE OF
Executive Director, Public Health
Health Department of Western Australia
P.O. Box 8172
PERTH WA 6849
CASES REPORTED AND INVESTIGATED ANNUALLY
Approximately 100-150 cases are reported to the
Executive Director, Public Health each year. Usually
less than 10% of these cases are classified I - III (ie anaesthesia might have played some
part in the death).
ANAESTHESIA MORTALITY COMMITTEE
This Committee which is composed of the President
of ANZCA, and the Chairmen of State Anaesthetic Mortality Committees meets at least
annually at the ANZCA headquarters in Melbourne to share information and produce national
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Last update: 06-May-2007