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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.

 ROLE OF THE COMMITTEE

To 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.

BENEFITS TO ANAESTHESIA AND THE COMMUNITY

CONFIDENTIALITY

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 other offences.

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 persons involved.

COMPOSITION OF THE COMMITTEE

All members of the Committee are appointed by the Minister of Health

Five permanent members (including deputies) who are nominated by

(a) The Regional Committee of the Australian and New Zealand College of Anaesthetists (this nominee will be chairman of the committee). 

(b) Commissioner of Health

(c) Senate of the University of Western Australia (Professor of Anaesthesia or his/her nominee)

(d) State branch of the Australian Society of Anaesthetists

(e) State branch of the Australian Medical Association

 An Investigator and a deputy investigator

 Seven 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 Practitioners (two)

(c) State branch of the Royal Australasian College of Surgeons

(d) Royal Australasian Nursing Federation (A registered midwife)

(e) State branch of the Australian Dental Association (A dental practitioner)

(f) University of Western Australia (Professor of Clinical Pharmacology)

Other medical practitioners or nurses with specialised knowledge may be co-opted to the Committee

CURRENT COMMITTEE 

The current committee may be obtained by contacting Anaesthesia WA Secretariat.

HOW THE COMMITTEE FUNCTIONS

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 report.

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

  1. 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

  2. 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.

  3. Cases in which the patient's death was caused by both the anaesthetic and surgical technique

  4. Death entirely referable to surgical technique

  5. Inevitable deaths, such as death due to severe general peritonitis, but in which anaesthetic and surgical techniques were apparently satisfactory

  6. Fortuitous death, such as death due to pulmonary embolism

  7. Death which cannot be assessed despite considerable data

  8. Death on which an opinion could not be formed because of inadequacy of data.

  9. The Committee further classifies category 1, 2, or 3 Cases Using The NH&MRC

NH&MRC CLASSIFICATION OF ANAESTHESIA RELATED FACTORS AND CAUSES OF DEATH

A.          Preoperative

  1. inadequate assessment
  2. inappropriate management

B.           Anaesthetic Technique                 

  1. inappropriate technique
  2.  inadequate ventilation
  3.  inappropriate airway management
  4.  equipment failure

C.           Anaesthetic Drugs                          

  1. inappropriate drug selection
  2. inappropriate drug dosage
  3. adverse drug reaction
  4. incomplete drug reversal or recovery

D.          Anaesthetic Management

  1. inadequate crisis management
  2. inadequate monitoring

E.          Post-operative                                  

  1. inappropriate management
  2. inadequate supervision and monitoring
  3. inadequate resuscitation

F.          Other                                                 

  1. inexperience/inadequate supervision
  2. incompetence
  3. other (specify)

 

WHICH CASES TO REPORT

Section 336B of the Act states:-

1.            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 the deceased.

2.           Where 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.

WHAT TO REPORT

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 medical records.

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.


Date

 Executive Director, Public Health

Health Department of Western Australia

P. O. Box 8172

Stirling Street

PERTH WA  6849

Dear Sir

 

CONFIDENTIAL REPORT TO THE STATE INVESTIGATOR

ANAESTHETIC MORTALITY COMMITTEE

 

PATIENT NAME: XXXX

ADDRESS: 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

TIME ANAESTHETIC BEGAN:  XXXX ENDED:  XXXX

DURATION INDUCTION TO DEATH:  XXXX

PRESUMED CAUSE OF DEATH:  XXX

 Text Summary……


ADDRESS FOR REPORTS

Executive Director, Public Health

Health Department of Western Australia

P.O. Box 8172

Stirling Street

PERTH WA  6849

NUMBER OF 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).

NATIONAL 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 reports.

 Dr Neville Gibbs , Chairman, WA Anaesthetic Mortality Committee, April 2001

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Webbed by Richard Riley (richard@pobox.com

 Last update: 06-May-2007