Mortality associated with surgery: a case review study

The review is based on an analysis of anonymous case record material at the London Office of a United Kingdom medical protection organisation for the 5-year period 1982-1986, in which death was associated with general surgical procedures. A total of 16 cases were analysed. The majority of deaths occurred in the course of elective procedures, the patients were relatively young (average age 48.4 years) and the doctors involved were primarily of consultant grade. While the types of procedure and the proximate causes of death were varied there were a number of common factors contributing to patient deaths, principally inadequate pre-operative assessment (4 cases), inadequate post-operative management (3 cases) and lack of experience with particular surgical procedures (3 cases). The results are discussed in terms of their relation to the findings of the National Confidential Inquiry into Perioperative Deaths. Suggestions are made concerning training, communication and the introduction of critical incident monitoring into surgical practice.