Education And Debate

Building a framework for trust: critical event analysis of deaths in surgical care

BMJ 2005; 330 doi: (Published 12 May 2005) Cite this as: BMJ 2005;330:1139
  1. A M Thompson, professor of surgical oncology (,
  2. P A Stonebridge, professor of vascular surgery2
  1. 1 Department of Surgery and Molecular Oncology, University of Dundee, Dundee DD1 9SY,
  2. 2 Institute for Cardiovascular Research, Ninewells Hospital and Medical School, Dundee DD1 9SY
  1. Correspondence to: A M Thompson.

    The British public's confidence in doctors and hospitals has been dented in recent years. Use of an independent review of deaths before, during, or after surgery reflects an attempt to improve care in this area and may also help to restore the public's trust in their health service


    Events over recent years have undermined patients' and society's trust in clinicians and healthcare institutions. For clinicians to restore and retain public confidence, they need to show that effective mechanisms exist for assessing events such as death and to justify patients' faith in the delivery of care.1

    In the high profile world of cardiac surgery, the audited results of key elective procedures may be sufficient to restore confidence.2 In wider surgical practice, simple death rates are unlikely to be sufficient; case-mix (particularly for emergency admissions), institutional, and national issues can jeopardise the interests of high risk patients.3

    Any critical incident review by peers working in the same speciality or subspecialty of patients who die under surgical care should take into account the nature of the patient and the circumstances of admission. In Scotland, the Scottish Audit of Surgical Mortality (SASM) is a national system of peer review of deaths that occur under surgical care that has been in place since 1994.4 Full details of how SASM works, and the annual reports, are on its website (

    Assessment process

    SASM uses the consultant surgeon responsible for the care of the deceased patient as a proxy for the secondary care system and includes all deaths under surgical care in Scotland (including the private sector) except for cardiac surgery and obstetric deaths, which are currently audited separately. SASM assesses the patient's last journey of care, not simply the role of a single clinician or clinical team.

    The method of case assessment and …

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