Deaths attributed to anaesthesia in New South Wales, 1984-1990

The New South Wales Special Committee Investigating Deaths Under Anaesthesia classified 1503 deaths before full recovery from anaesthesia occurring between 1984 and 1990. 172 deaths were attributed to anaesthesia, including 11 in which the anaesthetic choice or management could not be criticized. In the remaining 161 an average of 1.8 errors per case were identified, the most frequent being inadequate preparation of the patient (in 72 cases), inadequate postoperative care (52 cases), the technique of anaesthesia chosen (44 cases) and overdose (43 cases). Death was most commonly attributed to anaesthesia in elderly patients (modal age group 70-79), in males (1.9:1) and was most commonly associated with abdominal and orthopaedic operations, Urgent non-emergency cases, 10% of the 1503 cases classified, constituted 26% of those deaths attributed to anaesthesia. One death attributable to anaesthesia occurred per 20,000 operations and the rate of such deaths was 0.44 per 100,000 population per annum.