Mortality associated with anaesthesia. A case review study.

The review is based on an analysis of anonymous case record material at the Medical Protection Society's London Office for the 5-year period 1982-1986, in which death was associated with anaesthetic procedures. A total of 25 cases were analysed. The principal events which resulted in death were failed intubation, drug-related problems and problems with equipment. The principal contributory factors were inadequate supervision, inadequate pre-operative assessment and failure of communication. The present review suggests that supervision and training of junior staff, decision-making by senior staff and patterns of communication both within and between specialties are areas which should be selected for further research.