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Background: Necrotising fasciitis (NF) is a life-threatening bacterial infection with high mortality. This retrospective study aimed to investigate patient characteristics and potential areas for improvement in clinical management in NF cases in Australia. Methods Retrospective analysis of surgical death data from all public and private Australian hospitals in every state and territory, excluding New South Wales, collected through the Australian and New Zealand Audit of Surgical Mortality for the 9-year period, January 2009 to February 2018. Results A total of 290 NF cases were identified. Among these NF cases, obesity and diabetes mellitus were two of the most common comorbidities, with a prevalence of 26% and 41%, respectively. A total of 41 clinical management issues (CMIs) were identified among 36 NF cases. A larger proportion of NF cases had CMIs compared with non-NF surgical mortality cases. Delay in diagnosis was the leading CMI (n= 28, 68.3%), followed by delay to surgery (n= 7, 17.1%). The majority of delayed diagnoses were attributed to non-surgical clinicians in the hospital. Conclusion CMIs were identified in a larger proportion of NF cases than in other non-NF surgical mortality cases, suggesting that there are areas for improvement in NF diagnosis and management in Australia. The leading potentially avoidable issue identified in NF deaths was delay in diagnosis. This highlights the importance of awareness among non-surgical clinicians that NF is a surgical emergency requiring urgent debridement. Refereed/Peer-reviewed

Background: Independent peer review of mortality cases has potential to identify issues in cardiothoracic surgical patients. The Australian and New Zealand Audit of Surgical Mortality aims to improve surgical care through peer-reviewed assessment of all surgical mortality. The aim of this study was to describe common clinical management issues that contribute to patient mortality in a cohort of Australian cardiothoracic surgical patients. This approach may subsequently provide a basis for quality improvement. Methods: Cardiothoracic mortality reports to the Australian and New Zealand Audit of Surgical Mortality from February 2009 through December 2015 were reviewed. The surgeon report and assessor comments were coded to identify clinical management issues. These were divided into perioperative stages (preoperative, intraoperative, and postoperative), and at each stage a thematic analysis was performed. Results: Of the 908 cases analyzed, 1371 clinical management issues were identified. Postoperative issues were the most common (n = 552), followed by preoperative (n = 378) and intraoperative issues (n = 370). Communication issues were present at all 3 stages (n = 71). Overall the most common theme was intraoperative technical issues (n = 287). Many of these issues revolved around unintentional injury to anatomic structures during surgery and inadequate myocardial protection. Communication issues commonly related to surgical handover to the intensive care unit and lack of shared decision-making. Also common were consultant surgeons being unaware of patient deterioration or significant changes in management. Conclusions: The Australian and New Zealand Audit of Surgical Mortality provides valuable insights into issues affecting mortality in cardiothoracic patients. Potentially avoidable management issues play a large role in determining the outcome of these patients. Quality improvement initiatives targeting these areas may be valuable. Refereed/Peer-reviewed

Background: This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt. Methods: This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage. Results: The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant. Conclusion: Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care. usc Refereed/Peer-reviewed

Background: Mortality rates are commonly used to evaluate the quality of surgical care; however, a large proportion of surgical deaths are unavoidable. Examination of the potentially avoidable issues in surgical deaths can provide a strong basis for quality improvement. Using data from a well-established and comprehensive national surgical mortality audit, we sought to identify the most common avoidable factors in neurosurgical deaths, focusing on the lessons that can be learnt. Methods: This study analysed data from a peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2014, focusing on neurosurgery cases with identified areas for improvement in patient management. In the 6% of neurosurgical cases that had clinical incidents, there were 193 clinical events identified. These were first categorized based on the perioperative stage (pre-, intra- or postoperative) followed by thematic analysis within each stage. Results: The study found preoperative issues to be the most common (n = 107) followed by postoperative issues (n = 31) and intraoperative issues (n = 29). The most common theme was inadequate assessment (n = 65) followed by poor communication (at any stage of treatment) (n = 26). Conclusion: Neurosurgical cases with potentially avoidable mortality constitute a small but important subset. Avoidable contributors to mortality occurred most frequently at the preoperative stage, most commonly relating to inadequate assessment and delays. These findings can inform various stakeholders to improve the quality and safety of surgical care. Refereed/Peer-reviewed