Fig 1.

The pathway of data gathering and assessment starts with a surgical death and proceeds through the critical event pathway. Where there is a cause for consideration or concern, an adverse event may be identified and a case-note review requested. For 10% of the deaths where no adverse event is identified, the case is reassessed. The assessments and review are fed back to the individual clinician, who has the right to reply or request a further review, leading to a final feedback to the clinicians involved in the care of the patient before death