Review of death

The Western Australian Department of Health recognises that conducting review into deaths can help us to improve the overall quality of patient care that we provide.

Reviews of death are one component of an overall approach to clinical governance that includes clinical risk management, clinical incident management and complaint management. The National Safety and Quality Health Service (NSQHS) Standards (external site) (second edition) devote the entirety of Standard 1 to the importance of clinical governance within health service organisations.

Reviews of death (mortality reviews) provide valuable opportunities to examine the care provided to patients; to identify if the care was appropriate, whether it could be delivered differently or improved, and to evaluate the quality of end-of-life care. Reviews of death may also identify cases where sub-optimal care may have contributed to the death of a patient, and that death may have been preventable.

Mortality review in the WA health system is governed by the Review of Death Policy (MP 0098/18), which is applicable to Health Service Providers, and to private health care facilities that have a licence requirement to comply with it.

The purpose of the Review of Death Policy is to ensure that Health Service Providers and private health care facilities implement consistent and effective policies, processes and systems for recording and reviewing patient deaths, in order to identify potentially preventable deaths and opportunities for improvement in the delivery of health services, including the quality of end-of-life care. Each patient’s death is required to be reviewed for preventability and quality improvement opportunities within four months of the date of death.

Any preventable deaths identified via the review process are required to be notified as Severity Assessment Code (SAC) 1 clinical incidents and investigated in accordance with Clinical Incident Management Policy (if this has not already occurred). The Review of Death Policy also has a relationship to the Western Australian Audit of Surgical Mortality (WAASM) as participation in the WAASM fulfils mortality review obligations established by the Review of Death Policy.


The Review of Death Policy applies to all patient deaths that have not been referred to the WAASM or notified as SAC 1 clinical incidents including, but not limited, to those:

  • That occur in hospitals in Western Australia
  • That occur under the care of Hospital in the Home (HITH) and Rehabilitation in the Home (RITH) services, and
  • Involving Nursing Home Type category and Care Awaiting Placement patients in Western Australian public hospitals.

This includes deaths of patients that are not for resuscitation (NFR), not unexpected (e.g. terminally ill and palliative care patients), or that occur in Emergency Departments.

Health Service Providers and private health care facilities are also encouraged to review deaths of patients who received healthcare in ambulatory or community care settings (e.g. community mental health patients, terminally ill patients in the community).

Reporting requirements

Health Service Providers and private health care facilities are required to report their compliance with the Review of Death Policy to the Patient Safety Surveillance Unit (PSSU) twice per year.

Periodic reporting is due by 31 May (for deaths during the preceding period July to December) and 30 November (for deaths during the preceding period January to June). See the reporting templates for the Review of Death Policy.

More information

Patient Safety Surveillance Unit

Last reviewed: 08-04-2022
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Patient Safety Surveillance Unit