Special Committee Investigating Deaths Under Anaesthesia


To improve the quality and safety of anaesthetic administration in NSW. To reduce anaesthesia-related mortality in NSW.


SCIDUA looks for errors of management in the administration of anaesthesia and/or sedation. The committee also monitors anaesthetic outcomes and identify emerging trends that are associated with changes in anaesthetic, surgical and medical interventions over time. Lessons are identified and shared to facilitate improvements.


SCIDUA is an expert committee appointed by the NSW Government and has been reviewing anaesthesia-related deaths since 1960. In NSW, health practitioners are legally required to notify any deaths arising after anaesthesia or sedation for operations or procedures. SCIDUA provides confidential feedback on the review findings to health practitioners to facilitate reflective learning and practice improvement.


SCIDUA is an expert committee appointed by the NSW Government. The committee has been reviewing anaesthesia-related deaths since 1960 and is the longest-serving committee of its type in the world.

Initially the committee looked for errors of management, when the mortality was one in 3,500 cases, and a large number of children and pregnant women died from anaesthesia.

Today, anaesthesia administration is very safe, with a mortality rate of one in 32,000 cases and anaesthesia-related deaths largely occur in very sick or elderly patients.

In NSW, the Public Health Act 2010 requires health practitioners to notify deaths arising after anaesthesia or sedation to the Director-General by completing the State form (SMR010.511): Report of death associated with anaesthesia/sedation, which is reviewed by SCIDUA.

All information collected by SCIDUA has special privilege under section 23 of the Health Administration Act 1982 to enable robust discussion on the clinical management of the patient.

SCIDUA provides feedback on the audit findings to anaesthetists via:

  • confidential feedback to individual health practitioners on cases reviewed by the Committee
  • an annual report which is widely circulated within the NSW health system and available from the CEC website
  • submission of de-identified aggregate data to the Australian and New Zealand College of Anaesthetists for triennial national reporting
  • presentation of papers at scientific meetings

For more information about SCIDUA, including its peer review methodology, program governance and publications, please visit http://www.cec.health.nsw.gov.au/programs/scidua.


SCIDUA is a partner of the national mortality subcommittee coordinated by the Australian and New Zealand College of Anaesthetists (ANZCA). The committee contributes to the national triennial report on safety of anaesthesia, which is published by the ANZCA mortality subcommittee.

SCIDUA works with 17 local health districts to ensure compliance with the legal requirement of notifying anaesthesia and sedation deaths.

Key Dates

SCIDUA produces an annual report between September and December. Copies of the report are distributed to all anaesthetic departments at public hospitals and all private hospitals offering anaesthetics in NSW.

Pilot Sites

Implementation Sites

Legislation applies to all health facilities in NSW where anaesthesia or sedation is administered for an operation or procedure.


Notification data is reported monthly to senior executives of local health districts.

An annual report with de-identified and aggregated data on the audit findings is published and distributed widely within the NSW health system and made available on the CEC website.

Related Initiatives

SCIDUA shares its confidential information with the Collaborating Hospitals’ Audit of Surgical Mortality (CHASM).

Further Details


Paula Cheng
Manager, Special Committees
(02) 9269 5543

Dr David Pickford

Page Top | Added: 30 October 2013 | Last modified: 30 May 2014

Paula Cheng
Manager, Special Committees
(02) 9269 5543