Western Australian Review of Death Policy

The 2013 Review of Death (ROD) policy recognises the contribution that reviews of deaths can play in improving the quality of healthcare by providing opportunity to examine the care afforded to a patient, to determine if it was appropriate or could have been delivered differently, and also to identify improvements in end of life care.

Please note that this policy supersedes the Western Australian Review of Mortality (WARM) Policy: Guidelines for Reviewing Inpatient Deaths (2008).


The 2013 ROD policy applies to all deaths that:

  • occur in public hospitals and licensed private health care facilities in Western Australia
  • occur under the care of Hospital in the Home (HITH) and Rehabilitation in the Home (RITH) services
  • involve nursing home type category and Care Awaiting Placement patients in Western Australian government hospitals.

The  2013 ROD policy does not apply to Australian Government funded residential aged care facilities.

However, hospitals and health services are not limited from reviewing the deaths of this patient group or the deaths of those who received healthcare in other ambulatory, outpatient or community care settings (for example community mental health services). This recognises that hospitals/health services have expanded the scope of mortality review processes defined within the 2008 WARM policy.

Public hospitals and licensed private healthcare facilities are to ensure review processes incorporate review of death principles found within the 2013 ROD policy.

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.

Reporting requirements

Local hospital/health service reporting

Hospitals/health services are required to maintain the following information on all deaths (where applicable) that fall within the scope of this policy:

  • patient reference or de-identified code
  • date of death
  • date of review
  • categorisation level
  • date of completion
  • recommendations identified
  • implementation status of recommendations.

Reporting to the Patient Safety Surveillance Unit

An outcome of a review of death may be the notification of a severity assessment code (SAC) 1 clinical incident.

If a death is found to be preventable or falls within the definition of a SAC 1 clinical incident it must be notified as such.

WA public hospitals and licensed private health care facilities must identify when notifying a SAC 1 clinical incident if the notification was as a result of a review of death undertaken locally, or an outcome of the Western Australian Audit of Surgical Mortality (WAASM).

WAASM provides all surgeons with a copy of the status of their audits on a quarterly basis. Hospitals should obtain confirmation from surgeons that a WAASM is occurring in relation to deaths of patients cared for by a surgeon.


From 31 December 2013 WA public hospitals and licensed private health care facilities are to forward to the Patient Safety Surveillance Unit (PSSU), on a 6-monthly basis, the percentage of deaths categorised with respect to preventability within 4 months of the date of death.

Reports to the PSSU (using below templates) are due by the last business day in May for the previous 1 July to 31 December period, and the last business day in November for the previous 1 January to 30 June period.



All hospitals/Health Service Providers must nominate a senior officer within the organisation accountable for ensuring compliance with this policy.

It is recommended that area health services coordinate individual hospital submissions into a single report.

More information

Patient Safety Surveillance Unit
Email: pssu@health.wa.gov.au

Produced by

Patient Safety Surveillance Unit