'Service delivery issues' drive rise in surgical deaths

The Western Australian Audit of Surgical Mortality (WAASM) released this week found general surgery was largely behind the rise in deaths – accounting for 44.8% – but cautioned it was unlikely to be patient related.

The audit covered deaths from 1 January 2021 to 31 December 2025.

There was a total of 723 surgical deaths in 2025, up almost 4% from 697 in 2024 and steadily increasing from 2020.

These increases were initially attributed to the immediate impact of the COVID-19 pandemic; however, the audit notes this explanation is now less likely.

Over the entire reporting period there were a total of 3231 surgical deaths. Of those, 1446 occurred in general surgery.

There was an increase in the number of general surgery emergency admissions that did not have an operation.

In his report, WAASM Clinical Director Dr James Aitken said these admissions were likely to be very high-risk patients, suggesting general surgery emergency admission patients who undergo surgery should have a lower risk and reduced mortality.

“That has not occurred. Indeed, there has been a progressive increase in postoperative mortality after emergency admissions over the past five years. It seems unlikely the cause of this increase is patient related.”

Speaking to Medical Forum, Dr Aitken said he did not have a clear explanation for why general surgery deaths were rising, but suggested system issues may be at play.

“I don’t think that this is a patient-driven issue, I think it’s a service delivery issue,” he said.

“When you look at the data, there are difficulties like getting theatre access. Is it a contributing problem? Almost certainly, I would think.

“One of the problems with general surgery is that many of the cases are high risk and many are time critical, that may well be an issue because timely theatre access is a problem, not just in general surgery and not just in WA.”

Dr Aitken said part of the problem was linked to a stronger focus on elective surgeries, with emergency surgeries often playing “Cinderella” to elective.

“If an elective patient is cancelled on the day of surgery, that is a notifiable event, so the hospitals will give priority to finishing off an elective list and will make the emergency patient wait. For many emergency patients that delay is not helpful,” he said.

“For many of these patients, minutes matter. Even for orthopaedic surgery, hours matter. Whereas for elective surgery – I use the words advisedly here – days can go by and it doesn’t affect the outcome.”

A lack of nationally agreed emergency surgery urgency categorisation meant there was no standard for hospitals to be held accountable to, Dr Aitken said.

In his audit report, he notes Category 1 elective surgery (urgent) has a desirable admission waiting time of 30 days.

“Whether this surgery occurs at 29 or 31 days will not impact patient outcome, even surgery for cancer. Whereas many emergency operations are so time critical, especially if the patient has sepsis, that a delay of only a few hours may determine if a patient lives or dies, and – for the survivors – their quality of life.”

“One important issue in quality and safety is benchmarks and standards. You’ve got to be able to compare yourself against something,” he told Medical Forum.

“For patients who are high risk, we need to have a categorisation of time – should the operation be done in two hours, six hours, 24 hours. If we don’t have a benchmark, how do we assess the quality of care that we are delivering?”

Of the total number of surgical deaths, around 85% of patients had comorbidities. The median age was 78.

Just under 46% were considered to have severe systemic disease considered a constant threat to life.

Looking at other specialities, orthopaedic surgery accounted for 556 deaths (17.5%), neurosurgery for 483 (14.6%), vascular surgery for 269 (8.3%) and cardiothoracic accounted for 181 (5.6%).

A spokesperson for WA Health said while the report identifies an increase in deaths, there was no suggestion that patients are being inappropriately denied surgery.

“For many high-risk patients, non-operative management is consistent with their goals of care,” they said.

“The overwhelming majority of reviewed deaths had no identified clinical management issues.

“Our hospitals are seeing more older patients presenting with multiple co-morbidities. This increasing complexity is reflected in the WAASM data.

“Patients requiring emergency surgery are always prioritised, and surgical capacity continues to expand across the WA public health system to meet the needs of our growing community.”