Consultative Council on Anaesthetic Mortality and Morbidity

The Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) CONFIDENTIAL CASE REPORT INITIAL REPORT

Personal information recorded on this document is confidential to the Chairperson of the Council. Subsequent review by full Council is by case number.

REPORTING DETAILS

Please forward via email to: [email protected]

You can download this form from the Council website at: http://www.health.vic.gov.au/vccamm/

Identifying information on this document is confidential to the Chairperson and members of the Consultative Council.

Definitions: Anaesthesia related Mortality

Anaesthesia related mortality is defined as a death which occurs during an operation or procedure (or within 24 hours of its completion) performed with the assistance of sedative, analgesic, local or general anaesthetic drugs or any combination of these, or, a death which may be the result (either partially or totally) of an incident during or after such operation or procedure even if more than 24 hours has elapsed since its completion.

Anaesthesia related Morbidity

Morbidity is defined as any event related to an anaesthetic procedure, which causes a life-threatening incident, temporary or permanent disability or significant distress. Morbidity is categorised as major or minor according to outcome. For more information please refer to the Suggested List for Reporting to Council on the website at: http://www.health.vic.gov.au/vccamm/

This report is to be typed and not hand written. Please ensure all details are filled within the report.

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Confidential to the Chairperson and the Council

Patients Name: Person Reporting: Date of Birth and Age: Address: Sex Phone: Nationality: Consultant - Qualification:

Hospital Trainee Year of Training UR No. Level of Supervision On receipt of this preliminary report the Chairperson may send you a more detailed form.

CONFIDENTIAL REPORT INITIAL REPORT SUMMARY OF EVENT (Please attach additional information required to determine cause) Date of Event:

 Mortality Morbidity (Check the correct box)

Procedure: Elective Event: Unexpected ASA Category: Emergency Expected

Event Details

Opinion as to cause:

Forms and attachments are to be emailed to: [email protected] ------