Perioperative Mortality Review Committee Terms of Reference (May 2018)

The terms of reference for the Committee can be viewed below or downloaded in either Word or pdf formats:

1. The Perioperative Mortality Review Committee (the Committee) is a Mortality Review Committee (MRC), appointed under section 59E of the New Zealand Public Health and Disability Act 2000 (the Act) by the Health Quality and Safety Commission (the Commission).

2. A Mortality Review Committee is a ‘statutory advisor ’ to the Commission. The role of such a committee is to independently perform its functions, within the scope set by the Commission. These terms of reference constitute notice under Section 59E (1) of the Act.


3. The functions of Mortality Review Committees are set out in section 59E (1) (a) and (b) of the Act.

4. The Committee is required to work within their agreed work plans and budgets to:

4a. review and report to the Commission on deaths that are within the Committee’s scope, with a view to reducing deaths and to supporting continuous quality improvement through the promotion of on-going quality assurance programmes

4b. advise on any other matter related to mortality that the Commission specifies in writing

4c. develop strategic plans and methodologies that are designed to reduce morbidity and mortality and are relevant to the Committee’s functions.

4d. share information with other MRC(s) if the disclosing MRC considers that:

4d.(i) the information to be shared is relevant to their own functions and that of the receiving MRC(s); and

4d.(ii) sharing the information with the receiving MRC would not be inconsistent with the protections set out in the New Zealand Public Health and Disability Act 2000 (the Act) for information held by MRCs.

Applicable provisions

The provisions of Schedule 5 to the Act apply in relation to a Mortality Review Committee (s59E of the Act).


5. The Committee will be required to consider Perioperative mortality on an ongoing basis and other mortality and morbidity as directed by the Commission Board in writing, or as specified within the Committee’s agreed Work Plan.

6. There is significant overlap between those cases that occur as surgical deaths and anaesthetic deaths, therefore these two groups are usefully reviewed together. For the purposes of the Terms of Reference of the Perioperative Mortality Review Committee, perioperative mortality deaths include:

6a. a death that occurred during or after an operative procedure

6a.i. within 90 days

6a.ii. after both 90 days but before discharge from hospital to home or a rehabilitation facility

6b. The POMRC will continue to review deaths during or after an operative procedure that occur within 30 days in the categories set out above

6c. a death that occurred whilst under the care of a surgeon in hospital even though an operation was NOT undertaken.

6d. A death that occurred during or after an anaesthetic (local, regional or general) or sedation.

7. For the purposes of this definition:

7a. An operative procedure is defined as any procedure requiring anaesthesia (local, regional or general) or sedation.

7b. A surgeon is defined as a doctor who has achieved vocational registration with the Medical Council of New Zealand in a speciality of surgery (including oral surgery).

7c. For the removal of doubt, gastroscopies, colonoscopies, and cardiac or vascular angiographic procedures (diagnostic or therapeutic) carried out in designated endoscopy or radiological rooms would be included in this definition.

Expected Activities

8. The Committee is expected to oversee mortality review to ensure that relevant, evidence-based advice is provided to the Commission as quickly as practicable.

9. The Committee is expected to support the development and enhancement of systems to:

9a. ensure the security of personal information referred to in clause 3 of Schedule 5 of the Act

9b. provide the Commission with advance notice of media statements, public comment or publications

9c. monitor the number, categories and demographics of deaths relevant to its functions and to identify patterns and trends over time

9d. undertake or coordinate reviews locally as local quality improvement initiatives, for system and practice improvements to reduce avoidable perioperative mortality and as data collection systems for national review

9e. analyse and use data collected to develop effective recommendations that are useful for policy development at a national level.

10. The Committee is expected to support the development and enhancement of positive working relationships, with:

10a. existing Mortality Review Committees and the Commission, to ensure coordination and integration of functions and to minimise duplication, to improve efficiency and sustainability.

10b. relevant government bodies.

10c. relevant stakeholder organisations.

11. In carrying out its functions the Committee is expected to ensure:

11a. appropriate consultation (including relevant consumers) when developing methodologies to carry out its functions and disseminating its findings

11b. any advice and recommendations comply with the laws of New Zealand

11c. a plan for recommendation dissemination is made with the Commission (including publication), within agreed budgets.

12. The Committee is expected to submit a proposed three-year rolling Work Plan to the Commission by December of each year, for the following three financial years.

12a. If approved, budget will be assigned to the Work Plan. The Committee is required to achieve the Work Plan within the assigned budget.

13. The Committee is expected to submit an Annual Report to the Commission, which will include:

13a. a summary of the Committee’s work

13b. the Committee’s advice and recommendations

13c. the Committee’s rationale for its advice and any relevant evidence and/or documentation.


14. The Committee will have a maximum of 8 members.

14a. One member will have relevant consumer experience and will provide a consumer perspective and be well networked to consumer groups.

14b. The other 7 members will have expertise that includes the following:

14b.i. substantial clinical experience and national credibility in one or more of the following: anaesthesia; surgery; obstetrics and gynaecology; intensive care; surgical nursing; and procedural internal medicine (e.g. cardiology).

14b.ii. knowledge of and experience in clinical epidemiology.

14b.iii. knowledge of quality and risk management, in particular quality improvement in the health sector.

14b.iv. knowledge of data and information gathering systems and analysis.

14b.v. senior level health service provision and management, both public and private knowledge of Māori health

14b.vii. knowledge of health inequities.

15. The Committee is expected to self-determine its operations, with the advice of the Secretariat and within budget.

15a. Co-option of additional expertise can be made within budget (to the committee or to working groups of the committee), but co-opted members will not have voting rights and will not be entitled to membership fees.

16. Chairperson and Deputy Chairperson

16a. The Commission will appoint a Chairperson and a Deputy Chairperson to the Committee. The Chairperson is expected to preside at every meeting of the Committee at which they are present, unless they deputise their responsibilities to the Deputy Chair.

16b. The Chair of the Committee (or Deputy Chair) is expected to attend regular meetings of all the Mortality Review Committees’ Chairs (“Chairs’ Meetings”) to ensure cooperation and integration across Committees wherever possible, and the best allocation of limited resources.

16c. The Chair of the Committee (or Deputy Chair) will be required to meet with the Commission, on request.

16d. The Chair of the Committee (or Deputy Chair) may be required to attend other Committee meetings at the request of the Commission.

17. Management of Conflicts of Interest

17a. Members must perform their functions in good faith, honestly and impartially and avoid situations that might compromise their integrity or otherwise lead to conflicts of interest. Proper observation of these principles will protect the Committee and its members and will ensure that it retains public confidence.

17b. When members believe they have a potential conflict of interest on a subject that will prevent them from reaching an impartial decision or undertaking an activity consistent with the Committee’s functions, they must declare that conflict of interest and withdraw themselves from the discussion and/or activity.

18. Confidentiality

18a. The maintenance of confidentiality is crucial to the functioning of the Committee.

18b. Members must note the statutory requirements in section 59E (6) of the Act, which prevents disclosure of information of the kind described in clause 3 of Schedule 5 of the Act.

18c. Under this clause, information means any information that is personal information within the meaning of section 2(1) of the Privacy Act 1993; and that became known to any member or executive officer or agent of a Mortality Review Committee only because of the Committee’s functions being carried out (for example, because it is contained in a document created, and made available to the member or executive officer or agent, only because of those functions being carried out), whether or not the carrying out of those functions is completed.

18d. Members must note that the disclosure of information contrary to Schedule 5 of the Act is an offence and is liable on summary conviction to a fine not exceeding $10,000 (s 59E (6)).

19. Meetings will usually be held in Wellington. Actual and reasonable expenses for activities required by the Committee of its members (e.g., travel, accommodation, literature searches) will be met from the Committee’s budget provided prior approval is received.

20. The timing and frequency of meetings is to be coordinated with the Secretariat to fit within the allocated budget.

21. The Committee will regulate its own procedures, according to State Services Commission requirements and guidelines and ensure that a record of decisions is maintained.


22. The Commission employs staff to assist the Committee out of the Committee’s allocated budget.

23. The Secretariat provides:

23a. policy analysis and analytical support (as directed by the Committee)

23b. guidance on governmental and ministerial processes

23c. budget management, contract management and service procurement support to assist the Committee to achieve its Work Plan within its allocated budget

23d. central communications systems support for correspondence and public relations purposes, including secure communication between Committee Members and Agents

23e. liaison on behalf of the Committee within and across government and non-government organisations

23f. administrative support to organise, minute and follow up on committee meetings and/ or working groups as agreed within the Work plan and within the budget set.

23g. additional support for the Committee to carry out its functions, as agreed and budgeted for in the Work plans.


24. These terms of reference will be reviewed three years from the date at which they are approved by the Commission.


  1. A ‘statutory advisor’ provides independent guidance and advice within the parameters determined by statute.    Sections 3 and 4 define the statutory functions that mortality review committees are required to provide advice and guidance on.

Last updated 15/10/2018