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Review of the national mortality review function

The Health Quality & Safety Commission (the Commission) has commissioned an independent review of the national mortality review function (NMRF).


In September 2021, Francis Health was commissioned to undertake an independent review that looked at the ‘first principles’ of mortality review as a function. Based on these findings, a blueprint for a transformed mortality review function was developed for the Commission board to consider.

Recommendations and final report

The Commission board agreed to four key recommendations from the report that set out the structure of a transformed NMRF:

  • Within the Commission, a single strategic National Mortality Review Committee will be established.
  • Current mortality review committee (MRC) members will be invited to become subject matter and representative experts within the workstreams of the NMRF.
  • All current secretariat staff will transition and form part of the NMRF business unit, which will support the NMRF to fulfil its purpose.
  • Data will be brought together under the NMRF to ensure more integrated mortality data surveillance.

You can read the final report here.

Next steps

Over the coming months, the Commission will begin to implement the transformation of the NMRF. This will include developing key tools, such as the prioritisation framework for evaluating current and new areas of mortality review.

An interim National Mortality Review Committee will be stood up in early 2023 to provide expertise in the development of these core frameworks and identify emerging areas of mortality review.

The NMRF will continue to uphold key functions and activities of the existing MRCs, with a dual focus on reporting key mortality trends as well as assessing and prioritising areas of greatest need.

The interim National Mortality Review Committee and the Commission will work closely with the existing MRCs to transition institutional knowledge, and to ensure current members are well positioned to continue to provide an important voice as subject matter and representative experts. 

Mortality review workstreams across child and youth, perinatal and maternal, and suicide will continue in the 2023/24 financial year under the transformed NMRF. A national expert group will continue to provide oversight and advice on national trends in perioperative deaths. Family violence death review will remain in place for the long term.

Beyond this, the National Mortality Review Committee will have the flexibility to focus on both current and emerging priority areas, informed by an all-mortality prioritisation process.

The Commission will work with the MRC secretariat to plan and transition its role and function into the future NMRF.

On 1 July 2023, formal statutory powers under Schedule 5 of the Pae Ora (Healthy Futures) Act 2022 will be transferred to the National Mortality Review Committee. Existing MRC members are invited to continue as subject matter and representative experts.

The first year of operations in 2023/24 under the transformed NMRF structure will see further refinements, including exploring new areas of mortality review, introducing new ways to disseminate findings and recommendations, and further deepening relationships with key health and social system entities.

Related Pages

If you have any questions about the independent review or the new NMRF, you can email:

Previous updates

Last updated: 18th October, 2022