Consultative committee on road traffic fatalities: Trauma audit methodology

Background: Since 1992 the Consultative Committee on Road Traffic Fatalitie s in Victoria has identified deficiencies and errors in the management of 5 59 road traffic fatalities in which the patients were alive on arrival of a mbulance services. The Committee also assessed the preventability of deaths . Reproducibility of results using its methodology has been shown to be sta tistically significant. The Committee's findings and recommendations, the l atter made in association with the learned Colleges and specialist Societie s, led to the establishment of a Ministerial Taskforce on Trauma and Emerge ncy Services. As a consequence, in 2000, a new trauma care system will be i mplemented in Victoria. This paper presents a case example demonstrating th e Committee's methodology. Methods: The Committee has two 12 member multidisciplinary evaluative panel s. A retrospective evaluation was made of the complete ambulance, hospital and autopsy records of eligible fatalities. The clinical and pathological f indings were analysed using a comprehensive data proforma, a narrative summ ary and the complete records. Resulting multidisciplinary discussion proble ms were identified and the potential preventability of death was assessed. Results: In the present case example the Committee identified 16 management deficiencies of which 11 were assessed as having contributed-to the patien t's death; the death, however, was judged to be non-preventable. Conclusion: The presentation of this example demonstrating the Committee's methodology may be of assistance to hospital medical staff undertaking thei r own major trauma audit.