The audit process

NTASM is a peer-review process. Participation by consultant surgeons is a requirement of the College's Continuing Professional Development (CPD) Program.

To start: NTASM is notified by the hospital of all surgically-related deaths (before, during or after surgery).

Next: NTASM sends a surgical case form (PDF 574.05KB) to the consultant surgeon linked to the case. This will be notified by email with a link to the Fellows Interface (secure web-based system).

The Surgical Case form is:

1. completed by the consultant surgeon or delegated to a registrar 
2. returned to NTASM electronically using the Fellows Interface
3. de-identified and sent to a first-line assessor (a consultant surgeon: same specialty, different hospital) for anonymous peer-review.

If a second-line assessment (case note review) is not requested by the first-line assessor, the original surgeon will be sent written feedback to this effect (and the case will be closed).

If a second-line assessment (case note review) is requested by the first-line assessor that is, the case needs further investigation or insufficient information has been provided on the surgical case form (PDF 574.05KB) then these steps are followed:

1. a second-line assessor is chosen by NTASM's Clinical Director;
2. medical records are requested;
3. the second-line assessor then reviews the surgical case form (PDF 574.05KB) the medical records and the first-line assessor's comment, before writing a one or two-page report. Note: The review is carried out and the report written in a spirit of sympathetic inquiry, providing sufficient details for a clear view of events;
4. the report and relevant feedback is sent to the original surgeon. The case is then closed, and
5. at each stage of the process the original surgeon has right of reply.