With zero tolerance for negligence all mortalities morbidities must be discussed in professional forums as a continuous medical education to address a Q , Could we have dine better?.. in this priocess if someone is proved negligent must be dealt as per law.
Hospitals are not only places of healing; they are institutions of learning, accountability, and constant improvement. Every death in a hospital carries a story. Some are inevitable outcomes of disease, some are tragic but expected, and some force us to ask difficult questions: Could this have been prevented? Did we miss a step, a sign, or a safeguard? It is here that the role of Mortality and Morbidity Committees (MMCs) becomes indispensable. These committees, if transparent, unbiased, and systematic, hold the potential to transform hospitals into safer, smarter, and more accountable spaces of care.
A mortality review is not about blame. A morbidity review is not about shame. Both are about learning. When a patient dies on the operating table, or in an interventional bay, or collapses within twenty-four hours of admission despite appearing stable, the hospital must pause, reflect, and review. Not in whispers in corridors, not in selective “case presentations” for academic convenience, but in structured, transparent meetings that ask the tough questions. Why did this patient die? Was the system prepared? Were protocols followed? Was the communication adequate? Was the handover complete? Did fatigue, infrastructure gaps, or resource shortages play a role?
The cases that merit Mortality and Morbidity review are clear and need to be institutionalized. Deaths on the operating table should always be discussed, for surgery is never just about the surgeon’s hand but about anesthesia safety, nursing readiness, blood bank preparedness, and equipment reliability. Deaths in interventional bays—catheterization labs, dialysis units, radiological suites—must be dissected, because these are high-risk, high-stakes zones where seconds make the difference between survival and tragedy. Deaths within twenty-four hours of admission demand scrutiny, for they often reveal whether triage, emergency management, and rapid response protocols are functioning as they should. Equally important are deaths of patients who were admitted as stable, not critically ill, and were not expected to deteriorate. These cases expose gaps in monitoring, escalation of care, or failure to recognize subtle danger signs. Sentinel events—wrong-site surgery, retained instruments, medication overdoses, hospital-acquired infections leading to sepsis, falls, or sudden unexplained cardiac arrests—deserve no less than full transparency in MMC discussions.
The purpose is not to witch-hunt, nor to humiliate professionals already burdened by stress and workload. The purpose is to find where the system faltered. Was there a missing checklist? Was there a miscommunication between junior and senior staff? Did overburdened infrastructure, power failure, or delayed diagnostics play a role? These are system flaws, not individual negligence. Malpractice and gross medical negligence are separate matters to be dealt with legally and ethically. But system flaws—those silent cracks in the wall of care—must be studied by MMCs, because only when they are identified can they be repaired.
Sadly, in many institutions, Mortality and Morbidity Committees are more ritual than reform. They pick “safe cases” to discuss, often focusing on exotic diseases or textbook complications, while avoiding uncomfortable truths about preventable deaths or sentinel events. The committee becomes a stage for academic posturing rather than a workshop of improvement. Worse, favoritism creeps in: deaths from certain departments are ignored, politically sensitive cases are left out, and critical incidents vanish into files that no one opens. This is malpractice of another kind—the malpractice of silence.
If MMCs are to serve their true function, they must be mandated to review all relevant deaths and morbidities based on defined criteria, not selective convenience. An institution serious about improvement should begin by reviewing deaths, morbidities, and sentinel adverse events of the past two years. Not to point fingers, but to establish a baseline of institutional learning. Only by mapping where and why patients have been lost can hospitals set measurable targets for safer care. Such retrospective reviews also highlight trends—recurring equipment failures, repeated delays in blood availability, or patterns of late referrals—that no individual clinician may notice in isolation.
Why should mortality remain a mystery? The Ministry of Health and the Secretary of Health and Medical Education must direct every government and private hospital to empower their Mortality and Morbidity Committees to conduct Root Cause Analyses (RCA) of deaths and place their reports, with clear recommendations, before leadership and management. Yet, time and again, inquiries are ordered, as we observed in deaths in a private hospital and then quietly buried. Why are these reports never shared with the public? What is there to hide—systemic flaws, administrative failures, or worse? Silence only breeds rumour and mistrust. Transparency, not secrecy, is what builds accountability in healthcare.
Transparency is key. MMC meetings must have clear minutes, documented recommendations, and timelines for corrective action. These must feed into hospital Key Performance Indicators (KPIs) for self-assessment. Did we reduce deaths within twenty-four hours of admission this year compared to last? Did the number of sentinel events decline after we introduced a double-check medication policy? Did the purchase of new monitors reduce deaths among “stable” patients who suddenly collapsed? These are the yardsticks that matter. A hospital that hides its mistakes hides its progress as well.
Teaching institutions carry a greater responsibility. For medical students, residents, and young faculty, the MMC is not only a forum of learning clinical medicine but also a classroom of humility, ethics, and accountability. They must see their seniors admit mistakes, acknowledge flaws, and commit to improvement. That culture of honesty is more important than any lecture. Tomorrow’s doctors must not learn that errors are to be buried; they must learn that errors are to be studied, understood, and prevented.
The decision by the Director of SKIMS to constitute various committees, including the crucial Mortality and Morbidity Committee, is a step in the right direction. It signals that self-assessment is not optional but essential. SKIMS, as a premier tertiary care institute, can set an example for all hospitals in the region. But this will only happen if the committee functions transparently, fearlessly, and consistently. Not by choosing easy cases, not by shielding powerful departments, but by setting standards for honest institutional introspection. If SKIMS demonstrates this rigor, other teaching hospitals, district hospitals, and private institutions will have to follow.
The challenges are not small. There will be resistance. Professionals often fear that MMC discussions will damage reputations or careers. Administrators fear exposure of institutional weaknesses. But the reality is the opposite: an institution that reviews itself transparently builds trust with patients, regulators, and its own staff. A doctor who participates honestly in MMCs earns more respect, not less, for showing courage to learn. A hospital that documents and shares its improvements attracts more patients because it signals safety, not secrecy.
The time has come for hospitals in Kashmir, and across India, to adopt MMCs as more than rituals. The committee must be backed by administrative will, given legal protection from witch-hunts, and empowered to enforce corrective actions. The community, too, must recognize that not every hospital death is negligence. But every hospital death is a chance to learn. To waste that chance is to dishonour the patient who died.
Accountability in healthcare is not about punishment; it is about prevention. Transparency is not about weakness; it is about strength. Mortality and Morbidity Committees embody both, if allowed to function as intended. They are the mirrors in which hospitals must look, however uncomfortable the reflection. If we avoid them, we risk repeating the same tragedies. If we embrace them, we move closer to the promise of safer, more reliable, and more humane healthcare.
Hospitals owe it to their patients, their staff, and their own mission of healing to make Mortality and Morbidity Committees a non-negotiable pillar of governance. In the end, lives lost should not be lessons lost. Every death must teach, every error must improve, and every committee must speak the truth. That is how we do better.
Author is a surgeon at Mubarak Hospital, a clinical auditor, and a healthcare policy analyst. He can be mailed at drfiazfazili@gmail.com
