The structure and function of the Anaesthesia Mortality Committee of Western Australia are described. Reports of 500 deaths from 1990 to 1995 are analysed and discussed. The Committee determined that, in 21 cases, anaesthesia played a significant part in the death of the patient. These cases are further analysed. Deaths due mainly to anaesthetic factors are estimated to occur once in every 40,000 operations in Western Australia. One or two otherwise healthy people die each year in Western Australia from an anaesthetic mishap.