Abstract
Anaesthetists are acutely aware of the legal constraint of reporting to the coroner deaths in association with anaesthesia. The evolution of the office of the coroner in England is presented and the relationship with the discovery and evolution of anaesthesia is examined. The legal and medical climate in the 19th century is described, with some of the key participants named and their roles explained. The 19th century was an age of questioning and exploration, which led to the elucidation of the problems with chloroform and set the path for progress in monitoring in anaesthesia. Comments are made on the development of anaesthetic mortality reporting into its current system and some of the benefits flowing from it. The collaboration of the various state mortality committees in producing a triennial national report is an important way to ensure that the lessons of the past are kept in mind in the present. The author believes that mortality reporting, the analysis of data and the dissemination of information is a valuable field of research, monitoring and educational tool. Primum non nocere is particularly pertinent in anaesthesia.
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