The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) is now established in the United Kingdom (excluding Scotland) as a voluntary, confidential system designed to review the clinical practice which precedes a death within 30 days of surgery. The Enquiry is comprehensive, widely representative and authoritative. To date, two reports have been published and there is an ongoing programme planned. The influence of these reports on the practice of anaesthesia and surgery in Britain is undeniable.