Background: We undertook a COPD mortality review in response to a mortality outlier alert within our trust due to a high COPD SHMI. Aims: This review aimed to elucidate the cause of the high SHMI, highlight diagnostic errors and identify necessary changes to our practice to improve patient care and outcomes. Method: All patients with a primary diagnosis of COPD (codes J44.1, 44.0, 43.9, 44.8) who had died between January 2011 and February 2013 were identified and a random sample of these patients (n=38) were reviewed. Results: Overall 92% (35/38) patients had a background of COPD with other comorbidities. Some of the wrongly coded COPD deaths were due to lung cancer, pneumonia, peptic ulcer disease, myocardial infarction, sepsis due to other causes and bowel ischemia. No major management errors were found. As a result of this review we have introduced: - Daily COPD virtual ward rounds to review all admissions deemed as COPD exacerbations to correctly assign the first FCE diagnosis which is coded as the primary diagnosis. - A new respiratory ward with emphasis on appropriate management based on risk stratification, early assessment, intervention for type II respiratory failure and improved focus on integrated discharge bundles. Conclusion: This review highlighted that not all deaths are directly due to COPD. A concerted effort to integrate COPD in patient management pathways has helped reduce the coding errors and improved patient care and outcomes. As a result of these endeavours our COPD SHMI reduced from 139.2 to 103.17 with a projected proxy SHMI of 77.77 for 2014.