BACKGROUND: Major renal surgery describes a spectrum of operations with varying complexity and perioperative risk. This study aims to identify preventable issues contributing to perioperative mortality in patients undergoing major renal surgery. METHODS: Data was extracted from independent peer-reviewed first- and second-line assessments of perioperative mortality in the Australian and New Zealand Audits of Surgical Mortality (ANZASM) database from 2005 to 2015. A data-driven thematic classification was performed by two independent senior assessors on Clinical Management Issues (CMIs) raised in ANZASM assessments. This was used to identify recurrent areas of vulnerability in patient management and means for risk reduction. RESULTS: Eighty-nine cases of perioperative mortality were included and 68 CMIs identified. Thirty CMIs pertained to pre-operative issues, most relating to the decision to operate (10/30) or adequacy of pre-operative assessment and optimization (9/30). Twenty-three CMIs related to post-operative concerns, mostly bleeding (7/23), though delayed complication recognition (3/23) and communication issues (5/23) were also noted. Intra-operative CMIs were less common (15/68), but more directly causal to deaths. Most intra-operative CMIs related to major vascular injury (5/15) or delayed conversion (4/15). CONCLUSION: Several preventable clinical management issues were identified contributing to perioperative mortality. Most commonly, they concerned pre-operative patient assessment and optimization for anaemia and cardiovascular disease. The most harmful CMIs, however, pertained to delayed conversion and vascular injury in laparoscopic major renal surgery. This article highlights several actionable changes to reduce peri-operative mortality in major renal surgery.