Purpose: To compare in-hospital deaths of Australian metropolitan and non-metropolitan surgical patients and identify patient, hospital, and peri-operative factors that contribute to differences in healthcare outcomes. Methodology: Cross-sectional study of retrospective data collected by the Australian and New Zealand Audits of Surgical Mortality from 2017-2020. Factors measured included comorbidities, pre-operative death risk, peri-operative management and decision-making. Multiple logistic regression analyses adjusted for age, sex, and Aboriginality. Results: This study included a total of 4845 general surgical patients across Australia; 3483 (71.9%) from metropolitan hospitals and 1362 (28.1%) from non-metropolitan hospitals. After adjusting for potentially confounding variables, non-metropolitan patients were more likely to be of Aboriginal or Torres Strait Islander descent (odds ratio 7.89, 95% confidence interval 5.53–11.46), have cardiovascular disease (1.22, 1.06–1.40), diabetes (1.20, 1.02–1.41), to experience a delay to surgical diagnosis (1.71, 1.37–2.13) or experience an adverse event (1.29, 1.10–1.50). Delayed non-Metro patients were more likely to have post-operative complications than delayed Metro patients (1.73, 1.09–2.75). Conclusion: The increased incidence of delayed surgical diagnoses in non-Metro patients and their subsequent higher rate of post-operative complications, are identified as key areas where patient care could be improved in non-Metro settings. Delays to surgical diagnosis in non-Metro patients were associated with primary care. This study highlights deficiencies in socioeconomic opportunity, health literacy, and healthcare access outside of metropolitan centres.