Objective: To determine trends in crude and risk-adjusted mortality for major trauma patients injured in rural or metropolitan New South Wales, 2009e2014. Design: A retrospective analysis of NSW statewide trauma registry data. Participants: Adult patients (aged 16 years or more) who presented with major trauma (Injury Severity Scores greater than 15) to a NSW hospital during 2009e2014. Main outcome measures: The main covariate of interest was geographic location of injury (metropolitan v rural/regional areas). Inpatientmortalitywasanalysedbymultivariable logistic regression. Results: Data for 11 423 eligible patients were analysed. Inpatient mortality for those injured in metropolitan locations was 14.7% in 2009 and 16.1% in 2014 (P = 0.45). In rural locations, there was a statistically significant decline in in-hospital mortality over the study period, from 12.1% in 2009 to 8.7% in 2014 (P = 0.004). Risk-adjusted mortality for those injured in a rural location was lower in 2013 than during 2009, but remained stable for those injured in metropolitan locations. Conclusion: Crude and risk-adjusted mortality after major trauma have remained stable in those injured in metropolitan areas of NSW between 2009 and 2014. The apparent downward trend in mortality associated with severe trauma in rural/regional locations requires further analysis.