In June 2008, North Tees and Hartlepool Trust signed up to Patient Safety First. Our objectives were to put patients first and to develop a culture of patient safety. We implemented the intervention discussed here with the aim of preventing harm and reducing in-hospital cardiac arrest and mortality through earlier recognition and treatment of deteriorating patients. Acute illness is exacerbated by "failure to act" on recognised changes (Hillman et al, 2001). Analysis of serious patient safety incidents revealed that 11% of deaths were related to "deterioration not recognised or not acted upon" (National Patient Safety Agency, 2007a). The process can fail by not taking observations, not recognising early signs of deterioration, not communicating observations causing concern and not responding to concerns appropriately (NPSA, 2007b). We focused on improving all these areas.