In November 2005, an Australian teenager named Vanessa Anderson died at Royal North Shore Hospital following a golfing accident.
It was alleged that her death occurred due to inadequate care and a systemic hospital failure to recognize signs of a deteriorating patient.
In 2010, the NSW Health Department conceded that Vanessa's death was unnecessary, tragic and avoidable, and that a new system of monitoring vital signs to detect deteriorating patients was needed statewide.
This system includes red and yellow "Between the Flags" colour-coded observation charts for recording a person's vital signs, allowing for easy visual recognition of deterioration.
Medical officers, nurses, allied health practitioners (including physiotherapists) and other staff now undergo mandatory training to adhere to these standards.