Initial project focused on deterioration of ward patients prior to Critical Care admission with presumption that areas of improvement would be identified within ward area escalationInitial data collection completed April to November 2016. Analysis tool adapted to become the hospital wide Cardiac Arrest Review toolThematic analysis highlighted issues of escalation and handover within the Critical Care Team at time of admission and dischargeFocus switched to:1-Analysis of handover process at time of Critical Care Admission2-Completion of NEWS scoring prior to ward step down from Critical Care