<P> In November 2005, an Australian teenager named Vanessa Anderson died at Royal North Shore Hospital following a golfing accident . Her death, widely reported in the media, led to long - running controversy and motivated government - level changes to public hospital policy . It was alleged that her death occurred due to inadequate care and a systemic hospital failure to recognize signs of a deteriorating patient . </P> <P> On 6 November 2005, while attending a school sporting event at a golf course, Vanessa Anderson was hit on the head by a golf ball . She was taken to Hornsby Hospital and subsequently transferred to the Royal North Shore Hospital . She was allegedly treated inappropriately for a fractured skull, and two days later, suffered a seizure and died . The coroner determined that Vanessa died from respiratory arrest due to the depressant effect of opiate medication . </P> <P> The incident, among others, led to a 2008 commission, authored by Peter Garling, to investigate the standard of patient care in public hospitals, which found a "prevalent" problem associated with the care of the deteriorating patient . </P> <P> 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" color - coded observation charts for recording a person's vital signs, allowing for easy visual recognition of deterioration . Observation charts have been developed for Adult, Pediatric, Maternity and Emergency patients . </P>

Final report of the special commission of inquiry acute care services in nsw public hospitals