Recognition, response and treatment of deteriorating patients are essential to improving patient outcomes and reducing unexpected inpatient hospital deaths (Fuhrmann et al 2009; Mitchell et al 2010 ). Adequate management of the deteriorating patient is often insufficient if not managed in a timely manner (Fuhrmann et al 2009; Naeem et al 2005; Goldhill 2001). Detection of these clinical changes, combined with early and accurate intervention, can avoid adverse outcomes, including cardiac arrest and deaths (Subbe et al. 2003). One of these early interventions can be offered by Roper, Logan, Tierney (1980) called activities of daily living model. As explained in the presentation, the model consists of an individual's ability to perform self-care tasks such as functional mobility, self-nutrition, personal hygiene, and grooming (Roper, Logan & Tierney, 1980). Therefore, any change in these parameters can be considered a worsening patient. However, this approach not only lacks objectivity, but also fails to recognize the abnormal physiology that precedes this breakdown in self-care. For example, it has been reported that 70% of patients before cardiopulmonary arrest had a physiological decline in respiratory or mental function (Schein et al 1990). Observing worsening of activities of daily living alone does not accurately reflect the underlying physiological deterioration occurring in patients. Due to these limitations, other more efficient, objective and accurate tools are needed to improve acute hospital care. The National Institute for Health and Clinical Excellence (NICE 2007) has highlighted the importance of a systems approach and supported the use of EWS to identify and respond efficiently to... case as many studies have failed to validate these systems, some revealing poor sensitivity, poor positive predictive value, and low reproducibility (Gao et al 2007; Smith et al 2008; Subbe et al 2007; Jansen et al 2010). Considering the conflicting results between Despite the different EWSs, it is not known whether these scoring systems are effective in identifying and responding to worsening patients in acute hospital settings. This essay aims to establish how effective, if at all, the EWS, specifically the SHEWS, is in identifying deteriorating patients in acute surgical hospital settings. To do this we will return to Patient X, a 22-year-old Asian woman with a diagnosis of acute pancreatitis. By comparing the evidence base with reality, I hope to better understand how effective this tool is in identifying worsening patients.