In early 2008, a Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals was commissioned. This comprehensive and ground breaking commission became known as The Garling Report. It reported in November 2008. The NSW State Government responded in March 2009. It found a "prevalent" problem associated with the care of the deteriorating patient in NSW public hospitals. As a result, a statewide system of monitoring vital signs to detect deteriorating patients was introduced. 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. Observation charts have been developed for Adult, Paediatric, Maternity and Emergency patients. By 2012 it had been implemented in every public hospital in NSW.