In most training settings, the first physician point-of-contact for a patient with clinical deterioration is a junior doctor who must evaluate the situation and decide whether to alert a supervising physician—a process termed escalation of care. Delays in this process can lead to critical failure-to-rescue events, which may result in preventable deaths. This study used ethnographic observations, a risk assessment survey, and a formal health care failure mode and effect and analysis to examine the escalation of care process on surgical wards at three London hospitals. The investigation uncovered 18 hazardous failures, with multiple underlying root causes, including outdated communication technology, insufficient staffing, and challenges related to hierarchy. An extensive list of recommendations to improve these processes is included. A prior AHRQ WebM&M commentary discussed some of the pitfalls of hierarchy and the "surgical personality."