This study aimed to investigate the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units (ICUs) in a large district general hospital and a teaching hospital. The study used structured interviews and questionnaires to assess the quality of care, focusing on the recognition, investigation, monitoring, and management of abnormalities in airway, breathing, circulation, and oxygen therapy and monitoring. Assessors agreed that 20 patients received good care, 54 received suboptimal care, and 26 cases were disagreed upon. Suboptimal care was associated with increased morbidity and mortality, with 4.5% to 41% of admissions potentially avoidable. The main causes of suboptimal care included failure of organization, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. The study suggests that improved teaching, establishment of medical emergency teams, and widespread debate on acute care processes are necessary to improve the quality of care before ICU admission.This study aimed to investigate the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units (ICUs) in a large district general hospital and a teaching hospital. The study used structured interviews and questionnaires to assess the quality of care, focusing on the recognition, investigation, monitoring, and management of abnormalities in airway, breathing, circulation, and oxygen therapy and monitoring. Assessors agreed that 20 patients received good care, 54 received suboptimal care, and 26 cases were disagreed upon. Suboptimal care was associated with increased morbidity and mortality, with 4.5% to 41% of admissions potentially avoidable. The main causes of suboptimal care included failure of organization, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. The study suggests that improved teaching, establishment of medical emergency teams, and widespread debate on acute care processes are necessary to improve the quality of care before ICU admission.