There has been much recent literature on the technical parameters of electroconvulsive therapy (ECT) with regard to improving efficacy and minimizing adverse effects, but relatively little on ECT service delivery. This paper will discuss the development and characteristics of an ECT service at a teaching hospital in metropolitan Sydney, New South Wales, Australia. A mixture of qualitative and quantitative methods, including a selective literature review and audit of ECT use were used. The results of the audit were compared with the 2007 revision of the Royal Australian and New Zealand College of Psychiatrists' clinical memorandum on ECT. We discuss issues, such as the optimal site for ECT delivery, ECT mental health nurse coordinator role, credentialing of psychiatrists, registrar supervision, and the development of an ECT committee. A significant finding of the audit was that the majority of patients were treated under the New South Wales Mental Health Act, and voluntary patients were more likely to have a diagnosis of a depressive disorder, whereas involuntary patients were more likely to have a non-mood disorder diagnosis. This study has shown that auditing of ECT practices and services by mental health nurses is essential for quality improvement processes. The audit highlighted areas of service delivery that should be subject to review and evaluation against professional standards.