NHS: Mid Staffordshire NHS Foundation Trust

Earl Howe Excerpts

Tuesday 19th November 2013 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, I shall now repeat a Statement made earlier today in another place by my right honourable friend the Secretary of State for Health on the Government’s response to Robert Francis’s report on Mid Staffordshire Hospital. The Statement is as follows.

“With permission, Mr Speaker, I would like to make a Statement about the Government’s response to the Mid Staffordshire NHS Foundation Trust public inquiry.

Let me start by paying tribute to the men and women of courage without whom this darkest episode in the history of the NHS would never have come to light: people like Julie Bailey and members of Cure the NHS, who stood outside the Department of Health in all weathers because no one would meet them to hear about the inhumane care given to their loved ones; brave whistleblowers like Mid Staffs nurse Helene Donnelly; and campaigners who suffered tragedies elsewhere, like James Titcombe, who never gave up the fight after losing his son, Joshua, at Morecambe Bay. They suffered greatly for their selfless determination to make sure that their personal losses were not in vain. All of us in this House today are humbled to stand in the shadow of their bravery.

Robert Francis and his team also deserve huge credit. Their diligence and thoughtfulness led to an outstanding report which will transform our NHS for the better. Finally, let me pay tribute to all NHS front-line staff, for whom reading about these events in the media has been immensely distressing. We owe it to them to make sure that poor care is never again allowed to take root and survive unchallenged in our NHS.

Since our initial response to the inquiry in March, much has happened. Thirteen hospitals have been put into special measures as part of a tough new failure regime. Those hospitals, where poor care had been allowed to persist, are now being turned around, and I thank the Keogh inquiry team for its painstaking work in this area.

Independent, Ofsted-style ratings of hospitals are under way, led by Professor Sir Mike Richards, the new Chief Inspector of Hospitals. The first 18 trusts are currently being inspected, with quality of care and safety paramount. We have appointed new Chief Inspectors of Adult Social Care and General Practice, whose robust inspections of care homes, domiciliary care and surgeries start next year. Surgical survival rates for 10 major specialties have been published by individual surgeons, making the NHS a world leader in transparency.

Today, the Government are publishing their further response to the inquiry as well as our response to the Health Select Committee’s report on the inquiry. Both these responses have been laid before Parliament.

The NHS is a moral being or it is nothing. It was set up 65 years ago with the noble ideal that no one should ever be prevented by background or finances from accessing the best care. That is why it remains the most loved British institution, and rightly so. But each and every case of poor care betrays those worthy aims. I do not want simply to prevent another Mid Staffs; I want our NHS to be a beacon across the world not just for its equity but its excellence. I want it to offer the safest, most compassionate and most effective care available anywhere, and I believe it can.

But that is only if there is a profound transformation of the culture in the NHS. The inquiry shows the devastating effects of overly defensive responses: hurting families, suppressing the truth and preventing lessons being learnt. Failure cannot be addressed when it is covered up, so today I am announcing new measures to promote a culture of openness and transparency.

From 2014, every organisation registered with the CQC will have a statutory duty of candour. Patients must be told promptly about any avoidable harm, but there will be a statutory requirement to notify any harm that has led to avoidable death or serious injury.

We will consult on whether hospitals that are found not to have been open and transparent with patients or families at the earliest reasonable opportunity should risk having their indemnity from litigation awards reduced or removed by the NHS Litigation Authority. The signal must go out loud and clear to all clinicians: if in doubt, report an incident and tell the patient.

The professional regulators have agreed to place a new, strengthened professional duty of candour on all doctors and nurses. Failing to inform a patient, not reporting avoidable harm, or obstructing someone else seeking to do so will be subject to sanctions, including being struck off.

Inspired by the airline industry, this duty will cover “near misses”—occasions when mistakes were made that could have led to harm and from which we need to learn. Conversely, prompt reporting may be considered as a mitigating factor in a professional conduct hearing. This is not about penalising staff for making mistakes; it is about enabling them to learn from them. The NHS will adopt a culture of learning, as recommended by Don Berwick and his expert committee. I thank them for their seminal report.

A culture of openness also means learning from complaints. In line with the recommendations of the right honourable Member for Cynon Valley and Professor Tricia Hart’s excellent review, all patients will be able to access independent help in making their complaint, with clear signs in every ward explaining how to do so; the Chief Inspector of Hospitals will inspect complaints handling to establish whether trusts are genuinely seeking to understand and learn from them; every quarter, trusts will publish the number of complaints received and the lessons learnt; and the Health Service Ombudsman will dramatically increase the number of cases that she looks at.

It is impossible to deliver safe care without safe staffing levels. All hospitals will be required to monitor their staffing levels on a ward-by-ward basis, analysing precisely how many shifts meet safe staffing guidelines. By the end of next year, this will be done using models independently approved by NICE. No hospital will be able to conceal unsafe staffing from the public because from next June all these data, both at ward and hospital level, will be published alongside other safety data on a new NHS safety website, triggering CQC action if there is cause for concern.

Things are already changing for the better and I am pleased to report that trusts are planning to recruit an additional 3,700 nurses compared to a year ago. However, we need to go further to train and motivate staff, particularly healthcare assistants and social care support workers who perform so much vital care. Healthcare assistants and social care support workers will be required to have a new care certificate to ensure that no one is ever asked to perform personal care without adequate training, whether in hospitals or care homes. The title “nursing assistant” will be used widely in hospitals and paths to nursing careers will be improved. I thank Camilla Cavendish for her excellent work in this area. We also need to broaden the talent pool going into NHS management positions, in particular attracting more clinicians and those with good external experience. We have introduced a fast-track leadership programme, sending 50 people a year to a world-leading business school, followed by time shadowing top NHS chief executives.

Robert Francis correctly highlighted the failure of regulatory systems to identify quickly what happened at Mid Staffs. Subsequently it has become clear that Ministers put pressure on regulators which may have led them to tone down news about poor care. This is totally unacceptable, so we will strengthen the statutory independence surrounding reports into care quality. The chief inspector will be the nation’s whistleblower-in-chief and nothing must ever be allowed to stand in his way. The CQC can prosecute when fundamental standards are breached. Trusts put into special measures will have a strictly limited time to get their house in order before administration is considered. Foundation trusts in special measures will have their autonomy suspended and action will be taken to ensure that they quickly improve. No trust will be able to progress to foundation status unless they are rated good or outstanding.

Proper accountability must be at the heart of the NHS. I have therefore accepted Professor Don Berwick’s recommendation of legal sanctions for those found guilty of wilful neglect or ill treatment. There will be a new criminal offence for care providers that supply or publish false or misleading information. A new “fit and proper persons” test will enable the CQC to bar unfit directors from boards. Every hospital patient should have the names of a responsible consultant and nurse above their bed. Starting with over-75s from next April, there will be a named accountable clinician for out-of-hospital care for all vulnerable older people.

One of the most chilling accounts in the Francis report came from Mid Staffs employees who considered such care to be “normal”. Cruelty became normal in our NHS and no one noticed. The Francis report made 290 recommendations. I accept the principles behind all of them and, wherever possible, have adopted the practical solutions suggested by the inquiry.

Robert Francis himself has welcomed today’s announcement as a carefully considered and thorough response to his recommendations, which he says will contribute greatly towards a new culture of caring and making our hospitals safer places for their patients.

Today’s measures are a blueprint for restoring trust in the NHS, reinforcing professional pride in NHS front-line staff and, above all, giving confidence to patients that after Mid Staffs the NHS has listened and learnt and will not rest until it is delivering the safest, most effective and most compassionate care anywhere in the world. I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

My Lords, first, I welcome the noble Lord’s very positive comments about the various reviews that have been commissioned in recent months. I am glad that he agrees that, in broad terms, the Government are on the right lines in accepting the recommendations that have come forward.

The noble Lord asked a number of questions, the first of which was about why we have not implemented all the recommendations of Robert Francis in full. Most of the recommendations have been accepted in principle, in part or—in the main—in their entirety. In some cases, we are taking an alternative approach to that suggested in the inquiry if we believe it is likely to be more effective in reaching the intended outcome. In total, we have rejected just nine of the 290 recommendations and where recommendations have been rejected, a full response outlining the reasons for doing so and the alternative action that organisations are taking is provided in our system-wide response.

The noble Lord asked about the regulation of healthcare assistants, a matter to which we return at regular intervals in this House. I assure him that the Government keep this issue under regular review but, for the time being, our view is to tackle the key issue at its root, focusing on making sure that healthcare support workers have the right training, values, support and leadership to provide the high-quality care that we all want patients to receive. We are committed to ensuring that this part of the workforce receives high-quality and consistent training. We have commissioned Skills for Care and Skills for Health, as the noble Lord knows, to develop a code of conduct and minimum training standards. We have also announced the development of a care certificate, which I am sure will be particularly welcome to a number of my noble friends.

The noble Lord asked me about a situation in which employers might find that a healthcare assistant or social care support worker no longer met the standards required by the care certificate. In that event, Health Education England and the sector skills council will set out in guidance the requirements for ensuring that appropriate retraining is given or other disciplinary action is taken. The guidance will be that the worker in question should not work unsupervised until the problem has been resolved and the employer is confident that their care certificate remains valid. Of course, if a healthcare assistant is found to have harmed patients or have been a serious risk to patients, the Disclosure and Barring Service needs to be considered as the ultimate remedy to make sure that that person does not put patients at risk in future. However, that is an extreme situation, which I believe will not be the norm.

The noble Lord referred to the nurse numbers. In the last spending review, the NHS budget was protected in real terms, with cash funding rising by £12.7 billion by 2014-15. Alongside that, Health Education England has been working with NHS trusts to develop the overall workforce plan for England for next year, reflecting the strategic commissioning intentions. That work indicates that a number of trusts have already increased their nurse staffing levels during the current year and others are planning to do so, as I mentioned in the Statement. Initial plans indicate that trusts intend to employ an increase of more than 3,700 nurses this year.

Moving to staff ratios, nursing leaders have been clear—indeed, there is a letter in today’s Times about this—that hospitals should publish staffing details and the evidence to show that staff numbers are right. However, we do not think that prescribing a rigid set of rules from the centre is the right way forward. The National Quality Board and the Chief Nursing Officer are publishing a guidance document that sets out current evidence on safe staffing. By next summer, NICE will produce independent, authoritative, evidence-based guidance on safe staffing and review and endorse associated tools for setting safe staffing levels in acute settings. From next April, by June at the latest, NHS trusts will publish ward-level information on whether they are meeting their staffing requirements. A review every six months will allow for those staffing levels to be quality assured.

On the issue of candour, we have had a number of debates on this subject, both during the passage of the Health and Social Care Act and, more recently, in the Care Bill, and I believe that we have reached a place for which this House can take some credit because the Government have moved a considerable distance from their original position. We agree with Don Berwick’s intention that professional regulators are in the best position to strengthen the duty of candour for individual professionals working in a hospital. Of course, the duty of candour applies to the corporate entity but the GMC and the NMC will be working with the other regulators to agree consistent approaches to candour and the reporting of errors, including a common responsibility to be candid with patients when mistakes occur, whether serious or not, and clear guidance that professionals who seek to obstruct others in raising concerns or in being candid would be in breach of their professional responsibilities. The professional regulators will issue new guidance to make it clear that it is the responsibility of professionals to report near misses for errors that could have led to death or serious injury as well as actual harm, and they must do so at the earliest opportunity. We will seek advice from experts on how to improve the reporting of patient safety incidents, including whether the threshold for the statutory duty of candour should include moderate harm.

The noble Lord referred to the NPSA. He is right that the NPSA’s function of reporting safety incidents has transferred to NHS England, into which the National Reporting and Learning System has been absorbed. I do not see that transfer as, in any way, inhibiting staff confidence in reporting safety incidents. The essence of the system remains as it always has been.

The noble Lord asked about the responsibility for patient safety being transferred back to the CQC. I am sure that, on reflection, he will agree that patient safety is everybody’s business. In part, it is the business of the CQC but, above all, it is the business of those who work in the NHS. It is the business of trust boards and of commissioners. It is also very much the business of those whose job it is to look at the performance of the NHS on behalf of patients—chiefly Healthwatch, but also patient organisations. Therefore one cannot single out an individual organisation as taking sole responsibility for this.

I will write to the noble Lord about the Freedom of Information Act. However, he should not forget that the standard contract that the NHS operates binds anyone who provides services to the NHS into certain contractual terms, and the disclosure of relevant information is a part of that.

On death certification, the noble Lord asked me about medical examiners. We agree that they must be independent of the deceased person and their medical practitioner. That is because medical examiners need to carry out independent scrutiny of the medical circumstances and cause of apparently natural deaths to make sure that the right deaths are notified or referred to a coroner. However, we need to ensure that there are sufficient numbers of medical examiners to carry out this work, particularly in rural areas, so appointees are likely to have some sort of professional relationship with local care providers. Therefore the draft death certification regulations for medical examiners do not require that medical examiners are independent of the organisation whose patients’ deaths are being scrutinised. However, we are mindful of the need for a greater level of independence within the spirit of this recommendation and the Government will review how they can include further safeguards on this front.

The noble Lord suggested that the NHS constitution was not the right means of changing the culture of the NHS, and I agree with him. However, declaratory statements in the constitution are an important part of signalling to the NHS its vision and values in the broadest terms, and the duties that people should feel they are under. The values, rights and pledges set out in the NHS constitution form the basis of everything the NHS does. NHS England, Health Education England, the department and CCGs are developing a joint strategy to embed the constitution further, as we promised they would during the passage of the Health and Social Care Act.

On the system that we have put in place and the complexity that the noble Lord sees in that system, I say, simply, that the system we now have is more transparent than the one we had before. Accountabilities are clear, responsibility is clearly placed where it should be and it is backed by robust lines of accountability, including to Ministers and Parliament.

I hope that that answers most of the noble Lord’s questions, but I will of course write to him if I have omitted anything.

[Baroness Brinton (LD)]

My Lords, we on these Benches welcome both the Francis report and the Government’s Statement. In particular, we welcome the importance of openness, transparency and access to information to ensure that there is a change in culture. Can the Minister confirm that the new care certificate will be an NVQ qualification so that the public can be confident that staff have the right skills and training? We would also welcome registration and regulation for those staff in the way that the noble Lord, Lord Hunt, referred to earlier. Can the Minister also confirm that when complaints and other items have to be published, it will not be as a few lines in an annual report but on the web, and that it will easily accessible by patients and the public?

[Earl Howe]

My Lords, I very much agree with the spirit of my noble friend’s questions. Certainly as regards complaints, the public should have a clear view of the nature of the complaints that have been registered with a particular organisation. They should be able to have a sense of what those complaints relate to and what action the organisation has taken to address the matter in question.

On my noble friend’s first point, we are currently working through the question of the care certificate and will seek advice. It is important to arrive at an agreed formula that gives the maximum assurance, both to care assistants and to those they look after, that basic standards of training have been learnt and are being adhered to. It is important to define as closely as we can what we mean by that, and as soon as we have further details we will announce them.

[Lord Patel (CB)]

My Lords, I thank the Minister for repeating the Statement, and I welcome the Government’s comments on the Francis report. I apologise on behalf of my noble friend Lady Emerton, the matron, who is not here today as she is unwell, and also my noble friend—he is a friend, although he sits on the wrong Benches—Lord Willis. He cannot be here because he has been asked to undertake the duties of my noble friend Lady Emerton. They asked me to represent their views—which I will not do, because I would get them wrong, but perhaps I may make my own comments. I realise I am not allowed the same time as the noble Lord, Lord Hunt, had. That is a pity, because I have much to say about the Statement.

I welcome the statutory requirement to give notification of any harm or serious misses that have happened. During my time as chairman of the National Patient Safety Agency I tried to get that into statute and failed; it was not under the current Government, but that does not matter. I am therefore delighted that this will be a statutory requirement. The important thing is that, as Don Berwick said, this is about learning; reporting by itself is not enough. The Minister referred to the airline industry, which learns from what has happened by doing root-cause analysis. We need that system established in the NHS if we are to learn from avoidable harm and near misses. Whose responsibility will it be to do that, and how will that expertise be gained?

On staffing ratios, the Minister knows that if my noble friend Lady Emerton had been here she would have asked about ratios of trained to untrained staff. Now that there will be a new care certificate to ensure training for all care assistants and nursing assistants, which I welcome, she would have asked for regulation. However, we have passed that stage, and I welcome the fact that there will be a new care certificate following the training. Why, however, is all this to be only for hospitals? What about care homes? Why were care homes excluded from reporting on staffing ratios?

[Earl Howe]

I apologise, but I did not quite hear the last part of the noble Lord’s question. Was it why care homes were excluded?

[Lord Patel]

The Statement refers particularly to hospitals. They will have to report on staffing ratios, but it did not say that care homes will have to do that.

[Earl Howe]

I am grateful to the noble Lord. I am in complete agreement with him on his first point. The best thing might be for me to read out a very short passage from Professor Don Berwick, who said:

“The best keys to health care safety do not lie in blame, or regulation, or punishment, but rather in learning, support, and encouragement to the health care staff, the vast majority of whom are dedicated to excellence in care.

Leaders who aim for safe and effective care have a duty to supply the workforce with the tools, knowledge and encouragement to do the work that adds meaning to their lives”.

We have attempted, as far as we can, to make that philosophy the guiding principle of our response on patient safety. We do not want to create a blame culture; we want to create a culture that encourages everybody to feel ownership of the work that they do, and to feel well led. That is the other side of the coin to the culture that we have spoken about in other debates about innovation—about making innovation everybody’s business in an organisation. It comes down, in the end, to good leadership.

We are not insisting that every organisation should carry out root-cause analysis. On the other hand, we are saying that it is the business of trust boards to make complaints, mistakes, and lapses in patient safety central to their work and to the scrutiny that they undertake of their organisations, and for those matters to be discussed openly and resolved openly.

As regards care homes, as I said, we have commissioned NICE to work through the guidance that will underpin safe staffing. It is not yet apparent whether that will cover care homes and it is difficult to see how it could do so because care homes are clearly very different organisations from acute trusts. On the other hand, we expect the CQC to have some way of judging whether a care home can call itself safe. We will certainly look at the noble Lord’s points as we carry that work stream forward.

[Baroness Pitkeathley (Lab)]

My Lords, I am sure it will be welcome to patients and their families that the name of a responsible consultant will now be above the patient’s bed, but will the noble Earl say a bit more about the new attention to 75 year-olds that has been promised? In the extensive leaks of the Government’s response over the weekend, GPs were definitely named as the people who would be responsible for the over-75s. The Statement refers to “a named accountable clinician”. Is there a difference between the two?

[Earl Howe]

Yes. There were no leaks. The report that the noble Baroness saw was a report on the new GP contract that we announced at the end of last week. That was legitimate reporting by the press of an element of the new contract for next year, when we want all NHS patients over the age of 75 to have a named, accountable GP. However, we are saying in this response that every patient in a hospital setting should know who their consultant is, and therefore that there should be a named responsible consultant for every hospital patient. The two issues are, therefore, related but different.

[Lord Mawhinney (Con)]

My Lords, the Statement said that the NHS has to be a moral organisation or it is nothing. I am sure that my noble friend carried the whole House with him when he said that. Therefore, the raft of changes and the new legal accountability that will come in next year are very welcome in their own right as they will bolster that concept. However, how is it that no individual or individuals have been held accountable for the tragedy and disaster at Mid Staffordshire? I know that my noble friend keeps saying, on behalf of the Government, that they do not want to encourage a blame culture, but will he explain to your Lordships’ House how we can have an accountability structure without any blame attached?

[Earl Howe]

My Lords, the trust board at Mid Staffs was ultimately responsible, and individuals on it have been replaced. That was the first step in holding the system to account. We are introducing strengthened accountability for the future, including a fit and proper persons test for directors, as well as a single-failure regime triggered by failures in care. We have also appointed a Chief Inspector of Hospitals with power to ensure that the system acts quickly to tackle unacceptable care. In a range of ways I hope that we have addressed the central point in my noble friend’s question, which is very well placed.

[Baroness Masham of Ilton (CB)]

My Lords, I am pleased to hear about the transparency and the duty of candour, but will the noble Earl give the House an assurance that patients will be listened to? I am thinking about the young man who implored staff for a drink, and even telephoned the police on his mobile, but was ignored by staff. This was not Mid Staffordshire but a London teaching hospital. Further, will staff be protected when they blow the whistle? Will the noble Earl give an assurance that they will not lose their jobs?

[Earl Howe]

My Lords, I completely agree with the noble Baroness that the voice of the patient is an essential part of maintaining a culture of safety in the NHS. Improving the way in which the NHS manages and responds to complaints will be critical in shaping a culture that listens to patients and learns from them and ending a culture of defensiveness or, at worst, a culture of denial about poor care. That is why we welcome and accept the spirit of the review of the NHS hospital complaints system by Ann Clwyd MP and Professor Tricia Hart and the principles behind their recommendations.

On whistleblowers, the amendments to the NHS constitution have enhanced the protection for whistleblowers, but we are not complacent and we are already considering whether there is a need for more developments both to protect whistleblowers and to ensure that action is taken, where necessary, in response to concerns. We are looking, with the national regulators, at how whistleblowing concerns are dealt with at the moment and, where appropriate, we will introduce improvements to systems in the future.

[Baroness Knight of Collingtree (Con)]

My Lords, much of what my noble friend has said has given us satisfaction, but it is perfectly true, as we have already been reminded, that troubles were going on not only in the Mid Staffordshire area but all over the place. It is also true that it is not just the whistleblowers who warned time and time again about what was going on and who should have been listened to. I spent four or five years raising cases of people who had written to me. On one occasion I presented the then Minister, the noble Lord, Lord Hunt of Kings Heath, with a dossier of some 25 cases, all of which had been checked very carefully. All the details were correct, all the patients, or their relatives, had given permission for these cases to be raised and they were raised in this House. I am not blaming the noble Lord for failing to take these cases forward, or failing to listen to the arguments put out clearly in this House, because I think that he passed them on, but they were never properly investigated.

It is upsetting that for such a long period warnings were being given and were allowed somehow to filter into the ground and away, or into the past. I particularly warned about the practice, which was fairly unknown at that time, of failing to feed patients because food was put too far away from them and other examples. I worry about the people who suffered for those long years when something could have been done if those responsible at the grass roots had taken care of what was being said in this House. I beg the Minister not to leave aside the really serious point that cases raised with great sincerity and truth in this House should be regarded and not just pushed aside in the future.

[Earl Howe]

My Lords, my noble friend should be listened to with great care. Of course, I remember those cases. I was not the Minister in charge at the time she submitted those cases to the Department of Health, but she shared them with me, and I share her concerns, which are, of course, directly relevant to the matters we are discussing today. We have the new duty of candour and in April the Enterprise and Regulatory Reform Act strengthened the main whistleblowing legislation introduced by the Public Interest Disclosure Act so that an individual who suffers harm from a co-worker as a result of blowing the whistle now has the right to expect their employer to take reasonable steps to stop this. The idea is to ensure that people do not feel intimidated from speaking up. The Care Quality Commission is using staff surveys and the whistleblowing concerns it receives as part of the data in its new intelligent monitoring system. That data will guide the CQC about which hospitals to inspect. Since September, the commission’s new inspection system includes discussions with hospitals about how they deal with whistleblowers and handle them.

[Baroness Hayman (CB)]

My Lords, I declare an interest as a member of the General Medical Council. In no way do I speak on its behalf today, but it is obvious from the remarks that the Minister has made that the GMC has been working with the Government and other regulators and is committed to underlining professional responsibilities, particularly in relation to the duty of candour. That work will, of course, continue. On a personal level, I welcome the return to naming the consultant and the nurse responsible for an individual patient. It is emblematic of that personal sense of responsibility and accountability for patient welfare.

In respect of the new complaints procedure, as the Minister said, the care of patients and their safety are the responsibility of not only the named consultant and nurse but everybody in that institution. Does he agree that there is also a particular responsibility on the trust’s non-executive directors in that respect and that the new system should ensure that they are taking their responsibilities seriously? I know from decades ago, when I chaired the complaints panel at a London teaching hospital, that that resource, in terms not only of the ability to protect patients but of improving efficiency and the quality of care by understanding complaints, was a treasure trove that should not be abandoned.

[Earl Howe]

I entirely agree with the noble Baroness, who of course has immense experience in these fields. I agree with her in particular about the role of the non-executive director. If an organisation has what may look like quite a high number of complaints, it should be regarded as a sign of openness, transparency and the right kind of culture in that organisation. It is only where suspiciously low numbers of complaints have been recorded that alarm bells should start ringing. I agree that boards of directors, led and encouraged in this area by the non-executives, should make it a central part of their business to analyse complaints and make sure that they have been followed through, not just that the matters have individually been remedied but that any systemic issue has been properly addressed.