England and Wales High Court (Administrative Court) Decisions

IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT

		Royal Courts of Justice Strand, London, WC2A 2LL
		07/12/2016

Mr Justice Mostyn:

1. The claimant is a psychotherapist. She is a member of the British Association for Counselling and Psychotherapy (the defendant). She is also a member of the United Kingdom Council for Psychotherapy (the interested party). Both the defendant and the interested party are professional bodies for psychotherapists and counsellors. Psychotherapists and counsellors are not regulated by statute. The government is seemingly content with the system of voluntary regulation that prevails, notwithstanding that it is not a legal requirement that a practitioner must be a member of one or other body. In the real world a practitioner has to be member of at least one body. They would not get any work otherwise. Most are members of both.
2. The existence of two separate bodies regulating the same field is surprising. It was explained to me that this is a historical accident. It was argued by Miss Omambala that the interested party's membership is a larger set than that that of the defendant; but I do not accept that. Both cover psychotherapists and counsellors. The sets of practitioners governed by the defendant and the interested party are not intersecting but congruent. They are the one and the same. Similarly, the two sister bodies stipulate common ethical standards for their members. It is unthinkable that they should differ. Those standards may be expressed in different language by the two bodies, but they are nonetheless the same. Of that there can be no doubt.
3. The claimant asserts that the defendant's decision to take disciplinary proceedings against her for alleged misconduct amounts to an abusive duplicative action and is therefore unlawful. She says this because the interested party has concluded an exhaustive disciplinary proceeding against her based on identical facts alleged by the complainant. In that proceeding none of the contested facts were found proved. Some facts were admitted by the claimant. In relation to some of those admitted facts the disciplinary panel found that the claimant was guilty of misconduct, but it held that her fitness to practise was not impaired and it imposed no sanction. The claimant is appealing the findings of misconduct made by the disciplinary panel of the interested party. She says that when that process concludes that should be the end of the matter. She says that it is unfair, oppressive and unlawful that she should face a re-run of the process at the hands of the defendant.
4. The law about the restraint of duplicative proceedings goes back a long way. In the field of criminal law, the defences of autrefois convict or acquit can be traced back to the very earliest days of the common law. Only in highly exceptional circumstances can a defendant who has been acquitted or convicted be tried again on the same facts. The rule against double jeopardy is a constitutional right in the USA under the Fifth Amendment. The rule is incorporated in the European Convention on Human Rights and the International Covenant on Civil and Political Rights.
5. In the civil sphere the law's aversion to duplicative proceedings finds expression in the doctrine of res judicata. This means literally "the matter has been adjudged". The legal principles have been given magisterial exposition by Lord Sumption in Virgin Atlantic Airways Ltd v Zodiac Seats UK Ltd [2013] UKSC 46 [2014] 1 AC 160 at [17] - [26]. He explains that there is in effect a hierarchy of types of duplicative cases, and that the higher up the hierarchy the case is, the harder it will be to open the door to a second hearing. That hierarchy is as follows.

i) First, is "cause of action estoppel". This is where both the parties and the subject matter of the litigation are the same in both the first action and the prospective second action. Here, there is a near absolute bar on litigating the matter twice. The only exceptions are where fraud or collusion can be proved. A party cannot get round the bar by putting up a front-man to litigate anew. Whether the parties are the same has to be judged realistically not literally. Further, a party cannot get round the bar by seeking to argue new points which were not argued first time round. The subject matter of the original litigation extends to "every point which properly belonged to the subject of litigation, and which the parties, exercising reasonable diligence, might have brought forward at the time" (Henderson v Henderson (1843) 3 Hare 100 at 115 per Sir James Wigram V-C).

ii) Next, is "issue estoppel". Here the parties must be the same (in reality), but the subject matter of the litigation in the prospective second action is not the same as that in the original action. In this scenario a bar may arise "where a particular issue forming a necessary ingredient in a cause of action has been litigated and decided and in subsequent proceedings between the same parties involving a different cause of action to which the same issue is relevant, one of the parties seeks to re-open that issue" (Arnold v National Westminster Bank plc [1991] 2 AC 93 at 105E per Lord Keith of Kinkel). In this situation, the bar is not absolute. Here, the public policy on which the doctrine is based and principles of justice have greater force. A discretion arises to do justice. It is in principle possible to challenge the previous decision on the relevant issue not just by taking a new point which could not reasonably have been taken on the earlier occasion, but even to reargue in materially altered circumstances an old point which had previously been rejected.

In Virgin Atlantic Airways Ltd v Zodiac Seats UK Ltd Lord Sumption summarised the principles relating to these two species of estoppel at [22] as follows:

(1) Cause of action estoppel is absolute in relation to all points which had to be and were decided in order to establish the existence or non-existence of a cause of action.

(2) Cause of action estoppel also bars the raising in subsequent proceedings of points essential to the existence or non-existence of a cause of action which were not decided because they were not raised in the earlier proceedings, if they could with reasonable diligence and should in all the circumstances have been raised.

(3) Except in special circumstances where this would cause injustice, issue estoppel bars the raising in subsequent proceedings of points which (i) were not raised in the earlier proceedings or (ii) were raised but unsuccessfully. If the relevant point was not raised, the bar will usually be absolute if it could with reasonable diligence and should in all the circumstances have been raised.

iii) Finally, there is the situation where something has been decided in the original action which is sought to be re-argued in a second action but where the parties to the two actions are different, and therefore neither issue estoppel nor cause of action estoppel can operate. Lord Sumption explains at [25] that the famous case of Johnson v Gore-Wood & Co [2002] 2 AC 1, HL was in fact just such a case. He explains that in this type of case the court is deploying its procedural powers to prevent abusive conduct rather than applying rules of substantive law, although he accepts that the different means have "the common underlying purpose of limiting abusive and duplicative litigation".

This has been labelled the "collateral attack" doctrine. The most well-known case on the subject is probably the decision of the House of Lords in Hunter v Chief Constable of West Midlands Police [1982] AC 529, where Lord Diplock stated that the circumstances in which this abuse of process can arise are very varied. The entire jurisprudence was summarised in a definitive judgment of Sir Andrew Morritt V-C in Secretary of State for Trade and Industry v Bairstow [2004] Ch 1, CA. At [38] he formulated four principles, of which of which I need only cite the first and fourth:

(1) A collateral attack on an earlier decision of a court of competent jurisdiction may be but is not necessarily an abuse of the process of the court.

(4) If the parties to the later civil proceedings were not parties to or privies of those who were parties to the earlier proceedings then it will only be an abuse of the process of the court to challenge the factual findings and conclusions of the judge or jury in the earlier action if (i) it would be manifestly unfair to a party to the later proceedings that the same issues should be re-litigated or (ii) to permit such re-litigation would bring the administration of justice into disrepute.

It can be seen that in this scenario there is no starting point that the earlier decision should act as a bar to a second action. Rather, it is the other way round. It is for the party trying to stop the second action to show that either it would be manifestly unfair to him or her that the same issues should be re-litigated, or that to permit re-litigation would bring the administration of justice into disrepute. Subsequent cases applying (or not applying) this doctrine show that they are highly fact-specific: see, for example, the recent decision of Shalabayev v JSC BTA Bank [2016] EWCA Civ 987, where Gloster LJ stated at [55] that "it all depends on the particular circumstances concerned as to whether the principle is engaged".

6. These principles or doctrines may apply where the first judgment was given by default (see New Brunswick Railway Co. v. British & French Trust Corporation Ltd [1939] AC 1). They may apply even where the finding in the first proceedings is not explicit but where it is tacit and to be inferred (see R v Hartington Middle Quarter Inhabitants (1855) 4 E & B 780). They may apply where the first decision was no more than a consent order. Vanden Recycling Ltd v Tumulty [2015] EWHC 3616 (QB) was such a case. In contrast, in Spicer v Tulli [2012] 1 WLR 3088 Lewison LJ held that a consent order in that case did not act as a bar to a later action and stated that the rules "are all creations of judge-made law, and that judges have been careful not to lay down absolute limits to [them]".
7. The doctrines apply equally in quasi-judicial disciplinary proceedings: see R (on the application of Coke-Wallis) v Institute of Chartered Accountants in England and Wales [2011] UKSC 1 [2011] 2 AC 146, SC.
8. The question I have to decide is whether the facts of this case fit into one of the categories in the hierarchy I have identified. To those facts I now turn.
9. From January 2009 to August 2014 the claimant treated the complainant. From January 2009 until March 2010 the treatment was under the NHS at Putneymead. From March 2010 to September 2011 the treatment was private and given in the claimant's rooms at her home. From September 2011 to August 2014 the claimant was a member (but not the leader) of a multi-disciplinary team treating the complainant at the Priory Hospital in Roehampton.
10. The complainant is an intelligent and articulate person. She was an exceptionally challenging and demanding patient. The claimant's skeleton argument describes the complainant and the claimant's professional relationship with her in the following terms, which are not disputed:

"[The complainant] is an intelligent, educated and articulate. She was an exceptionally challenging and demanding patient with a particularly complex presentation for every professional who treated her. She has been diagnosed at various times with dissociative identity disorder, borderline personality disorder, post-traumatic stress disorder, anxiety and depression. From 2011, she had multiple episodes of prolonged dissociation, self-harm, and suicidal ideation. The usual response to anything with which she does not agree is one of violent rage, threats of suicide, prolonged dissociation or the making of a complaint. She is clearly a vulnerable person by virtue of her complex mental health presentation.

From 2013 onwards, as [the complainant's] presentation became more complex and challenging, the claimant tried on numerous occasions, with the agreement of colleagues of (sic) the Priory, to transfer [the complainant's] treatment to other, more specialist therapists. The complainant refused because she would not countenance the claimant being replaced by another therapist.

On 1 August 2014 the claimant told her colleagues that she felt that she had brought [the complainant] "therapeutically as far as she can". [The complainant] had been refusing alternative therapies. The claimant thought that the only way [the complainant] could move forward was to end their therapeutic relationship. The claimant asked [the complainant's] key worker to assist as she was going to have that conversation with [the complainant]. [The complainant's] response was fury. She called the claimant a "lying bitch", said she felt rage and expressed a desire to kill the claimant."

11. On 1 September 2014 the complainant spoke to the team leader at the Priory, Dr Hopley, and stated that she felt very angry with the claimant and was considering ways of gaining revenge, including self-harm. Dr Hopley encouraged the complainant to consider alternatives including making a formal complaint about her.
12. On 30 September 2015 the complainant made formal complaints about the claimant to the Priory, to Putneymead and to the London Borough of Wandsworth safeguarding team. I observe in passing that as a result of the complaint to the Priory the claimant has had her privileges discontinued there – she has in effect been dismissed.
13. On Friday 16 January 2015 the complainant made a formal complaint about the claimant to the interested party. It is 76 pages long and occupies pages 544 - 621 of the trial bundle. The complaint can be broken down as follows:

i) Pages 544 - 548 contain routine "box-ticking" material.

ii) Pages 549 - 561 contain text prepared by the complainant in turn broken down as follows:

a) Pages 549 - 550: front-sheet and table of contents

b) Page 551: introduction

c) Page 552: relevant references to the UKCP ethical principles and code of professional conduct

d) Pages 553 - 560 (8 pages): allegations

e) Page 561: conclusion

iii) Pages 562 - 621: fifteen appendices containing evidentiary material relied on.

14. It can be seen that of these 76 pages the core material is the 8-page section entitled "allegations".
15. On Monday 2 February 2015, that is to say 17 days later, the complainant made a formal complaint about the claimant to the defendant. The version in my bundle does not include its appendices, but does include its index of them. The main complaint runs from pages 458 - 473 and can be broken down as follows:

i) Pages 458 - 459: front-sheet and table of contents

ii) Page 461: timeline

iii) Page 462: relevant references to the BACP ethical framework for good practice.

iv) Pages 463 - 470: allegations

v) Page 471: conclusion

vi) Pages 472- 473: index of seventeen appendices containing evidentiary material relied on.

16. It is to be observed that once the formal prefatory parts of the complaint to the interested party are excluded, the two complaints are structurally virtually identical. The only structural difference is that the complaint to the defendant includes a "timeline".
17. In terms of content, the differences between the two complaints are minimal. As I have said, the second complaint includes a timeline. The summaries of the relevant ethics of the two bodies reflects the different language used by them to express their ethics. The introductions and conclusions are very similar but not identical. The second complaint has two more appendices (being material from the Priory and LB Wandsworth investigations). The remaining 15 appendices are virtually identical. The most significant comparison however is between the allegations in the two complaints. These are word-for-word identical. They have simply been copied and pasted from the first to the second.
18. No-one reading these complaints could conclude that they were not in substance exactly the same. No-one reading them could conclude that they were other than duplicative and exposed the claimant to double jeopardy.
19. I am now going to trace the course of the first complaint to the interested party.
20. On receipt of the first complaint the interested party drafted particularised charges or specific allegations deriving from the allegations made by the complainant. These are in the bundle at pages 622 - 627. On 21 September 2015 the claimant's solicitors invited the interested party to withdraw and discontinue certain allegations made against her on the basis that there was insufficient evidence to prove them. In response the interested party revised the allegations and withdrew a number of them. The revised allegations are at pages 642 - 646. These revised allegations were in fact later augmented by two further sets of allegations. These are set out at Nos. 8 and 9 on page 961, and say that the claimant behaved inappropriately following the making of the complaint by viewing the complainant's LinkedIn profile and following her Twitter feed.
21. Although I have not been shown a determination by the adjudication panel of the interested party there must have been a quasi-judicial sift of the original allegations in a process akin to a permission hearing in judicial review or appellate proceedings. In fairness, Miss Omambala has not suggested otherwise. Thus, I proceed on the basis that the withdrawn/discontinued allegations were the result of a quasi-judicial adjudication.
22. The remaining charges (as augmented) went to a full hearing by the interested party's adjudication panel over eight days between 20 and 24 June and 4 to 6 July 2016. There were 37 discrete acts of alleged misconduct. The interested party was represented by counsel. The claimant was represented by leading counsel. The documents amounted to over 1,000 pages. Six witnesses gave oral testimony, including the claimant and the complainant. The claimant gave evidence for two days. The process was exhaustive, and no stone was left unturned. The expenditure in terms of time, emotion and money was enormous. The stress imposed on the claimant must have been extremely high.
23. The panel rendered its decision on the facts in writing on 4 July 2016. The phase that followed was an evaluative exercise to determine whether any facts found proved amounted to misconduct, and, if so, whether a sanction should be imposed. This is a familiar process in disciplinary proceedings.
24. In their findings of fact the panel only accepted those facts that had been admitted by the complainant. These amounted to 28 out of the 37 allegations. These allegations were banal in nature. All the contested, much more serious, allegations (9 in number) were resolved in favour of the claimant. Essentially the panel found that the complainant was not a witness who could be relied on. In contrast, the panel found the claimant to be a witness who was credible and whose evidence could be relied on.
25. On 5 July 2016 the panel found that 10 of the admitted facts did amount to misconduct. It is not for me to question that finding, however surprising it may appear. However, on 6 July 2016 the panel found that the conduct was capable of remediation and had been remediated. Therefore, no sanction was imposed.
26. As I have said, the findings of misconduct are being appealed by the claimant.
27. While all this was going on the defendant was progressing the complaint made to it. One might have thought that elementary principles of fairness would have caused the defendant to stay its hand while the identical complaint was dealt with by its sister body. But it did not, and in my judgment it has unreasonably progressed the complaint in a dogged and obstinate matter, impervious to pleas that it should act reasonably and fairly.
28. On 7 July 2015 the defendant informed the claimant that the complaint would be considered by a pre-hearing assessment panel to determine if there was a case to answer. The claimant was told that she was not, at this stage, permitted to respond to the complaint. Again, it is not for me to question this procedure, however surprising it may appear.
29. On 13 July 2015 the claimant, through her solicitors sought that the process should be in effect be stayed pending the disposal of the identical parallel complaint to the interested party. Again, one would think that the obvious and reasonable response would be to agree, but the answer was no and the claimant was told that the matter would continue to a pre-hearing assessment panel hearing in the week of 14 August 2015 and (again) that she was not permitted to respond to the complaint. In argument I observed that this process had similarities to proceedings in the Star Chamber, but I accept that the question of the fairness of the process is not a matter for me to determine. The panel asked for more information, including a copy of the contract between the claimant and the complainant. Eventually, on 22 February 2016 the pre-hearing assessment panel produced a report which concluded that there was a case to answer. It particularises the complaints made by the complainant into 15 separate charges, which are in my bundle at 671 – 673.
30. Comparison between these charges and the original charges as formulated by the interested party (pages 622 – 627) reveals that they are in substance the same. Of course, as you would expect with different authorship, different language is used to describe the same things. Different language is used to explain why the facts amount to misconduct having regard to the fact that different language is used by the two bodies to describe their common ethical principles. It would be a specious exercise to engage in a narrow textual analysis to see if there were differences between the two sets of charges. For example, it was submitted to me that charge No. 11 in the defendant's list was not in fact replicated in the interested party's list. This says that the claimant failed to seek advice after her effectiveness became impaired when she became "burnt out". In the interested party's list at No. 3(e)(iii) it alleges that the claimant blamed the complainant for being burnt out and in No. 4(e) it says that that fact, among others, showed that she had lost her competence. The phrasing is not identical but the two allegations are in substance the same.
31. Between February and June 2016 the defendant steadfastly maintained the position that it would not agree to a stay of the complaint to it while the first complaint was being dealt with by the interested party. So, on 15 June 2016 these proceedings for judicial review were commenced. On 11 August 2016 Andrews J granted permission on two of the grounds namely (1) that to proceed with the second complaint would amount to a collateral attack on the decision by the interested party; and (2) that it was unfair or irrational to allow the complainant personally to prosecute her complaint to the defendant's adjudicatory panel (as its procedures appeared to require).
32. Meanwhile, on 21 June 2016 a consent order was made which prevented the defendant from taking any steps in the complaint to it before 3 August 2016. It also recorded that the defendant would "recognise" any decision made in the proceedings before the interested party "in accordance with [Professionals Standards Authority] standard 10(e)".
33. The Professionals Standards Authority for Health and Social Care is a state organ which oversees a number of statutory regulators and which also sets standards for, and accredits, voluntary regulators such as the defendant and the interested party. Standard 10(e) requires such a body to "recognise decisions regarding professional conduct made by regulatory bodies and other registers accredited by the Professional Standards Authority when deciding whether a person should be admitted, kept on or removed from their register".
34. The word "recognise" in the consent order and standard 10(e) is highly ambiguous. The Oxford English Dictionary supplies the more usual idiomatic meaning of the verb as "to acknowledge, consider, or accept (a person or thing) as or to be something". However, it also supplies the more legalistic meaning namely "to accept the authority, validity, or legitimacy of; esp. to accept the claim or title of (a person or group of people) to be valid or true." When a lawyer talks about someone "recognising" a foreign judgment he means accepting that judgment as valid, binding and enforceable against that person. This is certainly the sense in which recognition of foreign judgments is used at common law. It is the sense in which the concept is used in the Civil Jurisdiction and Judgments Act 1982, as well as in the original and revised Brussels Regulations (Nos. 44/2001 and 1215/2012) and in the original and revised Brussels II Regulations (Nos. 1347/2000 and 2201/2003). It is the sense in which Sir James Munby P considered an informal Indian adoption in the very recent case of Re N [2016] EWHC 3085 (Fam). When he says at [149] "English law recognises N's Indian adoption by the applicant in October 2011" he does not mean that English law merely has regard to the Indian adoption. He means that the court accepts the adoption as valid and effective to alter N's legal status.
35. In my judgment when the defendant agreed in the consent order "to recognise" the decision of the interested party it must be taken to have chosen the word carefully. It must be taken to have accepted that the decision would be valid and binding against it.
36. Notwithstanding the terms of the consent order it is abundantly clear that the defendant intends to press on with a full rehearing of the allegations in its list. I say this whilst acknowledging the eloquent arguments of Miss Omambala that no decision has as yet been reached on the shape or content of the hearing that the defendant intends to conduct. The true intentions of the defendant can be deduced from two sources. First, in a letter written by its solicitors on 1 August 2016 the defendant set out its list derived from its pre-hearing assessment panel and says "given that there are substantial matters which the pre-hearing assessment panel considered should be the subject of adjudication and which have not been considered by the UKCP, we are entirely satisfied that it is appropriate for the complaint to proceed to a hearing." I accept that it is possible that the author of that letter may not have been aware at that time that the UKCP had conducted a preliminary sift to remove a number of allegations, which allegations had resurfaced in the panel's list. But even when such awareness was achieved, or should be taken to have been achieved, the stance was the same. This is clear from para 68 of the recent witness statement of Christina Docchar on behalf of the defendant dated 18 October 2016 where she says:

"Given the number of allegations not explored at all or in full at any hearing, I respectfully suggest that it would be in the interests of justice to pursue BACP's hearing. It is also a matter of public protection to ensure that the allegations made are explored fully, and if findings are made against the claimant in relation to the allegation made by [the complainant] that the BACP professional conduct panel can address these findings by way of an appropriate sanction."

37. The premise of this argument seems to be that it is reasonable to proceed with those allegations which were sifted out by the interested party at the early preliminary stage of its proceedings.
38. I now state my conclusions.
39. I am satisfied that the subject matter of the two complaints is the same. The allegations made by the defendant to each body were identical. The ethical standards of the two bodies are the same, even if they are expressed differently. The two sets of charges cover the same ground, even if the language used to express them differs.
40. There has been a full quasi-judicial determination of all of the complainant's allegations by the interested party. Some were sifted out by means of a preliminary determination. Some were determined after a lengthy hearing. But they were all adjudicated.
41. A more difficult question is whether the parties are the same in each proceeding. A strict analysis would suggest that they are not. In the UKCP proceedings the parties are the interested party as prosecutor and the claimant as respondent. The complainant's status is that of a witness. In the BACP proceedings the parties are the complainant and the claimant. The BACP will assist the complainant but she is technically the prosecutor.
42. I do not think that this strict analysis reflects the realities. If the complainant is to be regarded as the true prosecutor in the BACP proceedings then by parity of reasoning she has the same status in the UKCP proceedings. I accept Miss Foster QC's argument that in the UKCP proceedings she is to be regarded as the interested party's "privy".
43. An alternative way of looking at the position is to find, as I do, that in "recognising" the UKCP decision the defendant adopted it and in effect became a party bound by it.
44. I am thus satisfied that the doctrine of cause of action estoppel operates and the defendant is therefore barred from proceeding to adjudicate the complaint made to it.
45. If I am wrong in my determination that a cause of action estoppel operates then I find that under the collateral attack doctrine it would be manifestly unfair to the defendant to allow this complaint to proceed. In my judgment this case is indistinguishable (in terms of principle) from The Secretary of State for Business, Innovation and Skills v Weston [2014] EWHC 2933 (Ch). There two separate organs of the state attempted in separate courts in separate proceedings to obtain a disqualification order against two company directors. The first attempt, at the suit of the CPS, failed in the Crown Court. A repeat application by the Secretary of State in the High Court was refused, the court holding at [52] that it would be unfair to the defendants to be exposed to the same claim on two occasions. In that case it was said that the second claim was for the public good, but that cut no ice with the court.
46. That case has very close parallels to this one. It would be equivalently unfair to the defendant to allow this second, identical, complaint to go any further.
47. In her submission to the court the complainant wrote:

"It is my opinion that a member of more than one professional body should not be able to pick and choose which and how many professional bodies can determine a complaint raised to another professional body. This being the case, I therefore consider that it is fair that my complaint also be heard by BACP"

I do not agree with this argument where the complaint to each body is identical and where the bodies are performing precisely the same functions over the same professions in accordance with common ethical standards. If the bodies were in fact regulating different professional activities, and if different ethical standards were applied by the two bodies, then the position would be quite different.

48. The first ground for judicial review therefore succeeds.
49. The second ground is in my judgment unarguable. It is not unfair or irrational to allow the complainant to act as formal prosecutor in the BACP proceedings. In reality she will not have to make all the running unaided. She will be afforded assistance by the defendant. But even if she had to do it alone then that would not render the proceedings unfair. In the family law sphere vulnerable and impoverished litigants are now routinely expected to conduct the most difficult cases entirely without assistance, and attempts to remediate the problem have been rebuffed: see Re K and H (Children) [2015] EWCA Civ 543 [2015] 1 WLR 3801, CA.
50. The second ground for judicial review is therefore refused.
51. It is my opinion that the two bodies need to reach an understanding as to how identical simultaneous complaints should be dealt with so as to avoid in the future the problem that has arisen here. Miss Foster QC is right to describe this case as unique. There is no case in the books where two regulators in the same field have been considering identical complaints at the same time. But the fact that there is this curious anomaly where these two bodies seem to be exercising the same functions over the same people in the same field means that it is foreseeable that the problem will arise again. Steps need to be taken to address it.