OK then we are saying similar things. You said upthread, ‘Matt Hancock commissioned it’, which is not the case. The NHS commissioned it. Hancock may have been in support of it happening and that’s a good thing- although how could he not be when such huge concerns were being raised.
i’m just emphasising this distinction because the political dimension to making sure this doesn’t happen again hasn't been explored yet- so much of the pressure on GIDS and families attending GIDS services and on the waiting lists has huge implications for inaction and worse behaviour at governmental political leadership level.
I’m not being purely politically partisan here I actually have respect in some ways as a Health Sec for Hancock who tried to keep the digital agenda going in the NHS where other health secs hadn’t really championed that. However facts remain, that the government for past 14 years has sat on its hands and it could have (with the kind of concern you suggest) run all kinds of investigations and made all kinds of policy changes prior.