In terms of getting back to my original question about the reason for the shortcomings, is it because the requirements were not understood or because they weren't clearly enough laid out?
I'm a layperson when it comes to this stuff. When I read the ombudsman's report, he says that there are clearly laid out requirements for documentation, and those requirements were not met. Either they were not met because they were missed, because they weren't understood or because the people filling out the documentation didn't want to. I'm trying to understand why they weren't there.