Dr. Peter McKenna:

One could say that it was. I say that because I have been involved in research ethics committees for a long time. It is a moot point whether all audit should go in front of a research ethics committee or not but something of this magnitude would have benefitted from review. On such a committee, one would have had, as well as colleagues and service users, an ethicist. A core principle for successful work is that one does not impose a duty on somebody who is not represented in one's protocol. At the heart of this is that clinicians were expected to do something that they had not been involved in from a very early stage. If they had been, then much of the subsequent debate as to who should have done the informing would have been short-circuited.