A key objective of any review into the death of a loved one, is that the family feels it has been thorough, transparent and fair.
The Parliamentary and Health Service Ombudsman found that the Trust in Matthew’s case was ….
“not open and honest [with the complainant] … about the steps being taken to improve safety”.
The family is therefore entitled to feel unsure of where else might the Trust not have been open and honest.
This leaves a lingering injustice capable of causing enduring and damaging pain.
It seems to me that a public inquiry is required in order to properly serve this family and Society.