Chapter 6 - The administrative system—an overview

Chapter 6 - The administrative system—an overview

6.1       The administrative system is primarily concerned with decisions and processes associated with the command and control, operations and administration of the Australian Defence Force.[371] The right to report a wrongdoing or to make a complaint is an integral part of the administrative system.

6.2       This chapter looks at the various avenues for reporting wrongdoing or making a complaint about unacceptable or inappropriate behaviour. It examines the opinions and experiences of those who have raised concerns about various aspects of the reporting processes available to ADF members.

Avenues for complaint

6.3       The ADF has a range of measures in place for reporting wrongdoing or inappropriate conduct so that the circumstances of a report can be investigated, the facts of the complaint determined and corrective action taken where appropriate. The diagram on the following pages sets out the various processes that may be taken to lodge a complaint. They range from the most informal of approaches to the more formal written complaint that initiates official procedures.

Self initiated resolution or alternative dispute resolution

6.4       The Defence Force encourages members to seek to resolve a problem at the lowest level of command. Initially, complainants are advised to rely on their initiative to rectify a situation by working with the other parties to the dispute or grievance to reach a resolution. If such an approach is not appropriate or does not produce a satisfactory result, the complainant is encouraged to obtain the support of a third person to work informally toward a resolution with the parties involved in the conflict.

6.5       For situations not amenable to this informal approach, the ADF promotes the use of alternative dispute resolutions involving mediation or conciliation as the most suitable next course. Supervisors or personnel in the chain of command are available to help resolve a problem. According to the Defence Equity Organisation, mediation can only be facilitated by an accredited mediator who has received formal training, and both parties must be willing to participate in the process.

Figure 5.1—Options for resolution of unacceptable behaviour

Self-Resolution by Complainant


Complainant resolves the situation for themselves

Complainant to be provided with advice on how to approach the respondent. Using the “I” statement the complainant privately addresses their feelings with the respondent.

Supported Self-Resolution

Complainant resolves the situation for themselves with a third party there for support

Complainant may not feel comfortable in approaching the respondent without support of a third party. The third party does not speak on behalf of, or become involved in the discussion between complainant and respondent but is present for moral support. The respondent may also have a third party present.

Make a Complaint

Submit a Complaint to a commander or manager

A complaint of unacceptable behaviour is the disclosure of any unacceptable behaviour to a commander or manager through any means: verbal, written or observed.

(Any ADF member, Defence APS employee, Defence contracted staff or member of a foreign defence force can make a complaint)

Commander or manager to conduct a quick assessment to determine what has happened and then determine whether the matter can be resolved through informal means or if a formal inquiry is required.

Refer DI(G) PERS 35-3 - Management and Reporting of Unacceptable Behaviour.

Informal Resolution - After receiving a complaint, the commander or manager is to assess whether or not informal resolution is suitable (best for low-level issues where disciplinary or administrative action is not required). If appropriate, the commander or manager can recommend that the complainant try self-resolution. Alternatively, the commander or manager can informally counsel the people involved or conduct staff training.

Another option is for the commander or manager to arrange Alternative Dispute Resolution (ADR), bearing in mind that participation is voluntary. Refer DI(G) PERS 34-4 – Use and Management of Alternative Dispute Resolution in Defence. Contact DADRCM by phoning 02 6265 2050.

Formal Resolution – Conduct an inquiry. Following an inquiry, the commander or manager is to decide on the appropriate manner of resolution, which may be formal or informal. Refer to the Administrative Inquiries Manual, ADFP 06.1.4 or the Defence Workplace Relations Manual, DRB 19 for guidance.

Dissatisfaction with Complaint outcome

Submit a Redress of Grievance (ADF member) or a Review of Actions (Defence APS employee).

Redress of Grievance – ADF member lodges a written complaint through the chain of command.

Refer DI(G) PERS 34-1 - Redress of Grievance – Tri-Service Procedures.

Review of Actions - Defence APS employee lodges Review of Actions grievance to the Delegate.

Refer Defence Workplace Relations Manual, DRB 19, Part 19, Chapter 1.


A complaint is reported to the Defence Whistleblower Scheme

If a complainant is worried about victimisation, the Defence Whistleblower Scheme offers an alternative and independent process for reporting and investigating concerns. Contact can be made by phoning 1800 673 502.

Make a Complaint to an External body

Commonwealth / Defence Force `Ombudsman

A complaint is lodged with the Ombudsman

The Ombudsman will encourage the use of internal options first. Refer DI(G) PERS 34-3 - Inquiries by the Commonwealth Ombudsman and the Defence Force Ombudsman Affecting the Department of Defence and the Australian Defence Force. Contact can be made by phoning 1300 362 072.

Human Rights and Equal Opportunity Commission (HREOC)

A complaint is lodged with HREOC

Person lodges a written complaint to HREOC. This is an alternative to submitting a complaint through the chain of command. HREOC may encourage the use of internal options first. Refer DI(G) PERS 34-2 - Complaints of Discrimination and Harassment Through the Human Rights and Equal Opportunity Commission. Contact can be made by phoning the central office on 1300 656 419 or the local state number.

Ministerial complaint

A complaint is lodged with the Minister.

A complaint can be forwarded to the Minister or the local Member of Parliament.

State/Territory Police or Courts

A complaint of sexual assault or any other harassment or discrimination complaint is reported to police or pursued through legal means.

Matter is addressed either directly to the police or through a legal adviser to be pursued through the civil court.

Sexual Assault: Do not “counsel” for sexual assault. Refer immediately to Commanding Officer or senior Manager to initiate steps to notify police if the complainant requests. Refer to medical officer and to professional counsellor. Complainant’s wishes should be taken into account and confidentiality appropriately observed.

Refer DI(G) PERS 35-4 - Management and Reporting of Sexual Offences.

Other Unacceptable Behaviour: In the case of some criminal matters, a complaint may be made to police. Civil litigation may also be an option in some cases.

Department of Defence, Defence Equity Organisation, Options for resolution, (11 March 2005)

6.2       Additional strategies to help members resolve complaints include new policies on the use of alternative dispute resolution practices and a directorate established in June 2001 to develop and assist in the adoption of these practices. According to Defence, these initiatives set high standards and allow the ADF to take a lead in complaint resolution, resolving issues before they need to be referred to other Commonwealth bodies.[372]

6.3       The Directorate of Alternative Dispute Resolution and Conflict Management is responsible for facilitating the provision of dispute resolution services across the ADF.[373] It is developing a comprehensive training program designed to inform the Defence community about the benefits of using alternative conflict management processes and provides training in the necessary skills to employees, managers and practitioners in alternative dispute resolution.[374] Requests for access to the dispute resolution services are made through the Complaint Resolution Agency (CRA), the Defence Equity Organisation, Commands, commanders and line managers at all levels and personnel managers.[375]

6.4       The committee notes the work being done to encourage the use of alternative dispute resolutions. It did not explore in any depth this avenue of settling disputes during the course of the inquiry. The committee notes, however, that a number of the matters raised in submissions started as relatively minor disputes that escalated into major concerns as the administrative system seemed to compound difficulties rather than ameliorate them. The CRA noted that the most common matter raised in redress of grievance is 'general harassment as well as personality conflicts'.[376] Dispute resolution measures are an ideal mechanism for defusing these types of conflicts at an early stage and the ADF is right to include them in their range of options for managing unacceptable behaviour.

6.5       The committee urges the ADF to place a high priority on promoting and encouraging the use of alternative dispute resolution measures as a means of settling conflicts and resolving grievances at the unit level. It should ensure that there are sufficient well-qualified staff readily available to assist ADF members resolve conflicts.

Making a formal complaint

6.6       Where alternative dispute resolution is not feasible or has not achieved a satisfactory outcome, the Defence Force has a more formal approach whereby the complainant lodges a complaint officially. He or she may submit the complaint, which does not have to be in writing, to command, to manage and inquire into. The complainant may lodge a redress of grievance to his or her commanding officer where the member considers that he or she has a grievance concerning any matter relating to his or her service. This type of complaint must be lodged in writing. According to the Defence Equity Organisation, this option is suitable where the complainant has exhausted internal options or where the complaint has been investigated by the chain of command and the complainant is dissatisfied with the result.[377] The redress of grievance process when used as a means of seeking a review of a decision which adversely affects a member is discussed in full in chapter 10.

6.7       Although the ADF prefers that problems or difficulties be settled at the lowest level of command, the reporting system allows for complainants to raise their concerns outside the chain of command, for example through the Defence Force Ombudsman. The newly appointed Inspector-General of the Australian Defence Force may also receive complaints. The work of these two bodies is dealt with in chapter 11 as part of the committee's consideration of the appeal and review processes.

The importance of reporting wrongdoing

6.8       A sound and workable administrative system relies on mechanisms that encourage the exposure of impropriety, maladministration, inappropriate conduct, abuse, negligence or unsafe or dangerous work practices within an organisation. Effective reporting processes ensure that an organisation is made aware of shortcomings in the workplace and is well placed to rectify any impropriety and prevent accidents or mishaps. The following section looks at the strengths and weaknesses of the institutional arrangements in the ADF that are intended to facilitate the disclosure of wrongdoing or inappropriate or unacceptable conduct in the forces.

The effectiveness of the current reporting system

6.9       Confidence in the reporting procedures and a willingness to use them are central to the success of such mechanisms. Recent studies, however, suggest that a number of members do not avail themselves of the opportunities to report their concerns about improper conduct. There were a number of reasons for this: ignorance of process, a lack of belief in fair outcomes and a fear of reprisal. In 1999, the ANAO conducted an audit of the redress of grievance process in the ADF. It found:

From ANAO's interviews with members, it was apparent that many were unaware of the ROG system or had only a limited understanding of it. Many of those who had made a complaint, or indeed read the relevant Defence Instruction, had difficulty understanding how to use the system. Others doubted that any ROG they submitted would be treated fairly. Some were concerned about possible adverse treatment if they submitted an AROG against a decision of a superior officer.[378]

6.10      A survey conducted of experiences of unacceptable behaviour in the ADF released in February 2001 found that a small but significant proportion (14.6%) of junior sailors reported that they had been physically bullied, assaulted or threatened with violence at least once in the previous 12 months. Statistics also showed that 9.5% of SNCO's; 3.2% of junior officers and 2.4% of senior officers reported the same experience. For the Army, 29.1% of SNCOs and 18.6% of other ranks reported that they had been bullied, assaulted or threatened with violence, with a substantially smaller proportion of officers reporting the same experiences.[379] The Air Force data showed a smaller proportion of personnel experiencing physical assault. It is particularly important to note that:

Less than a quarter of those that had experienced unwanted harassment sought the assistance of an equity advisor, chaplain or psychologist. Fewer still chose to make a formal complaint or to seek a redress of grievance. Respondents that took these actions were generally not satisfied with the results, with many indicating that they felt victimised as a result of their actions.[380]

6.11      The Survey went on to report that:

The most common explanation [for not seeking assistance] was that the respondent took care of the problem themselves...Other common reasons were 'I did not think it was important' and 'I thought it would make my situation unpleasant'. Around one fifth of respondents of both genders took no action because they believed nothing would be done, a similar proportion were worried that they would be labelled a troublemaker if they pursued the issue.

Encouragingly, only 3.4% of males and 7.2% of females took no action because they thought that they would not be believed, and only 3.4% of males and 5.0% of females reported that they did not know what to do.[381]

3RAR—reporting of wrongdoing

6.12      Further evidence about the reluctance of members of the ADF to report wrongdoing came to light during inquiries into allegations about the use of illegal or informal discipline in 3RAR. In August 2000, the JSCFADT decided to examine the events alleged to have occurred in the battalion.[382] Two months later, in October 2000, the ADF announced it was establishing an inquiry into military discipline to be headed by retiring Federal Court judge, Justice James Burchett.

6.13      The Chief of the Defence Force (CDF) also held a stand-down period on 5 February 2001, at which each unit was addressed via video by the CDF and the relevant Service Chief.[383] This public demonstration was to announce to all Australians and ADF members that the 'highest standards of military justice and behaviour' were expected. It was also intended 'to assure all members of the ADF that the law is there for their protection, and that they should respect its procedures and come forward with any personal concerns'.[384]

6.14      In April 2001, the JSCFADT tabled its report on 3RAR. It determined from the evidence that extra-judicial procedures and illegal punishments were employed within 3RAR. It also found that there was 'a system in place that inhibited soldiers from speaking out in relation to the bashings'. Of interest to this committee is the joint committee's finding that:

One of the most surprising aspects of the 3RAR allegations has been the reluctance of soldiers to speak out about what was happening. There is no direct evidence to suggest that the battalion headquarters staff were aware of what was happening. There is evidence that the unit padre was informed of some aspects of the events, but testimony by previous unit equity officers and doctors indicates that the allegations now being made about 3RAR were not raised with them. This 'wall of silence' was maintained despite all key unit appointments having received briefings in ADF equity policy.[385]

6.15      The Burchett report, released in August 2001, gave added weight to the joint committee's findings. It found that four soldiers from 3RAR committed assaults in the guise of disciplinary measures and moreover that they were able to do so unchecked for a time.[386] It accepted that bastardisation practices had existed at some military institutions, and 'discipline by the fist' had been practised by some (perhaps only a few) in a number of units.[387] It was of the view that the events at 3RAR occurred during a period of two years which, if it had not already come to an end, apparently did so when police investigations began on 29 September 1998.[388]

6.16      According to the report, the first complaint in relation to 3RAR was that made by [Mrs K] in March 1998, alleging that her son had been assaulted and harassed whilst in Malaysia. Investigations were unable to find conclusive evidence of an assault.[389] That same year, the father of a 3RAR soldier had also complained that his son was ill-treated by members of the unit. The report notes that this complaint, which was not related to illicit disciplining, was not 'ultimately pursued'.[390]

6.17      Of significance to the committee was Burchett's observation that:

...the fact that complaints may not always be made easily by the use of the avenues currently available, was amply demonstrated by the situation that developed in A Company 3RAR.[391]

6.18      The committee does not have any recent statistics available to gauge the current levels of bullying and harassment in the ADF, if any exists, nor to indicate the willingness or otherwise of persons to report such incidents. It does, however, have strong anecdotal evidence to suggest that there are pockets in the ADF where bullying and harassment have been tolerated and furthermore that there are still substantial obstacles preventing members from reporting such inappropriate behaviour.

School of Infantry, Singleton—reporting of wrongdoing

6.19      The committee now turns to the School of Infantry (SOI), Singleton, as an example of where the failure of the reporting system allowed bullying and discriminatory practices to continue unreported and apparently unknown to senior officers at Singleton. The committee received extensive evidence on these matters.

6.20      Much of the evidence came from the parents of young soldiers who experienced the worst aspects of this environment. In the most extreme cases those soldiers took their lives. The committee acknowledges that once a member enters the ADF, personal and family relationships are changed by this new professional environment. It also acknowledges that Defence must walk a fine line in the management of its engagement with family of personnel. The committee is concerned, however, that in case after case, worried and sometimes frightened parents felt that they had no other option but to contact the ADF directly about their concerns of mistreatment. In some instances, even this significant step was still not enough to move senior officers to act.

6.21      Between March and May 2000, a young soldier was subjected to inappropriate treatment while undergoing Initial Employment Trainees training at the School of Infantry (SOI), Singleton. Even though his parents alerted authorities to the conduct, such practices continued. The parents then contacted the minister's office in the hope that senior officers in Army Headquarters would be made aware of the problems. The parents informed the committee:

Even with the minister's department involved our son was still billeted in the guardhouse and segregated from other EITs. It was for this continued inappropriate treatment that our son elected to discharge from the army in June 2000.[392]

6.22      In the later half of 2000, the allegations about bastardisation at 3 RAR spurred the parents of the young soldier at Singleton to press their concerns further. Mr Robert Amos, the father, stated:

We then wrote to the minister officially requesting an investigation into events at SOI. This ensured that an official investigation would be conducted and the incident no longer swept under the table. At this point our concerns were that soldiers receiving this type of inappropriate treatment may not have had the close support our son did, this fear was later borne out.[393]

6.23      Although an investigation into this incident at SOI took place in 2001, the ill-treatment of young soldiers continued. A later inquiry in 2003 was to find practices of abuse at SOI similar to those that had been observed in the 2001 investigation. It identified a culture at SOI where there was a widespread use of negative reinforcement to motivate recruits under training.

6.24      Mr Amos was not alone in raising concerns about the treatment of young soldiers around this time. Ms Avril Andrew explained that her son Scott had sustained an injury to his back and knee in October 2002 when undergoing his basic training at Kapooka. She told the committee:

At first he was directed to ignore the pain and 'suck it in' and was not allowed to miss training even though he could barely walk, much less march. Finally it became impossible to cope with and he was sent to the Digger James Rehabilitation Unit (DJ's).[394]

6.25      In recounting her son's experiences, she stated that for young soldiers the Digger James Unit 'represented weakness of the worst possible kind—a message which was indoctrinated from day one'. She explained:

When he was sent there his comment was that he had been sent to join the 'window lickers'. From the start he was unhappy at the stigma attached to being in the unit, as during their induction there were many references to people who were sent to DJ's being 'weak' and useless. When recruits marched past the DJ building they were given the 'eyes right' command and told to observe the 'window lickers' and other such derogatory remarks.[395]

6.26      Ms Andrew, whose son has been discharged from the Army and has been under constant psychiatric care, expressed her apprehension at the way in which the Services treat their recruits. She concluded:

I accept that the army have a difficult job to do and that all personnel must be able to obey orders immediately, without question or hesitation, particularly in hostile circumstances. I do not agree that the way to achieve that is to break their spirit and then attempt to rebuild them as 'army'. Surely there is a better way?[396]

6.27      The committee agrees. Clearly, abuse and intimidation are not the way to develop responsible and well-disciplined ADF members. Indeed, it is the circumstances surrounding Private Jeremy Williams' suicide that highlighted the extent of harm that can result from the failure to stamp out incidents of harassment and abuse. They also exposed a serious lapse on the part of senior officers to learn explicitly from the investigation into the treatment of Private Amos and to implement the necessary changes to alter their own behaviour and procedures. This is a lesson for all ADF officers. Mr Amos explained:

Senior-staff at SOI assured us that they had fixed the problem they even went as far as to invite me down to inspect the changes they had made, an invitation I now wish I had accepted. This was backed up by the investigation report covering letter that claimed that the report's recommendations had been implemented. We accepted their word in the firm belief that Orders and Instructions contained in reports are to be acted upon...however it has since been admitted by the army that the recommendations had not been implemented.[397]

6.28      With the findings of the joint committee, the Burchett Report and the investigation into the treatment of Private Amos at SOI still fresh, allegations were raised in early 2003 that young Recuperation & Discharge (R&D) Platoon soldiers at Singleton were being subjected to:

...abuse, denigration, harassment, bullying (including threats of physical violence) staff and other Initial Employment Trainees (IETs); plus the absence of efficient and effective support services or mechanisms where these soldiers could seek redress beyond their NCOs for a wide range of problems they were encountering...[398]

6.29      Yet despite warnings, no one in the ADF took action. Jeremy committed suicide by hanging at the SOI, Singleton, on 2 February 2003. According to his parents, in the week prior to his death they became increasingly aware of his traumatised, distressed and anguished state. Jeremy told them that he 'was made to feel worthless, useless, scum and shameful because he was injured and had been transferred to R&D Platoon'.[399] His sister recalled the events leading to his suicide:

On the morning of 29 January my father rang Singleton and spoke to a sergeant at the base. He rang because he was deeply concerned about Jeremy's general state. That night before this phone call Jeremy had been in tears on the phone to my parents and he was convinced that his career with the Army was over. My father's call the next day was the Army's chance to save Jeremy, but the importance of his warning was not heeded. The Army took a flippant approach to this warning and they failed in their duty of care. Furthermore, assurances given to my father that this call be kept confidential were broken. Someone at the base told Jeremy of that phone call, and he said to my parents that evening, 'I was told my parents rang the Army,' and he was angry and inconsolable over this. After his death, the investigating officer was not able or was unwilling to find out who had breached my father's confidence, who told Jeremy of that phone call and why that crucial warning that could have saved his life was not properly heeded.[400]

6.30      Even following this death, Army chose to ignore what were now clearly endemic problems at SOI until Jeremy's parents, after repeated attempts, were successful in pushing for a thorough inquiry into conditions at SOI. At the time of their son's death, they were assured by the Commanding Officer of the Infantry School that their concerns about the alleged abuse were groundless and that the base was run professionally. They told the committee:

Had we taken this officer at his word we would simply have walked away and nothing would have been done about the situation at Singleton or indeed within the Army; and how many more young men would have suffered the same fate, not including the two deaths (that we know about) subsequent to Jeremy.[401]

6.31      The Executive Summary of the Investigating Officer's Report into the Death of Private Williams found:

...a widespread use of negative reinforcement to motivate recruits under training. This includes disparaging and negative comments about Weary Dunlop and Digger James Pls (discharge and rehab/remedial training respectively). While the intentions of staff are commendable, in many cases they are using the wrong methods to achieve their aims...

The allegation of a culture of denigration is not proved, however, it is believed that there is a culture of negativity towards Weary Dunlop and Digger James Pls.

6.32      It went on to find:

There is a strong negative feeling among both staff and IETs against some IETs who are getting discharged and those IETs who are perceived as using injury or failure as a way to avoid hard training. At the time PTE Williams was at SOI, most of these IETs were located in R&D P1, along with all other injured IETs. There is also a perception that many of those in the P1 are 'weak'. As a consequence, all members of the P1 were subjected to widespread denigration and harassment from both staff and IETs still in training.

6.33      It also found the use of extremely offensive language common at SOI.[402]

6.34      The full report, which remains a confidential document, gave a more complete picture. It found:

A culture of denigration and harassment existed towards R&D P1 at the time PTE Williams was present in the P1. As a result, members of the P1 were not treated with dignity, respect and sympathy.

6.35      It identified the following factors that contributed to this culture:

The report noted that 'while denigration of R&D was not universal among junior staff, there was no evidence of steps being taken to stop this culture'. [404]

6.36      Although the report found no evidence to support the view that a culture of brutality, bullying and stand-over tactics existed at SOI, it noted that the incidents reported, 'seem to be isolated incidents from differing individuals that highlight inappropriate behaviour by individuals rather than a culture.' It went on to state that there is evidence that a small number of staff members do use the threat of violence and some may have used physical violence on IETs. Furthermore, it found that 'cases of violence between IETs have been widely reported and are considered to exist'.[405]

6.37      The report noted that, at the time of writing, 'a culture of denigration and harassment of R&D P1 was not apparent'.[406] It should be noted that the earlier 2001 report reached the same conclusions, yet two years later the abuse was still occurring.

6.38      Indeed, the investigating officer's report referred to the 2001 investigation into the alleged mistreatment of another private at SOI in 2000. Importantly, it observed that the earlier report had identified a culture at SOI with distinct similarities to that described two years on in the later report. The earlier report had accepted that as a result of changes in 2000/01, there was a far more professional and positive attitude at SOI. The later report surmised:

Either the changes and remedial action identified in 2001 were not followed through by the chain of command in 2001, or they were lost in the space of a single posting cycle.[407]

6.39      With regard to the investigation into the death of Jeremy Williams, Major General Gordon, in his Appointing Officer's decision document stated:

One of the most important matters that has come from the Investigation is the need for an enduring solution to the existence or re-emergence of a culture of denigration and harassment especially towards injured soldiers and towards soldiers who are not able to continue training (at the School of Infantry). This problem was severe at the time that Private Williams took his life and has previously been evident. The problem has existed in a milder form at the Army Recruit Training Centre.[408]

6.40      On 14 April 2003, Gunner John Satatas committed suicide at A Battery (A Bty) 4 Field Regiment Holsworthy. He had recently completed his IET at the School of Artillery (SOA). He had also spent six months in R&D Pl from February to August 2002. The Investigating officer's report into his death refers to the findings of the report into Jeremy Williams' death and concluded from an analysis of the evidence that 'the same culture of denigration and harassment existed during the period of Gunner Satatas's attendance at SOI and specifically in R&D P1'.[409]


6.41      Based on the findings of the investigations into the treatment of Private Amos, Private Williams and Gunner Satatas, it is beyond doubt that between March 2000 and February 2003 there were serious problems at SOI which were not addressed by senior officers.

6.42      The Burchett report noted the critical importance of a recruit's first experiences of the military and of discipline and its role in 'forming the character of those who make up the Defence Force and their ideas about their duties to which they are bound'. In its view, 'The plain conclusion is that the respect for discipline of a member of the ADF grows in some measure from the Recruit Training School.'[410] The committee agrees with this assessment which makes the incidents at SOI all the more disturbing.

6.43      It is clear that there is something wrong with a reporting system that failed to expose this type of improper conduct. Young men chose to remain silent about abusive behaviour; seriously concerned parents raised concerns which were not acted upon; and, more importantly, members of the ADF in command positions were either blind to, or ignored warning signs.

6.44      The following chapters seek to examine the reasons that allowed these situations to develop and to continue unchecked.

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