The lack of clarity, and the delay that flowed in part from this lack of clarity, reveals a flawed system," Butler says in her report. "Even if a better communication system or protocol was implemented among the different groups to improve coordination, it is not optimal for one complainant to have to tell her/his story to four or five different people, and to have to be asked on numerous occasions if she/he wants to go through a resolution process, all of which happened in this case.