Sales Order shows completed/fulfilled but no package/shipment ever created

I have 2 examples of this happening now, and it's very worrying as our back office now has to comb over every single order and cannot trust the dashboard for order status.

The Sales order shows nothing in the history that the status was changed by the system or a user, there are no packages or shipments for the sales order, and both our zoho books and inventory preferences are set to close the sales order when "Shipment is fulfilled".

How is this happening?

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