An investigation has found it was wrong to keep people with disabilities and their families in the dark for years following an inquiry into how their loved ones were mistreated — and in some cases died — in South Australia's public health system.
In 2018, Health and Community Services Complaints Commissioner Grant Davies looked into systemic issues in the way the health system treated people with disabilities, after seven people complained to his office about abuse, neglect and preventable deaths.
But those people and their families had not seen his report and were still waiting for answers in July 2020, when the ABC reported on their frustrations.
One of those people was Dianne Badman, whose son Jason Foster had an intellectual disability, epilepsy and diabetes.
After a fall at his residential care facility, he ended up in the Flinders Medical Centre, where he stayed for two years before dying of a heart attack.
Ms Badman said she was often frustrated by the care he was given and she believed his death could have been prevented.
"He was last on the list, so to speak, and he was denied physio," she said.
"For a short while he received physio. Then he was, in our opinion, deemed not worthy."
After the ABC's report, the commissioner released a summary of his findings.
But the ABC's reporting also sparked South Australian Ombudsman Wayne Lines to launch an investigation into Professor Davies's decision to keep the full report secret.
Mr Lines found that, even with the release of a summary, he did not believe all the relevant information had been provided to the families.
"Some of the conclusions are very alarming," Mr Lines said.
"There is no way for the complainants to identify which conclusion related to them or to the person on whose behalf they made their complaint."
Mr Lines found the commissioner failed to clearly communicate with the families whose complaints triggered the investigation.
He also found the commissioner, Professor Davies, decided not to release the report in part because of a request from the father of one of the complainants, but did not ask any of the other families for their opinions.
The ombudsman's report shows the commissioner had a pre-existing, professional relationship with the father. However, Professor Davies denies that influenced his decision.
While they are not identified in the ombudsman's report, Mr Lines interviewed a number of families which all expressed their frustration at the lack of closure they received through the process.
"The failure by the Health and Community Services Complaints Commission (HCSCC) to notify me of the closure of my son's file was indeed an enormous shock to me," one said.
"I still have no answers to the questions I raised in each of my appendices attached to my complaint, and still struggle with the circumstances of my beautiful daughter's death," said another.
In another case, a mother's hopes the commissioner could intervene and save her son were dashed.
She said had contacted the HCSCC "in a desperate plea to help my son" but "nothing was done" and she felt her son would be alive if the HCSCC had taken the matter seriously.
The ombudsman found the commissioner's decision to not consult all the families whose cases sparked the report was an error.
He has recommended the commissioner reconsider his decision not to release the report, taking into account what the other families want.
He has also recommended the commissioner formally advise each family of the reasonings and findings he made in relation to their individual cases.
In his response to the ombudsman's preliminary recommendations, Professor Davies said he did not accept the recommendation to reconsider his decision.
He said the decision was not in error, and was within his statutory discretion.
But he did apologise for failures in communication to the families who made complaints.
"The length of time it has taken for the ombudsman to finalise his investigation shows this is a complex matter requiring substantial consideration," Professor Davies said in a statement to the ABC.
"I will consider the ombudsman's findings and recommendations and will respond to him within the timeframe he has requested."
The commissioner has until August 17 to formally respond to the ombudsman's findings.
