A federal investigation into the death of Adelaide woman Ann Marie Smith has recommended the National Disability Insurance Scheme Commission act earlier to identify Australians with disabilities who are vulnerable to harm or neglect.

Ms Smith died on April 6 from septic shock, multi-organ failure, severe pressure sores, malnutrition and issues connected with her cerebral palsy after being stuck in a cane chair for 24 hours a day in her Kensington Park home.

Her death prompted multiple inquiries, including by a state taskforce and the NDIS Quality and Safeguards Commission, which appointed former judge Alan Robertson to lead an independent review.

He found Ms Smith – an NDIS participant – died “after a substantial period of neglect, having been living in squalid and appalling circumstances”.

Mr Robertson considered the NDIS response to the case, and whether steps were taken fast enough to “ban Ms Smith’s sole carer, [Rosa] Maione, from working in the disability sector at all”.

He made 10 recommendations, including that vulnerable NDIS participant should have multiple carers, and that the commission should consider forming its own community visitor scheme to monitor such people.

The report found there were not any “significant failings” by the NDIS in response to the death but urged the commission to act earlier to identify people with disabilities “who are vulnerable to harm or neglect”.

“No vulnerable NDIS participant should have a sole carer providing services in the participant’s own home,” the report stated.

“For each vulnerable NDIS participant, there should be a specific person with overall responsibility for that participant’s safety and wellbeing.”

The report found that the commission relies on the disability care organisations it regulates to inform it about participants.

It identified “a number of structural impediments to the commission acting earlier”, including an “inability to access participant data in real-time” and reliance on the care providers.

Mr Robertson argued the commission should have access to more information about participants.

“The commission’s access to that information, and its ability to assess it and to take proactive action, should not depend on ad hoc responses by providers, on complaints and on reportable incidents,” his report said.

Ann Marie Smith died in squalid conditions on April 6.

‘No face-to-face contact’

The regulation of the NDIS care delivery model is divided into two separate areas of responsibility.

The NDIS Commission is responsible for regulating care providers, whereas the National Disability Insurance Agency (NDIA) is responsible for developing care plans for individuals.

Mr Robertson said that although care plans are meant to be “person-centred”, the NDIA’s approach was better characterised as “transactional”.

He found that the preparation and approval of Ms Smith’s care plan involved “no face-to-face contact and no observation of the setting” in which she lived.

“Such contact may have allowed for greater focus on or awareness of Ms Smith’s vulnerability and risk factors in the preparation and approval of her plans,” he said.

Ms Smith’s carer Rosa Maione was arrested and charged with manslaughter in August, after police declared Ms Smith’s death a major crime.

Ms Maione has since been released on home detention bail and the case is due to resume in February 2021.

Under the home detention conditions, Ms Maione will be banned from working as a carer, will have to surrender her Italian passport and will be prohibited from applying for an Australian passport.

In May, the NDIS Commission fined Ms Maione’s employer, Integrity Care, for failing to immediately report Ms Smith’s death.

The commission later banned the organisation for providing disability care altogether for what it described as a number of breaches of the NDIS Act.

-ABC