The Community Visitors Schemes Review – a report co-commissioned by all Australian governments – recommended broadened safety-checking visits to prevent neglect in circumstances such as those experienced by Smith.

The comments and revelation of the review’s contents are likely to increase pressure over Smith’s death on the South Australian government, particularly given allegations it restricted the coverage of people with disabilities by the state’s community visitor scheme subsequent to the report’s completion.

SA police, coronial and state and federal investigations are underway into the death of Smith, a woman with cerebral palsy who died in hospital on April 6 from septic shock, multiple organ failure, severe pressure sores and malnourishment, which developed at her Kensington Gardens home.

Despite being assigned a “full-time” carer by NDIS-administered non-government organisation Integrity Care SA, SA police said the 54-year-old spent 24 hours a day sitting in a cane chair for more than a year, with little food in the house.

Smith’s death has been declared a major crime, with police launching a manslaughter investigation.

Her death has also caused debate about the inadequacy of protections afforded to her, and the loss of safety checks by the state government’s Community Visitors Scheme for many vulnerable South Australians with disability who have transitioned from state disability services’ care to the NDIS.

For the state to have had this report six months prior, and in June last year to still cut the community visitors’ scope … beggars belief.

Responsibility for Smith’s care was shifted from state-run Disability Services SA to the newly-established federal NDIS in 2018, with Disability SA subsequently dismantled and state services no longer checking on Commonwealth clients.

The review, commissioned to determine the role community visitors should play in the fully implemented NDIS, found state-run community visitors schemes should be formally incorporated into the NDIS protections framework “so that the safety net for vulnerable people is not lost”.

It also raised the prospect community visitors checks could broaden to include private homes.

In South Australia, community visitor checks have been done only in accommodation where disability care is provided under state government funding arrangements.

“In the future there will be many more accommodation types and actual locations, as well as potentially multiple providers for each individual,” the report said.

“There is also the question of service provision taking place in the family home.

“States and territories may wish to consider whether their Community Visitors have sufficient legislative authority to enter and inspect.”

The report cites as an example amendments passed in 2018 by the Australian Capital Territory parliament, which added some private homes into the list of residences that its community visitor equivalents, known as “official visitors”, could inspect.

Roger West, director of WestWood Spice, the consultancy firm that produced the report, told InDaily the scenario of Ann Marie Smith’s neglect and death “was the sort of risk we were concerned about”.

“When you have got reliance on a particular operator (looking after someone), you need another pair of eyes if there aren’t natural informal supports ready to do that for somebody.

“We saw that — the community visitors’ role — as part of the safeguarding system.”

All Australian governments have long acknowledged that protections for vulnerable people with disability are needed as they are more vulnerable to violence, exploitation and neglect than others in the community.

Disability advocates argue the NDIS Quality and Safeguards Commission protections framework is inadequate because it relies heavily on reacting to complaints rather than proactive inspections of houses and residential facilities, which community visitors perform.

Former SA Principal Community Visitor Maurice Corcoran said the report “certainly enables and suggests that state governments could have the ability to extend visiting into private houses” and the question of whether that change could have prevented scenarios like the death of Smith was “a really important question that the inquiries (underway) need to address”.

“That question [of providing protections in the light of changing accommodation models] should have been given appropriate consideration by both the department and the minister,” he said.

“For the state to have had this report six months prior, and in June last year to still cut the community visitors’ scope … beggars belief.”

Corcoran’s last community visitors annual report, for 2018-19, detailed state government “advice” – which he contests – that community visitors no longer had a “right of entry” for checks on 2200 South Australians with disability, including “some of the most vulnerable citizens of South Australia”, who had transitioned to the NDIS.

He wrote that he was “astounded that, as far as I’m aware, the government and DHS has not acted upon the national review of Community Visitor Schemes” and that many SA community visitors felt a “deep sense of abandonment of the … residents…that we can, at this stage, no longer provide a safeguarding and advocacy service to”.

In a statement, Human Services Minister Michelle Lensink said that after receiving the review report “late last year” she had requested the government’s Disability Advocate, David Caudrey, to “review the CVS scheme in South Australia to ensure national consistency and identify any gaps in the system and that review continues”.

She said the Community Visitors Scheme “continues to visit people living with disability in State Government operated facilities” and that in October the government had “expanded the … role to include our most vulnerable South Australians who are under the guardianship of the Public Advocate.”

In October, Lensink said 550 South Australian NDIS participants were under guardianship.

Her statement yesterday added: “Ann-Marie Smith’s recent tragic death has highlighted gaps in the NDIS system and we are determined to ensure all the proper safeguards are in place to prevent such an event happening again.

“The Marshall Liberal Government moved swiftly to announce a new taskforce that will examine current gaps in oversight and safeguarding for people living with profound disability in South Australia and make recommendations to the State Government and the NDIS.”

It is believed the review report was provided to state and territory departmental officials under an embargo that lasted up to 11 months before being provided to Lensink.

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