This report considers the evidence given by witnesses during its fourteenth Public hearing, held in Adelaide from 7 to 11 June 2021.

The report includes an examination of the South Australian and Australian governments’ responses to the reports of two inquires (the Robertson and Safeguarding Reports) into the shocking death of Ms Ann-Marie Smith on 6 April 2020.

The responses of the South Australian Department of Human Services (DHS), NDIS Quality and Safeguards Commission (NDIS Commission) and National Disability Insurance Agency (NDIA) to the recommendations made by the two inquiries are also addressed.

The report also examines two case studies involving ‘Mitchell’ and Daniel Rogers, two South Australian men living with autism and intellectual disability, who were residents of supported disability accommodation operated by DHS.

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