The shocking neglect case of Adelaide woman Ann Marie Smith has led to a series of issues being opened up to further investigation at the disability royal commission.
Ms Smith, who had cerebral palsy, died in hospital in April 2020 from septic shock, multiple organ failure, severe pressure sores and malnourishment.
The 54-year-old was found living in squalid conditions in her own home while largely confined to a cane chair. She had been receiving support from a registered NDIS service provider.
Her carer, Rosa Maria Maione, was jailed in March for at least five years and three months after pleading guilty to manslaughter.
Two directors of the care provider Maione worked for were subsequently charged with criminal neglect causing death and failing to comply with a health and safety duty of care.
In a report handed down on Wednesday, the royal commission said Ms Smith's death shocked the Australian community and sparked a number of inquiries.
Most notable of those were an investigation by a state government task force and an independent review of the case instigated by the NDIS Quality and Safeguards Commission.
The royal commission said those inquiries raised a number of issues which would be the subject of continued investigation.
* The adequacy of mechanisms to identify and respond to NDIS participants at heightened risk of violence, abuse, neglect and exploitation.
* How disability service providers and their regulators can be encouraged or, if necessary, required to implement person-centred practices.
* Whether a conflict of interest arises when a person receives support coordination and other support services from the same service provider, and the appropriate response to such a conflict.
* How communication between people with disability and their supporters and disability services and regulators can be supported and encouraged.
* The quality of disability support services.
* The interaction between community visitor programs and the NDIS.
* The continued operation of providers of last resort.
In response to the latest arrests in Ms Smith's case, South Australia deputy police commissioner Linda Williams said it was important that those who accepted a duty of care for the most vulnerable delivered to the highest standards.
"In this case, we will allege that, sadly, that did not occur and it resulted in the death of Annie," she said.