A vulnerable teenager was put in a "potentially life-threatening" situation after a disability care coordinator left him alone at a public bus stop.
The deputy health and disability commissioner Rose Wall released a report into the incident on Monday which occurred in May 2018.
The boy, who was in his early teens, was due to be picked up by a support worker from a public bus stop after finishing school.
However a support worker did not attend and the boy was left on his own at the bus stop until a member of the public helped the boy, and phoned his mother.
The disability service conducted an internal investigation after receiving a complaint.
The report found the support worker rostered to pick the boy up had informed the care coordinator they were unable to work the shift.
But after receiving the call, the care coordinator received another and was "inundated with more issues" leading her to forget to remove the support worker from the shift and find a replacement, or inform the boy's mother.
She told the deputy commissioner it was a "regretful and terrible mistake" and is deeply apologetic to the family.
She said she understood that "as coordinator this undoubtedly falls on [her]".
The disability service also sincerely apologised that the boy was left in a vulnerable position, and for the stress and anxiety created for the boy's mum.
In the report, the boy's mother said the company was "continually failing their organisation and communication with their clients or families of clients".
"My son was left in a potentially life-threatening situation as he is vulnerable," she said.
The mother said she wanted the disability service to make changes to its systems.
Deputy commissioner Wall found the care coordinator had failed to provide the services required with reasonable care and skill.
"While the care coordinator’s error was administrative and unintentional, it was a fundamental aspect and requirement of her role, and resulted in the boy being placed in a vulnerable and potentially dangerous position," she said.
The disability service was found to not be in breach of the Code of Health and Disability Services Consumers' Rights, but Wall said that there was valuable learning they could take away from the case.
She recommended they provide updates on changes taken to improve systems for arranging relief support workers.
