An inquiry into Adelaide's scandal-plagued Oakden nursing home has cleared former ministers Jack Snelling and Leesa Vlahos of maladministration but Premier Jay Weatherill says his government accepts responsibility for the failings.
Independent Commissioner Against Corruption Bruce Lander declared the Oakden affair a "shameful chapter in the state's history".
Mr Lander described the facility as a disgrace and said the residents were forgotten and ignored.
"Every South Australian should be outraged at the way in which these consumers were treated," he said in his report released on Wednesday.
"It should not have happened. It must never happen again."
Mr Weatherill said he was "deeply sorry" for the mistreatment of residents, and the government had overhauled aged care procedures.
"It happened on our watch and it is wrong and shameful and we're taking steps to make sure it never happens again," he said.
Mr Lander began his inquiry into Oakden after a report by SA's chief psychiatrist revealed failures in clinical governance as well as incidents of rough handling of patients, excessive use of restraints and a high level of injuries.
He made findings of maladministration against five people who either worked at Oakden or were health department officials.
He found it "astonishing" that a succession of mental health ministers did not know about the shocking level of care at Oakden.
But he ruled that the conduct of Mr Snelling, the former health minister and Ms Vlahos, the former mental health minister, did not amount to maladministration.
"Those findings do not, however, tell the entire story of responsibility for what went wrong at the Oakden facility," the commissioner said.
"Senior people, including some ministers and chief executives who were responsible by virtue of their office for the delivery of care and services to the consumers should have known what was going on but did not."
Mr Weatherill was quick to distance himself from Ms Vlahos, reiterating several times she was no longer a candidate for the Labor party at the March state election.
The premier said the ICAC ruling in relation to Mr Snelling and Ms Vlahos brought no relief, and brushed off suggestions the findings would hurt his government's chances of re-election.
"What people will be looking at is how we respond," he said.
Opposition Leader Steven Marshall said the Oakden report was a "dark day" and a "shocking indictment" of a disgraceful government.
"They've failed our most vulnerable citizens, it's time for them to go," he said.
SA-BEST leader Nick Xenophon said the premier's apology was "hollow words" unless he released all cabinet documents related to Oakden, documents Mr Lander was denied.
Barb Spriggs, whose husband Bob died when he was a patient at the home and who first blew the whistle on its problems, said she was disappointed the names of the doctors, nurses and carers involved in the day-to-day care were not included in the report.
"It worries me big time that those people are still out there, working in our healthcare facilities, whether it be in South Australia or Australia," she said.
