In this context, the Ombudsman concluded that prior to the death, DPTI had not carried out regular and judicious inspections of the sites under its responsibility, contrary to its obligations under the AGFMA. The Ombudsman found that the ITP`s practices in this area posed an inappropriate risk to the health and safety of persons using government buildings. The Ombudsman concluded that prior to the death, SAPOL had also failed to ensure that its workplaces were regularly inspected by DPTI as part of the AGFMA, which also posed an inappropriate risk to the health and safety of persons using SAPOL`s premises. The Ombudsman made several recommendations to the DPTI and the Government of Southern Australia in order to resolve the problems identified in the inquiry. .