One year ago, Queensland’s Public Advocate released the “most important” report the office had ever produced. They found half of all disability deaths in care were potentially avoidable.

Today the independent government-funded body warns changes haven’t been made. Calling for the state government to act before looming NDIS changes cause “catastrophic outcomes”.

It was a 40-degree day and 68-year-old disabled patient Leon Streader had been sitting outside. Without a hat or sunscreen for most of the morning.

He returned to the “muggy stifling heat” of an inner Brisbane aged care facility with no airconditioning and only a few fans about lunchtime.

By 3pm on February 22, 2004, he was dead.

A fellow Pinjarra Lodge resident found the overweight man with epilepsy and high blood pressure, coronary artery disease and a mild intellectual disability slumped in his chair and called the carer when he couldn’t wake him.

That carer, Donna Norwood, told an inquest her shift had begun at 8am Saturday and wouldn’t end until 8am Monday. A 48-hour stretch she often served solo, caring for 30-50 residents.

It was the only inquest into a disability death in care carried out between 2009 and 2014. The period over which a damning review from Queensland’s public advocate, found more than half of 73 deaths were potentially preventable.

The review identified a “high degree” of under-reporting in the sector. But its author, public advocate Jodie Griffiths-Cook, said it was impossible to know how many deaths slipped through the cracks.

On March 17 last year, she urged the state government to use the report as a trigger to find ways to improve health services. And discuss minimum standards and improve reporting processes.

A government spokeswoman said it had undertaken a “range of activities” in regards to the review but Ms Griffiths-Cook’s successor, Mary Burgess, said nothing had changed.

“We are working closely with other organisations to improve the knowledge and capacity of health service providers. Those that work with people with disability,” the government spokeswoman said.

In the case of Mr Streader, the inquest did not blame the facility, Ms Norwood or co-owner Dr Nyst for his death. But did highlight problems with staffing levels, record keeping and medications. These were improved after the death. Dr Nyst could not be reached for comment.

But Ms Griffiths-Cook’s report unearthed other shocking individual cases. Including several involving tragic and preventable choking accidents.

One man in his 40s died after choking on a piece of cake he was given. Despite a meal plan detailing he eat only “soft food cut up into very small pieces and given to him gradually”.

There have been numerous strikingly similar scenarios at other facilities. A man with a history of choking, who’d been placed on a restricted diet, was left unattended and choked to death on a sausage.

In yet another disturbing incident, a man in his 60s on a soft-food diet, had been called to treat on several occasions. He was served a burger and chips for lunch. He died before the paramedics could arrive.

Of the 73 reported deaths in care over that period, most of them died overnight, and 17 weren’t even found until the next morning.

The report warned of “catastrophic outcomes” if changes weren’t made. Furthermore, the National Disability Insurance Scheme reported double the amount of people seeking disability care.

Public advocate Mary Burgess, who replaced Ms Griffiths-Cook in May, wrote to Premier Annastacia Palaszczuk’s office this month. Again urging action but was yet to hear back.

She said the report was “probably the most important thing this office has ever done”. She echoed her predecessor’s warning a year on, saying nothing had changed.

“What’s the worst thing that can happen to you? You die,” she said.

“It’s hard to imagine, there aren’t worse outcomes for people than what we’ve studied in this report”.

“It’s a really thorough examination of these matters and it’s just, well It’s disappointing but it’s also disturbing that a year later we don’t have any formal response to it.”

The government spokeswoman said the report annually on deaths in care would be in place from this financial year. The coroner would work to develop a specific investigation standard for disability deaths in care.

She said training and workshops had been developed in palliative care and leadership. These included sessions specific to disability care and support.