"Many of the decisions and actions we saw were not only unjust and wrong. Some were downright immoral and unethical." Ms Glass was also critical of the regulator WorkSafe. She said even when unethical decisions made by agents were brought to its attention, WorkSafe did not intervene or require the agents to overturn their decisions. She said the regulator "appeared reluctant" to deal with agents making unreasonable decisions, which raised "the troubling prospect that WorkSafe feels beholden to the agents and dependent on their participation to deliver a financially viable scheme". In one case slammed by Ms Glass, an aged care worker was unfairly surveilled without adequate justification. The investigation also uncovered that a factory worker's payments were terminated when he failed to take part in occupational rehabilitation, despite experiencing psychotic hallucinations.

Loading In relation to a police officer who developed post-traumatic stress disorder, an independent medical examiner (IME) concluded in 2017 the man was indefinitely incapacitated for all work, Ms Glass’ report states. "However, the agent tried to change the IME’s opinion by highlighting that the man played golf, asking, 'Would this not translate to a partial capacity for suitable alternative employment or capacity to participate in occupational services?' "The IME then said it was ‘possible’ the man had improved since he saw him and that he could now participate in occupational rehabilitation, to which he was then referred. The man complained to WorkSafe, saying the IME’s claims were ‘baseless’ and a ‘guess’, not an opinion.” WorkSafe chief executive Colin Radford said improvements introduced after the ombudsman’s 2016 investigation had "unfortunately not been enough".

"No one chooses to be injured at work. When injuries or illness do occur, workers deserve to be treated with empathy and respect and to receive the right support and the right entitlements in a timely manner,” he said. "To those injured workers for whom this has regrettably not been the case, I apologise." In a statement, Attorney-General Jill Hennessy said the report revealed disturbing examples of workers being unfairly treated and unjustly denied their legal entitlements. "I have written to the board of WorkSafe detailing my expectation that the recommendations are actioned quickly, in particular to ensure injured workers have access to a timely independent review of their case," she said. Two recommendations made to the government have been accepted. It has agreed to commission a review into models of claims management to ensure appropriate compensation is paid to injured workers who have complex claims. It will also introduce a new dispute resolution process. Ms Hennessy said 13 recommendations made to WorkSafe had also been accepted.

Nick Wakeling, the opposition's spokesman for workplace safety, said the state government "had failed to act" despite the ombudsman's damning 2016 investigation. "As the ministers responsible for WorkCover since 2016, Robin Scott and Jill Hennessy should be apologising to Victorians who’ve been let down by the system," Mr Wakeling said.