A blind teenage boy who needed "constant supervision to be safe" was left alone at a public station stop after a support worker failed to turn up.
A report into the incident by the Deputy Health and Disability Commissioner found the disability care coordinator breached its code in the incident.
The boy was in his early teens classified as having "total blindness". He was also noted as a falls risk and he needed "constant supervision to be safe", according to his service plan.
He was supposed to be picked up from the bus stop by a support worker after school, but was left alone.
A member of the public found him and called his mother for him.
"My son was left in a potentially life threatening situation as he is vulnerable," the boy's mother told the Health and Disability Commission.
An investigation by the disability service found there were issues when his scheduled support worker wasn't able to attend the shift, and the care coordinator tried to book a replacement.
The boy's mother wasn't told of the changes and the care co-ordinated hadn't communicated with the proposed replacement, Deputy Commissioner Rose Wall says.
She found the care coordinator has not provided services to the boy 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," Ms Wall says.
She recommended the care coordinator apologise to the boy and his mother in writing and that the disability service update the HDC with changes made and systems improved after the incident.
The names and locations of those involved have not been released to maintain their privacy.