The treatment of 10 leukaemia patients who were underdosed at two major hospitals in Adelaide was disrespectful, lacked empathy and failed to understand their pain and suffering, a report has found.
The parliamentary investigation into the dosing errors has also pointed to systemic cultural problems within SA Health and identified a lack of action after the errors were discovered.
"Patients were left in a position of uncertainty never knowing the potential impacts of the chemotherapy under-dosing on their chance of surviving their illness," the committee said in its final report released on Tuesday.
"The realisation that the error also prevented the opportunity to access further trials and studies was a constant source of anguish for the patients and their families."
The dosing errors occurred at the Royal Adelaide Hospital and the Flinders Medical Centre between July 2014 and January 2015.
During the course of their treatment, the 10 patients received only a single daily dose of the drug cytarabine when they should have received two.
Four of the patients have since died and an inquest is under way to determine if their deaths were related to the mistakes.
The committee found there were significant failures of clinical governance at the Royal Adelaide with a failure to follow routine processes and procedures.
It said SA Health also failed to provide adequate support to the patients once the errors were discovered and said it was unacceptable that the victims were subjected to the additional burden of engaging lawyers to make compensation claims.
The committee handed down 12 recommendations including calls for better communication and training, more performance reviews for health staff regardless of their seniority and the implementation of stricter treatment protocols.
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