The complaints pointed to a pattern of recurring themes of systematic failure to adequately undertake its statutory role, Ombudsman George Brouwer fround.

Complaints cited inadequate or no investigations at all, significant delays in finalisation - sometimes in excess of three years - a lack of procedural fairness and poor documentation practices, including failure to provide information about internal review processes and external review mechanisms.

As a result of the number of complaints, Brouwer launched his own investigation and made 28 recommendations for reform.

He recommended the power to review merit-based decisions - where there were deficiencies in investigations or errors in decisions - be implemented. Otherwise, he said, "injustice to complainants" and allowing "practitioners to avoid detection and/or prosecution" would continue.

Brouwer's report found that staff also lacked understanding about the agency's statutory powers and had a restricted skill-set to conduct investigations.

A review of case files, he said, showed investigators from the LSC lacked knowledge of basic techniques of investigative processes including planning, follow-up of serious allegations, substantiating documents such as practitioners' files, timely conclusions and reasons for decision.

In one example, a complaint was dismissed against a lawyer because of "insufficient evidence" but it was found the commissioner had failed to interview the complainant or legal practitioner and did not exercise its power to obtain documents.

Victoria Marles, the Victorian Legal Services Commissioner who leaves the position on 23 October, said the recommendations had been implemented.

- Sarah Sharples