That is the finding of an investigation by the Victorian ombudsman into the Department of Health’s border exemption scheme, which offered residents a pathway back from COVID-stricken NSW this year.

Ombudsman Deborah Glass said the decision to shut the border to Sydney and others parts of NSW in July left thousands suddenly stranded and unable to get an exemption.

Of 33,252 exemption applications from July 9 to September 14, when the probe was launched, only eight per cent were granted.

In all, the watchdog received 315 complaints including from stranded souls paying double rent with no job, caravanning pensioners with no internet access who were asked for documents they did not have, and a farmer afraid of having to destroy her animals when she could not get home.

A woman also had her request denied to enter the state to put her intellectually disabled sister in a care home.

Glass did not criticise the border closure call, saying the department’s intention was to protect people in the face of a public health emergency.

But she took umbrage at the narrow use of discretion, with most applications not even reaching a decision-maker.

“People’s anguish when they spoke to us was palpable,” Glass said in the report released on Tuesday.

“While we did not review all decisions and I do not suggest that all were unfair, the overwhelming majority of applications did not get to a decision-maker at all, and the guidance did not change even as case numbers in Victoria grew and the risks evolved.

“The consequences of that were vast, and unfair, for many thousands of people stuck across the border.”

She said it led to some of the “most questionable decisions” during her seven years in the top job.

Despite scaling up its exemption team from 20 staff in July to 285 by early September, those responsible for categorising and prioritising applications were expected to complete 50 per hour or one every 30 seconds.

People were also required to provide extensive evidence to support their application, including statutory declarations, proof of residence or ownership of animals, letters from doctors, and statements from dying loved ones.

“The effect of a complex and constrained bureaucracy meant some outcomes were downright unjust, even inhumane. People felt caught up in a bureaucratic nightmare,” Glass said.

“It appeared to me that the department put significant resources into keeping people out rather than helping them find safe ways to get home.”

The ombudsman has recommended the state government acknowledge the distress the system caused, improve policy and guidance for such schemes and consider redress payments by application to help those denied exemptions to cover financial costs.

The report comes as Victoria recorded 1185 new COVID-19 infections and another seven deaths in its latest reporting period, taking its toll from the pandemic to 1385.

The health department confirmed on Tuesday the state is managing 13,050 active cases, dropping from 16,503 on Monday.

There are 297 patients in the state’s hospitals, 102 of whom are in intensive care and 25 requiring ventilation.