Norman Fisher’s enemy lived within him.

If he didn’t properly mix two medications each day, his diabetes would attack his body and mind. Once, his out-of-control blood sugar left him so delirious that he drove his car into a ditch.

For two decades, support staffers defended Fisher against the disease by helping him organize his medications and buying his groceries. But in late 2014, the people assisting the Biddeford man, who was mentally disabled, said he needed more help than they could provide.

With none of Fisher’s family able to step in as his caretaker, the York County Probate Court turned to the program of “last resort,” a public guardianship administered by the state. The state assigned him two public guardians at different times during the next four years, and they were responsible for making all medical and housing decisions for him.

Those guardians submitted one-page reports once a year to the probate judge overseeing Fisher’s case, but the reports offer little detail of his care: How often the guardians went to see him. If they talked to Fisher about his medications. Whether they knew his needs and wants.

There’s also no evidence in the court records that the probate judge raised questions, even after each guardian submitted virtually identical reports two years in a row.

Then, in August 2019, Fisher was taken to a hospital and released to a home for adults with disabilities, one run by Residential and Community Support Services, where the workers didn’t...

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