Failures by Serco left a cellmate to care for the gangrenous toes of an ill prisoner, who resorted to cleaning them with toilet paper.
The older prisoner was being treated for a number of health problems, including lymphoma and foot circulation issues.
He was under the care of the Department of Corrections but temporarily transferred to a Serco-run prison in 2013, where he spent 18 days, for court hearings. But during transfer his drug charts and some medication were left on the bus, including medical instructions to dress blisters on his toes daily.
A report by the Health and Disability Commissioner reveals it took three days to return the papers and medication, Serco staff consistently failed to give him his painkillers as prescribed, and there was no record of his feet being checked or treated for several days.
A fellow prisoner was instead left to clean his feet with toilet paper each day, claiming his request to see a doctor was ignored.
He was also denied a wheelchair and slept on the floor because his infected toes prevented him from climbing into his bunk.
When he returned to the first prison assessment notes describe his as looking "absolutely shocking" and that his black toes looked "ready to drop off".
A further court appearance saw him return to the Serco-run prison for another four days; again his feet were not checked or dressed.
He returned to the first prison, but his health deteriorated later that year and he died in hospital.
Deputy health and disability commissioner Kevin Allan describes the man's care as "a significant departure from accepted standards".
His report criticises Corrections for failing to ensure the prisoner's medication and documents were transferred safely, but lays the majority of the blame with Serco.
"There was a pattern of failures by multiple providers' responsible for [the man's] care, and ultimately Serco is responsible for those failures."
Serco has been made to apologise to the man's family and has since carried out a recommended audit and training for health service staff.
The Department of Corrections took back management of the prison from Serco earlier this year.