The cellmate of a cancer-stricken elderly prisoner was forced to clean his friend's gangrenous toes with toilet paper after the prison failed to provide adequate care.
Details of the incident, which happened at Auckland's Mt Eden Prison in 2013 while it was managed by the multinational company Serco, were revealed in a report released by the Health and Disability Commissioner.
As well as failing to treat the prisoner's toes, the report slams Serco for failing to provide painkillers and denying him a wheelchair despite there being two available.
The man died later in the year.
After being sent to prison in 2011, the man was diagnosed with stage four non-Hodgkin's lymphoma the following year.
He began chemotherapy in early 2013 and was hospitalised with pneumonia and circulation issues in his hands and feet.
During this period he was transferred to Mt Eden for court hearings where he spent 18 days.
He was discharged from hospital with prescribed medicine and instructions to dress blisters on his toes daily, several of which had turned black.
But some of his medication and drug charts were left on the bus he was transferred on and were not returned to Serco for three days.
There was also no record of his toes being checked until seven days into his stay, and no records of them being checked after that.
Instead the man's cellmate and friend cared for him, washing his toes with toilet paper and warm water each morning.
With both men older and physically unable to sleep in the top bunk, the man's friend made the sick prisoner a bed on the floor.
After the man left Mt Eden for another prison, the admission notes described him looking "absolutely shocking" with black toes that "look ready to fall off".
When the Mt Eden head of clinical services, a registered nurse, was emailed about his condition he described the comments as an "over the top emotional response".
The prisoner wrote two letters of complaint about his treatment at Mt Eden, where he described his feet as "stinging with the pain".
"When I had to go to the toilet I had to crawl on my knees until I could reach the toilet and pull myself up."
Deputy health and disability commissioner Kevin Allan described the treatment as a "significant departure" from accepted standards.
"There was a pattern of failures by multiple providers responsible for [the man's] care, and ultimately Serco is responsible for those failures."
He recommended Serco apologise to the man's family, provide more training to staff and conduct an audit.
Serco declined an interview request, but in a statement justice managing director Paul Mahoney admitted the medical care received fell well below expectations.
An apology had been made to the man's family and immediate steps were taken to ensure a similar situation did not happen again.
"Despite these and other improvements to our healthcare services in [Mt Eden], we accept that we should have done more, earlier.
"We do not dispute the Health and Disability Commissioner's findings. We are determined to learn from them and ensure that this doesn't happen again."
In April the Department of Corrections took back control of Mt Eden from Serco, after issues of prisoner mistreatment and "fight clubs" began to emerge.
Corrections director of offender health Bronwyn Donaldson said work was underway to transition all prison operations, including health services, to departmental policies and procedures.
Work would be done to implement the recommendations and Mt Eden.
"Prisoners are often suffering from extremely poor health (both physical and mental) when they arrive in prison.
"The healthcare they receive often far exceeds what they were accessing in the community."
SECOND REPORT CRITICISES CORRECTION
A second recently released report by Allan investigated the care of a second inmate at an unspecified prison between December 2011 and November 2012.
During that time the man regularly requested medical treatment for toothache and bleeding gums.
After dental work that included the extraction of two teeth and antibiotics, the man began to suffer loose bowel motions.
Since he was young and had no family history of bowel cancer, no further investigation was done.
When symptoms persisted a letter was sent to the gastroenterology department asking if a colonoscopy was needed.
But this was not passed on to a second prison after the man was transferred.
Further miscommunication between the two prisons led to a more than eight month delay for the man to receive tests that had been requested by a hospital.