A prison operator has been rapped over the knuckles for neglecting an inmate's blistered feet.
The feet deteriorated so much the prisoner was forced to clean them every morning with toilet paper.
Health authorities have today come down hard on the unnamed prison, which provided treatment slammed as "sub-optimal".
"Deputy health and disability commissioner Kevin Allan released a report finding the Serco-managed prison breached the code of health and disability services consumers' rights over its failure to treat a male prisoner's feat or administer prescribed medication."
Twice, the man was transferred from one jail to another so he could appear in court. Both times, instructions were passed on about treating the man's feet but there is no record that staff at the second prison acted on these.
A doctor saw the man and noted that staff were to watch for signs on infection in his blistered feet, but there is no record any nurse checked on him or that his feet were treated or monitored.
The man was not given pain relief as prescribed and staff didn't document any reason for this.
Allan's investigation found the man cleaned his toes with toilet paper every morning, according to his cellmate.
When the blistered man finally returned to the first jail, nurses recorded in their clinical record he was in poor physical shape and that toilet paper was soaked with warm water on his toes.
Mr Allan described the second jail's failures as "seriously suboptimal".
"The lack of treatment of the man's feet and the failures in relation to medication management cumulatively amount to a significant departure from accepted standards," says a statement from the commissioner's office.
"Mr Allan commented that there was a pattern of failures by multiple providers responsible for the man's care, and ultimately the operator of the second facility was responsible for those failures."
He recommended the second jail train its staff in wound-care management and how to appropriately respond to inmates' healthcare needs.
The prison must report back to the commission on its progress and also audit it's compliance with documentation professional standards.