The Department of Corrections has been found not to provide an adequate assessment of a prisoner's condition, medication and ongoing care requirements.
The man, aged in his 50s, required daily medication for coronary vascular disease and twice-daily medication for HIV.
However, a report released by Deputy Health and Disability Commissioner Kevin Allan found Corrections in breach of the Code of Health and Disability Services Consumers' Rights.
During the man's incarceration, Corrections staff failed to administer his medication on a number of different occasions, and missed doses of HIV medication could have significant long-term implications for a patient.
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"A number of staff at Corrections failed to administer prescribed medications, and placed this man's health at risk," Allan said.
"He had no control over his access to medication, and was reliant on the staff at Corrections to provide him with adequate care. It is unacceptable that they did not do so."
On arrival at the facility, a registered nurse did not record his recent hospitalisation for chest pain or evaluate the importance of his medication as required by policy, the report found.
An initial health assessment was not completed at this time, or at any other time during the man's incarceration, despite being required by policy.
Allan concluded Corrections had failed to provide services with reasonable care and skill and noted a prisoner does not have the same choices or ability to access health services.
He recommended Corrections conduct an audit of receiving office documentation, administration of medication and employing additional health staff.
Corrections told HDC they had apologised to the man for the breach and have since made a number of changes since these events.