An inmate had a heart attack and was hospitalised five times after the Department of Corrections failed to provide him necessary medication following an initial stroke.

Corrections, along with Clendon Pharmacy and a doctor had all failed in their responsibilities to provide appropriate care for the man, the Health and Disability Commission has found.

The man had been prescribed long-term clopidogrel, medication used to reduce the risk of heart disease and stroke, after he had been hospitalised following a stroke on June 17, 2016.

He received the medication for only a month before it was stopped in error.

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It was not until the man was readmitted to hospital several months later, after suffering a heart attack and having four stents placed in his heart, that he began receiving the clopidogrel again.

However, after two months the clopidogrel was again stopped incorrectly.

It was not until several months later, after the man had been hospitalised a further three times, that he began receiving clopidogrel again.

Deputy Health and Disability Commissioner Kevin Allan there were a number of failings by Corrections staff that represented a "pattern of poor compliance" with Corrections' policy and a "concerning lack of critical thinking", which all contributed to the man not receiving his medication as intended.

Under the Corrections Act, Corrections was required to ensure a "standard of health care that is available to prisoners in a prison must be reasonably equivalent to the standard of health care available to the public".

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Prisoners also did not have the same choices or ability to access health services as person living in the community, including direct access to medication or to a GP.

"They are entirely reliant on the staff at Corrections' health services to assess, evaluate, monitor, and treat them appropriately," Allan said.

There were also deficiencies in the care Clendon Pharmacy provided, including dispensing the medication without a current medication chart, discontinuing the medication when it was charted to continue and not having internal procedures in place for processing orders from Corrections.

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He recommended Corrections and the pharmacy provide written apologies to the man, which they had both done.

Allan was also critical of the doctor incorrectly transcribing the hospital prescriptions which contributed to the man not receiving clopidogrel for as long as was intended.

The case has been referred to the Director of Proceedings to decide whether any legal proceedings should be taken against Corrections.

Corrections and Clendon Pharmacy were also recommended to meet to discuss HDC's report and any further issues identified, and report back to HDC.

Recommendations for Corrections:

• There should be an independent, external review of the level of GP cover provided at Auckland Prison.

• Corrections should report new processes for medication self-administration signing sheets to the Health and Disability Commission.

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• Corrections should review a sample of recent discharges from hospital to Auckland Prison to ensure that appropriate care plans are in place.

Recommendations for Clendon Pharmacy:

• Undertake a random audit of dispensing to the prison health centre.

• Develop an anonymised case study based on HDC's report as the basis for training staff and sharing this study with the Health Quality and Safety Commission.