Prison operator Serco has been slammed for its treatment of an inmate with cancer, whose cellmate had to scrub his gangrenous toes with toilet paper.

Photo: RNZ / Diego Opatowski

A report by the Health and Disability Commissioner has revealed Serco failed to treat the man's toes, give him painkillers or provide a wheelchair, despite his toes eventually turning black.

The man, who had stage four non-Hodgkin's lymphoma and had also had pneumonia, spent 18 days at Mt Eden Prison while awaiting court hearings in mid-2013.

He died later that year, having written two letters complaining about his treatment at Mt Eden.

"My feet were stinging with the pain, I asked to see the doctor, which was the next day. He had a look at them and said 'we will have to keep an eye on them'. About two weeks later, nothing happened, 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," one letter said.

The commissioner's investigation and subsequent report described a "pattern of failures" for which Serco was ultimately responsible and recommended the operator provided its staff with better health training.

"Mr A shared a cell with another prisoner... that prisoner said he cleaned Mr A's toes with toilet paper every morning," the report said.

"When Mr A returned to [another prison], nursing staff recorded comments in the clinical record about Mr A's poor physical state, and noted that toilet paper was soaked off his toes with warm water."

In a statement, Serco said it had apologised to the man's family and since revamped its health unit.

"Immediately following the incident, we took steps to implement actions to ensure a similar situation did not happen again. We initiated a change management process, appointing a new head of clinical services, clinical team leader and five additional staff," it said.

"All RNs [registered nurses] and healthcare assistants were given additional training to ensure they were familiar with all legislative processes and Serco policies and procedures.

"Despite these and other improvements to our healthcare services in Mt Eden Corrections Facility, we accept that we should have done more, earlier."