But the territory's Corrective Services is unrepentant, saying that decisions made at the time of the incident, in August 2012, would be made in the same way in future.

Health Services Commissioner Mary Durkin launched her investigation in November 2012 after The Canberra Times revealed details of the incident that unfolded after an AMC prisoner was brought to hospital's psych ward after a serious “self-harm” incident at the prison.

Staff at the hospital's Adult Mental Health Unit were appalled when the two prison officers escorting the convict insisted that he be cuffed to his bed and restrained with shorter handcuffs whenever he went to the toilet or left his room for other reasons.

The objections of doctors and nurses at the psychiatric clinic were brushed aside by the prison officers and their superiors who continued to keep the man cuffed, arguing it was for the safety of the medical, staff, the corrections workers, other patients and the prisoner himself.

Prison managers said the man was a high security prisoner serving a lengthy sentence for a serious crime and had been behaving irrationally and unpredictably when he was taken to the psychiatric ward.

But after a lengthy investigation, the Health Service Commissioner found that the medical treatment given to the prisoner was compromised by the heavy restraints, although Ms Durkin did not provide details for privacy reasons.

She also found that treatment decisions made in mental health facilities should be made by doctors and nurses, not prison guards and the decision to handcuff the patient for five days was inconsistent with the rules on the use of such devices.

Prison officers are supposed to ensure that “instruments of restraint” should be a last resort, only to be used "if other methods of control fail", and that "such instruments must not be applied for any longer time than is strictly necessary".

The commissioner also found that decisions were not properly documented, including the initial decision to slap the cuffs on the prisoner or the “purported regular reviews” of that choice.

The investigation found that the ACT Health staff did not believe they were at risk during the man's first four days in their care and that the “justification for mechanical restraint on the basis of immediate risk of harm to self or others… arguably became less strong as those days passed, particularly as it relates to the concept of "last resort”.

Ms Durkin wants an overhaul of the procedures for transferring patients from the city's jail to its main hospital and for prison authorities to conduct an individual risk assessment each time such a transfer was made.

The commissioner also wants supremacy restored for medical decisions in the ACT's medical facilities.