A prisoner was allegedly left in urine-soaked clothing after not being provided access to a toilet while she was driven to Perth from regional Western Australia.
The case of the Indigenous woman identified as "Anna" was raised in a report by the Office of the Inspector of Custodial Services into the transportation of prisoners in regional and remote WA.
It follows the 2008 death of Aboriginal elder Mr Ward, who succumbed to heat stroke in the back of a prison van without air-conditioning.
Anna, who had a psychosocial disability, was transferred in May last year from Greenough Regional Prison to Perth's Bandyup Prison.
Despite being held in a secure pod in a Department of Justice-owned vehicle, she was placed in handcuffs and leg irons for the 400km trip.
She was not offered a change of clothes after urinating on herself, the report released on Monday said.
The officers' logbook noted "toilet break in pod" in reference to Anna during a stop for fuel.
The officers, who described being abused by Anna over the cell call system, later claimed she had turned down an offer to use the toilet.
Anna told the inspector she had asked for some fresh air but was rebuffed.
"She said she was told that she had to stay in the vehicle, and then the officers allegedly started talking amongst themselves and were laughing," the report said.
"She told us she had wet clothes for half of the journey and it made her feel cold."
Inspector Eamon Ryan said there had been a clear focus on safety since the death of Mr Ward but the department's processes had been lacking at times.
"Anna's experience highlights how the safety, welfare and dignity of a prisoner can be jeopardised when there is a lack of compliance and poor transparency," he said.
"No person should have to endure the type of treatment experienced by Anna on that journey.
"Transporting prisoners over long distances comes with inherent risks ... the case of Mr Ward remains a tragic reminder of the deadly consequences that can result when compliance vigilance slips."
A risk assessment for the transfer listed "no major concerns" even though an earlier private transfer was aborted due to Anna's erratic behaviour which included her refusing medication at Greenough.
The inspector's office requested CCTV footage and cell call recordings but was advised they were unavailable, in breach of the department's standards.
This was attributed to a faulty hard drive which was subsequently replaced.
The Department of Justice highlighted the inspector's finding that prisoners were generally transferred safely and efficiently.
It agreed to review the circumstances of Anna's experience and supported 10 other recommendations.
But it rejected a recommendation to revise medical escort security procedures to reduce the use of restraints, noting an escape risk "can equally apply" to low, medium and maximum-security prisoners.
