He made 20 recommendations,including that a nurse who injected Mr Dungay with a sedative while he was being held down be referred to the Nursing and Midwifery Board for possible review of his professional conduct.
Mr Lee also recommended Corrective Services provide"specialist practical training"in positional asphyxia to officers who regularly restrain inmates and basic training to all other staff.
However,Mr Lee said he could not refer two prison guards to the DPP for possible prosecution,which Mr Dungay's family had sought.