The PPO investigation concluded that the healthcare Khan received in prison, delivered by Spectrum Community Health CIC, was not of the required standard.
Mr Usher found that on 30 June, 2022, GP services at the prison failed to share irregular blood sugar readings with nursing staff, who therefore did not monitor him effectively.
He had also been referred to the prison’s long-term conditions clinic for oversight of his diabetes and high blood-pressure, but the nurse who ran it was on maternity leave.
While a clinical expert instructed by the PPO said she could not be sure closer monitoring would have saved him, she concluded there were “missed opportunities”.
A spokesperson from Spectrum said the service was “fully committed” to implementing changes recommended by the report.