The deaths of some prisoners could have been prevented if not for "disturbing" trends in the Correctional Service of Canada, says a report released Wednesday by the federal prisons ombudsman.

The report said some inmate deaths could have been averted by better risk assessments and preventive measures, as well as more timely responses by the CSC.

"The findings are disturbing and indicate that the Correctional Service has not rigorously fulfilled its mandate to keep all inmates safe and act on recommendations related to inmate deaths," said ombudsman Howard Sapers, whose official title is the Correctional Investigator of Canada.

The investigation into federal inmate fatalities reviewed 82 deaths due to factors other than natural causes from 2001 to 2005. It found that the country's prison authority made errors "incident after incident" by failing to incorporate lessons learned and implement corrective actions. It said the CSC failed to act on a "large proportion" of coroners' and medical examiners' recommendations.

Institutional staff were faulted for failing to perform their duties as required, and accused of committing "gross errors" when responding to emergencies by frequently failing to administer first aid. Another major concern was the absence of automatic external defibrillators as standard equipment in prisons.

Important information about the risk of prisoner suicide and violence often went unrecorded or uncommunicated, the report said. It also raised concerns about mental health programming and control of illicit and prescribed drugs inside Canadian prisons.

"Although the Correctional Service says it takes corrective action to ensure similar situations do not occur again, the same problems are repeatedly occurring, resulting in the tragic loss of human lives," said Sapers.

The report noted that the annual number of prison fatalities is not declining.