The report into the death of Zahid Mubarek concluded yesterday that the welfare of vulnerable prisoners is being sacrificed by prison overcrowding and under-funding because their cause is not a vote winner.
One of the most far-reaching inquiries into prison practices listed a "catastrophic" range of failures and painted a picture of degrading treatment of inmates, overcrowding, low staff morale, incompetence and indifference to hate crimes.
Mr Justice Keith's report was published on the day it was revealed that the prison population had reached an all-time high of 77,865 in England and Wales, up from 61,000 in 1997 when Labour came to power, and was now close to breaking point.
Mr Mubarek, 19, was fatally bludgeoned by his racist, psychopathic cellmate Robert Stewart on 21 March 2000, just hours before he was due to complete a short sentence for theft. He died a week later later.
The inquiry into the teenager's killing listed 186 separate missed opportunities to save his life and took the rare step of naming and shaming 20 key figures.
Among those named were two former governors at Feltham young offender institution, Clive Welsh and Niall Clifford. The former was accused of "achieving little" during his four-month tenure and the latter was said to be unable to lift staff morale.
Sundeep Chahal, a prison officer, was castigated for failing to conduct a more thorough search of the cell the men shared, while John Byrd, race relations officer at Feltham, was partly blamed for a failure to tackle racist behaviour by staff and inmates.
Other officers were blamed for not taking steps to make it plain that Stewart was dangerous.
Mr Justice Keith made 88 separate recommendations following what he described as a "bewildering catalogue of shortcomings, both individual and systemic" among Feltham staff.
He said: "The bottom line is that you are only going to get the prisons you are prepared to pay for.
"Either you keep the prison population down by changing sentencing policy or you accept that the prison population will increase, and you inject sufficient funds into the system to ensure that prisoners are treated decently and humanely.
"The trouble is that neither of these options is a vote winner. Electoral success rarely comes to those who say that fewer people should be locked up; just as it rarely comes to those who argue that more money should be spent on prisons and the prisoners detained in them.
"It is almost too obvious to say it but if you ask where prisons come in the pecking order for funds compared with hospitals and schools, prisons will always come last.
"As Churchill said, societies are judged by the way they treat their prisoners, and if more resources are needed not to ensure that our prisons are truly representative of the civilised society which we aspire to be, nothing less will do."
Seven years after the Macpherson inquiry into the murder of the black teenager Stephen Lawrence, which prompted a major change in how the police treat racist crime, Mr Justice Keith said it was time that the Prison Service caught up. The inquiry chairman went further, calling for a new definition of institutional religious intolerance after reports of the increasing persecution of Muslims in jails.
Mr Mubarek's family, who had fought a legal battle against the Home Office for a public inquiry, described his death as "institutional murder" insisting the system was to blame. "The Prison Service and Home Office were both, before and after Zahid's death co-conspirators in a woeful conspiracy of incompetence and indifference of truly criminal magnitude," said their barrister Dexter Dias.
Their solicitor, Imran Khan, called on John Reid, the Home Secretary, to act on the findings of the inquiry. "In my view, there is no doubt this report is to the Prison Service what the Stephen Lawrence report was to the police service," said Mr Khan.
"It is absolutely imperative the Prison Service changes and this Home Secretary accepts these recommendations and acts on them." He said the family was considering legal action against the 20 named individuals.
In his summing up, Mr Justice Keith talked of Mr Mubarek as a young man who had fallen into petty crime but had written letters of remorse to his family. He was never to get the chance to prove he had put the past behind him," said the chairman.
Stewart's increasingly bizarre and dangerous behaviour was too often ignored, he said. Files went missing, vital information was not passed on, and, when it was, it was not acted upon.
Mr Justice Keith described the care of Feltham inmates with mental health problems as "unacceptably poor". During Stewart's eight previous spells in jail he had set fire to his cell, been involved in a riot and strongly implicated in the stabbing of another inmate.
"Stewart should have stood out from the crowd," said the chairman, adding: "Because of a pernicious and dangerous cocktail of poor communications and shoddy work practices, prison staff never got to grips with him."
Pointing out it should have occurred to staff that Stewart, who had a cross and RIP tattooed on his head and wrote copious violent letters, was a racist, he added: "At the heart of it all was a catastrophic breakdown of communications not just between one prison and another but also within individual prisons themselves.
"The tragedy was officers on Swallow Wing had no idea about the sort of man they were dealing with."
Mr Justice Keith said he found no evidence that the inmates were placed in a cell in a deliberate attempt to watch and bet on them to fight - a practice referred to as "gladiator games". But he added: "The real possibility that unsuitable prisoners have at times been put into the same cell - either to wind them up so they would misbehave when they were let out or to see whether they would argue - is certainly one which cannot be excluded."
Lord Ramsbotham, a former chief inspector of prisons, said he thought the public inquiry had broken new ground and hopefully set a precedent. "If they [the prison authorities] have got nothing to hide they have got nothing to fear from such inquiries."
A life of violence
From an early age Robert Stewart began to display signs of mental illness and violence that would culminate in the sadistic murder of an Asian teenager.
He grew up in Middleton, a deprived area of Manchester, with his father, Joseph, a bricklayer, his mother, Beverley, an occasional factory worker, his older brother, Ian, and younger sister, Karen.
When he was eight, a child psychiatrist noted that he was easily upset and disregarded his own safety. He would sometimes scratch himself until he bled. His school records showed that, while he had potential to succeed, his behaviour - including starting fires and floods - brought him into constant clashes. When a gas explosion devastated the family home, they moved across Manchester to the predominantly white Hattersley.
Stewart began stealing cars and burgling homes. At 13, he set light to the back yard of a shop. A psychiatrist said he displayed signs of a personality disorder. He rarely attended school and when he did he was disruptive - setting light to a girl's hair, starting fires and flooding classrooms, even slashing his own wrists. While he had some black friends and girlfriends, he adopted the racist attitudes around him, going out with friends in Hyde to go "Paki bashing".
In one year alone, he was convicted of 17 offences of burglary and criminal damage. At 14, he was taken into care, setting fire to another resident's bedroom. Ten days after his 15th birthday, he was locked up for burglary and theft.
He rarely spent more than a few months outside young offender institutions. At 16, he was released on New Year's Eve. Drunk, he had RIP tattooed on his forehead - the same initials that his mother had tattooed on her arm.
He also began writing racist letters in which he talked of making Ku Klux Klan outfits. In 1998, a prison officer marked him down on his file as a "disaster waiting to happen".
The next year he stabbed a fellow inmate and threatened to take a teacher hostage. A mental health nurse diagnosed "a long-standing, deep-seated personality disorder" but recommended no further action.
It was on 21 March 2000 at the age of 19 that his years of violence and racism came to a head when he beat his cell mate, Zahid Mubarek to death. He was sentenced to life in jail.
Race killings that shamed Britain
Stephen Lawrence died London 1993
Stabbed to death by white gang while waiting at bus stop. Inquiry into police handling of case reached conclusion that Met force suffered from "institutional racism". Jack Straw, who was Home Secretary, said: "I want this... to serve as a watershed in our attitudes to racism."
Peiman Bahmani died Sunderland 2002
Died after being stabbed with a kitchen knife. Mr Bahmani had earlier urged friends to stand up to racists. Superintendent Paul Weir said: "It should not have happened, but it did and I choose to use it as a catalyst for change."
Kriss Donald died Glasgow 2004
Aged 15, he was abducted by Asian youths who stabbed him before setting him on fire. Daanish Zahid, 20, convicted. Kay Hampton, the deputy chair of the Commission for Racial Equality, said: "Racism, wherever it comes from, is always deplorable."
Kalan Kawa Karim died Swansea 2004
Former political activist who opposed Saddam Hussein, he sought asylum in Britain and fell victim to Swansea's first racially motivated killing. Welsh Assembly member Leanne Wood said: "Racism is abhorrent - we will fight it, and we will defeat it."
Isiah Young-Sam died Birmingham 2005
IT worker, 23, murdered during last year's Birmingham race riots between blacks and Asians. Mr Justice Mackay said: "[He was] set upon because he was Afro-Caribbean and for no other reason. He was killed for the colour of his skin."
Anthony Walker died Liverpool, 2005
Student murdered by white assailants. Superintendent Ali Dizaei said: "The murder is an unequivocal indication that the cancer of racism is still here. We will not tolerate these acts on young, innocent people."
Ian Herbert and Gustavo Montes De OcaReuse content