For the past four months barristers and officials have debated the countless errors and failings that led to an Asian teenager being battered to death.
In the chambers in central London, an atmosphere far removed from the tension of the UK's largest young offenders institution, Feltham, they have raked over every detail of how Zahid Mubarek came to be sharing a cell with Robert Stewart, a psychopathic racist who beat him to death on 21 March 2000, the day he was to be released from his short sentence.
But there has been one glaring absence in the chamber - Stewart. Yesterday, as the evidence in the inquiry came to a close - with final submissions not expected until next month - Stewart was 48 miles away at Woodhill Prison, sentenced to life for murdering the 19-year-old.
Much has been said of Stewart's disturbed behaviour during his latter years in institutions - including smearing excrement on the walls of his cell and starting a fire. Another report said he had covered himself in margarine, placed a noose around his neck and also ate soap.
But very little has been revealed about his earlier years and, more specifically, how an angelic looking child became a sadistic killer.
His early years were spent in Langley, a deprived, sprawling estate once used to rehouse those made homeless by Manchester's post-war slum clearance programme.
It was in a large ugly house on Greystoke Drive that he grew up with his father, Joseph, a bricklayer now 75 and suffering from lung cancer, his mother, Beverley, an occasional factory worker, along with older brother, Ian, and younger sister, Karen. Mrs Stewart, whose 18-stone frame led to her being nicknamed "Fat Mama" by her own children, admits she had a liking for whisky and cannabis.
Her middle son was a clever child with a stubborn streak, who rarely revealed his feelings and shrugged off affection. On one occasion, he scrubbed his own face out of a photograph because he felt he was too ugly. He would win competitions and then deny entering them.
He was obviously clever, memorising books she read to him and turning puzzles face down on the carpet to make them more challenging.
However, from his early days at Langley Primary he sought attention with disruptive behaviour. The accidental death of a friend on a school trip, his mother said, also affected him deeply. "If another child was cleverer than him he would destroy their work," explained Mrs Stewart, 45. By the age of 10, his teachers had already advised that he see a psychiatrist.
Asked to draw his family, he painted them as stick men without arms. When the psychiatrist pointed out the omission, he retorted confidently he had not forgotten the arms, they were simply behind their backs.
"He was quick-witted. If I could turn the clock back, I would have listened to teachers But, at 20, you think you know better," said his mother.
His move to Queen Elizabeth High School saw his bad behaviour grow. 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 another estate in the predominantly white, deprived community of Hattersley.
But when Robert and Ian stole from some older teenagers, bricks were put through the windows and they had to move again.
In the rubbish-strewn cul-de-sac in Hattersley where they settled, neighbours remember the family with open loathing. "They were a nasty family. People were terrified of them," said one former neighbour. "They used to make threatening phone calls, have gang fights on the path outside. I would not wish them on anyone except the devil, that's where they belong," said another. Stewart began a pattern of stealing cars and burgling homes. At the age of 13, he set light to the back yard of a shop. At the time, a psychiatrist said he displayed signs of a personality disorder.
He rarely bothered to attend 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.
He finally burst into an open evening and threatened a teacher and was expelled. At one point, he stabbed a neighbour with a screwdriver and he ran away so often police once called to say a body found in the ship canal was thought to be him.
While he undoubtedly had some black friends and girlfriends, he lapped up the racist attitudes around him, going out with friends in Hyde to go "Paki bashing". It was "just something we did", he would say later.
In one year alone, he was convicted of 17 offences of burglary and criminal damage. At 14, he was taken into care, where he ended up setting fire to another resident's bedroom. Just 10 days after his 15th birthday, he was incarcerated for the first time for burglary and theft.
He would rarely spend more than a few months outside young offenders institutions, becoming hardened and unrepentant. At the age of 16, he was released from a sentence on New Year's Eve. Drunk and in a celebratory mood, he and his friends tattooed RIP on his forehead.
He adopted the name "spliffy", took a fancy to gangsta rap music and tattooed the name of Bob Marley on his arm. Yet he also began writing deeply 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.
No one took him seriously; that is until the early hours of 21 March 2000.Reuse content