Twenty individuals faced criticism for failings which led to the racist murder of Asian prisoner Zahid Mubarek in a damning official report published today.
High Court judge Mr Justice Keith warned that ministers must find extra cash to cope with growing prison numbers and called for the Prison Service to eliminate forced cell sharing.
He outlined a devastating series of 186 individual and "systemic" failures which gave racist psychopath Robert Stewart the opportunity to bludgeon his teenage cellmate to death in March 2000 at Feltham Young Offenders Institution in west London.
The judge said the Home Office and Prison Service should introduce a new concept of "institutional religious intolerance" to help combat prejudice against Muslim inmates.
And his report said there was a "real possibility" that a game called Gladiator did exist at Feltham in which prison officers placed unsuitable inmates together in the same cell to generate violence.
"The real possibility that unsuitable prisoners have at times been put into the same cell - either to wind them up so that they would misbehave when they were let out or to see whether they would argue with each other - is certainly one which cannot be excluded, even though no hard and fast examples of such a practice have been given," the report said.
But it went on to exclude the possibility that officers had bet on the outcome of such games.
The inquiry concluded there was ample evidence available of Stewart's violent, racist nature before he was placed in the same cell as Zahid a few weeks before the murder, including his involvement in an earlier killing of 18-year-old prisoner Alan Averill at another prison.
"If an event as rare as a homicide in prison, coupled with Stewart's suspected involvement in it and his recent behaviour in custody, was not sufficient to warrant some thought being given to the risk he might pose, it is difficult to imagine what would," said the report.
"The history of Stewart's management within the prison system before he went to Feltham for the last time reveals a number of missed opportunities.
"It is easy to be wise after the event, but by the summer of 1998, Stewart should have stood out from the crowd.
"We can only speculate about what would have happened if Stewart's potential dangerousness had been properly addressed."
The proposed new definition of institutional religious intolerance would be along the same lines as the "institutional racism" phrase drawn up by the Stephen Lawrence inquiry, said the chairman.
His report was published on the same day the prison population reached a record high of 77,865.
The report detailed how a letter from Stewart which referred to "niggers" and "Pakis" was discovered by staff but insufficient action was taken because of the "unacceptably relaxed view taken of racist language which the culture at Feltham had bred".
However "fate played its hand" in the circumstances of Zahid's death, said the 700-page report.
On the night Stewart arrived back at Feltham after a court hearing, the cell where he murdered Zahid - Cell 38 on Feltham's Swallow Wing - was the only space available on the unit.
Mr Justice Keith said he was satisfied that Zahid asked officers to be moved from Cell 38 "quite soon" after Stewart's arrival.
The possibility that Stewart was influenced by watching a violent film about neo-Nazis two days before the murder could not be ruled out, the report said.
The Australian movie Romper Stomper starred Russell Crowe as a skinhead gang leader who orchestrates battles with Asians.
"The possibility that it played a part in what was to happen is not wholly implausible and is one which cannot be discounted," the report said.
Psychiatrists could not rule out the possibility that Stewart was re-enacting a scene from the film when he bludgeoned Zahid with a table leg, on the very day the 19-year-old was due to be released.
In a clear message to the Government, the chairman said in his report: "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."
He went on: "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."
He said that the Prison Service was doing its best within current funding levels.
"But if those resources are simply not enough, and the prison population continues to increase, ministers must find the extra money to enable the Prison Service to deliver a proper regime for the prisoners it is required to hold."
Mr Justice Keith made 88 recommendations for improvement, with the first being that elimination of enforced cell sharing should be a "high priority" for the Prison Service.
The organisation should also consider whether racist allegations and other serious complaints should be investigated by an independent body.Reuse content