Mr Justice Keith's recommendations
Mr Justice Keith identifies in his 700-page report at least 19 members of the Prison Service whose professional failings played a part in creating the circumstances leading up to the death.
Saying that he had been "uncompromising" in naming names, the chairman commissioned an appendix to the main report listing these individuals and the role they played. They include:
Dr Andrew Greenwood, Hindley jail: Dr Greenwood twice saw Robert Stewart in September 1997 at Hindley Prison. On the second occasion, Mr Justice Keith said, the doctor's examination of Stewart through the window of a segregation cell was wholly inadequate because he effectively ruled out mental illness, despite not having had chance to properly assess the inmate.
Harold Dunne, head of operations, Hindley jail : Mr Dunne decided against monitoring Stewart's mail despite one letter talking of an armed robbery. Mr Dunne believed that the inmate was "showing off" but Mr Justice Keith said the reasons for his decision were "insufficient".
Chris Kinealy, mental nurse, and Jim Farrell, unit manager, Altcourse jail: Mr Kinealy assessed Stewart at the request of another member of staff. He concluded that the inmate was not a risk to others without having seen all the security files. Mr Farrell in turn did not tell Mr Kinealy all he knew about the prisoner. Mr Farrell declined to give evidence to the inquiry.
Steven Martindale, senior officer, Feltham : Mr Martindale advised a fellow officer to return a racist letter to Stewart saying it would not be sent out. He did not make a note in the security files or in the withheld letters log, or investigate whether the inmate had a history of racism. Mr Justice Keith said this was an "unacceptably relaxed attitude towards racist language".
Niall Clifford, governor of Feltham when Zahid Mubarek died : The governor was headhunted to try and turn around the failing prison. But just over a year into the post, shortly after Mr Mubarek's death, he was promoted. Mr Justice Keith said Mr Clifford's personal style "may not have been right for this critical time in Feltham's history". He said he alienated staff, including a militant Prison Officers' Association branch, and failed to improve conditions.
Keith Denman, principal officer, Feltham :
Mr Denman was "struggling with his management responsibilities" as the jail remained in crisis, said the chairman. His visits to units were "little more than perfunctory" and he was defeatist.
Ken Penwright, principal officer, Feltham :Mr Penwright "was even less pro-active than Mr Denman," said the chairman. "He had begun to become idle as his retirement approached".
John Byrd, governor responsible for Swallow Unit: Mr Byrd ran the unit which housed Zahid Mubarek and Stewart's cell. Mr Justice Keith said he did not really know how bad things were and "lacked vision" to tackle problems. Secondly, he was "singularly ineffective" as the prison's race relations liaison officer and "must take his fair share of responsibility - successive governors should have realised that he lacked the skills which the job required."
Mr Justice Keith said there had been a "bewildering catalogue of shortcomings" that contributed to the death, in a wide systemic collapse of an effective prisons system.
There was a casual disregard towards racism at Feltham with some officers in denial. Racist language or banter was not taken seriously by staff and some ethnic minority officers in the prison service reported being victimised. Mr Justice Keith believed that Stewart's tattoos, including RIP on his forehead, if properly interpreted, were a clear sign of his racist mind.
Feltham as "gigantic transit camp"
Feltham was unable to effectively cope with the numbers coming and going through its doors on a daily basis. With staff morale at rock bottom and inspectors saying the jail was failing, the prison had no strategic direction. This played a key role in Stewart arriving at the jail and being placed with Zahid Mubarek because it was the only bed available.
Despite evidence in the prisons system and elsewhere that Robert Stewart had severe personality problems, this information was not sufficiently shared between prisons, when he was transferred within the estate. Security files or other records of the prisoner's behaviour did not correctly travel to new locations or were not properly shared as part of a well-organised flow of information.
Stewart attacked Zahid Mubarek with part of a table leg that he had broken away from furniture in their shared cell. The fact that this was not spotted by officers was part of a widespread problem of poor inspections and management of dangerous prisoners.
Stewart was allowed to watch an extremely violent film, Romper Stomper, depicting a gang of neo-Nazis in Australia, two nights before he attacked his cell mate.
Stewart was never inspected by a doctor at Feltham and nobody therefore picked up on his personality disorder.
Prison overcrowding and low staff morale played a key role in Feltham collapsing as an institution in the run up to the death.
"The bottom line is that you are only going to get the prisons you are prepared to pay for," said Mr Justice Keith. "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 prisons are treated decently and humanely. The trouble is, neither of these options is a vote-winner."
The chairman of the inquiry made 88 recommendations. These include:
- End enforced cell-sharing as a high priority
- Link the Police National Computer to the prison estate to help share security information
- Appoint key officers to oversee the proper flow of information between prisons and within them
- Inmate mental health assessments should address the risk which they pose to staff and other inmates
- The Prison Service and Commission for Racial Equality should work harder on key issues to improve equality, including possible asking outside bodies to investigate allegations of racism
- The Prison Service should consider whether to recognise a concept of institutionalised religious intolerance along the lines of institutionalised racism adopted by the inquiry into the murder of Stephen Lawrence.