The public inquiry into the killing of Zahid Mubarek in Feltham Young Offender Institute six years after his death has revealed the shocking circumstances which allowed Robert Stewart to bludgeon his cellmate to death under the noses of the prison authorities.

Mubarek was murdered just hours before he was due to leave prison. Stewart had completed his sentence the day before, but remained at Feltham as an unconvicted prisoner on remand awaiting trial on charges of harassment. He was known to various authorities as an extremely disturbed young man who had displayed racist behaviour.

When finished his report, Mr. Justice Keith, a public law specialist who spent a decade at the Hong Kong Court of Appeal, said he was “shocked and dismayed” by what he had heard and seen.

The public inquiry was ordered in 2004 following an appeal to the House of Lords by Mubarek’s lawyer for an independent investigation into the circumstances of Mubarek’s death under the European Convention on Human Rights. Prior to this, internal inquiries were carried out by the prison service in 2000 and the Commission for Racial Equality in 2003.

The Home Office actively opposed a public inquiry. Dexter Dias, the family lawyer, said, “It brings great shame on the Home Office for trying to conceal these failings from the public’s scrutiny.... Robert Stewart was a deeply disturbed young man. He was mentally disordered, he had that excuse for what he did. And the question posed by the Mubarek family is this—Robert Stewart had that excuse, what excuse does the Home Office have?”

Mubarek’s uncle Imtiaz Amin said, “He died because of institutional murder. The report exposes a litany of failures from prison staff to senior management, all of which are culpable for the circumstances in which Zahid was placed in a cell with a known racist and psychopath. It was obvious what would happen.”

Robert Stewart’s problems were known from an early age. The report catalogues years of gross neglect on the part of the prison authorities in failing to provide him with any support, highlighting how many potential tragedies there are waiting to happen due to the lack of identification and treatment of mentally ill prisoners.

Homicides in custody in Britain are rare. Much more prevalent are suicides. In the period 1990 to 2001 there were 26 homicides compared to 759 suicides. The report states that this is why there is a greater focus towards prisoners at the risk of self-harm, but fails to ask the question why there are so many mentally ill prisoners.

Justice Keith points repeatedly to institutional failings, suggesting a system that, at the time of the murder at least, did not appear to function. Failings include incomprehensible levels of ineptitude or muddle when it came to simple matters like passing on security information about the dangers prisoners posed. The Mubarek inquiry found that prison reception officers very often had no clue about a new inmate, other than his name and most recent offences.

In his summing up, 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 was strongly implicated in the stabbing of another inmate.

“Stewart should have stood out from the crowd,” said the chairman. “Because of a pernicious and dangerous cocktail of poor communications and shoddy work practices, prison staff never got to grips with him.”

The report states that racism was at the heart of the inquiry, not simply because Stewart was a racist but “because of the need to explore whether explicit racism on the part of individual prison officers had been the reason for Zahid sharing a cell with Stewart in the first place or continuing to share a cell with him.”

The two previous investigations had found that the Prison Service in general and Feltham in particular were institutionally racist.

The report ruled out that there had been a “gladiatorial” aspect to the placing of such a known racist as Stewart in the same cell as Zahid, but stated, “the possibility of the practice existing cannot be excluded, even though no hard and fast examples of such a practice have been given.”

The inquiry discovered that explicit racism on the part of individual officers was found to be prevalent at Feltham from a series of focus groups held in 2001 by the Hounslow Racial Equality Council. For example, in the report, Black Minority Ethnic (BME) prisoners were called “monkeys” and “black bastards” and were told that “they should be sent back to their own country.”

Black prisoners were sometimes accused of racism themselves in order to divert attention from what was going on. And black staff would sometimes turn a blind eye to what was happening in order to fit in. The inquiry also discovered that the problems they faced throughout the Prison Service had been highlighted by a critical report from outside consultants commissioned in 1998, which contained disturbing findings about the blatant discrimination on the part of some white officers.

Whilst racism was undoubtedly a key aspect of the poisonous atmosphere that existed in Feltham at the time of Mubarek’s murder, the overriding reason for his death is a penal system that incarcerates thousands of young people as a solution to a much wider social crisis.

The same day that the report was published 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 the breaking point. It was also revealed that nine out of every ten prisoners have mental health problems.

In the case of Robert Stewart this was something that was repeatedly ignored. From an early age Stewart showed signs of being troubled—including fire setting and flooding. During his second year at secondary school, he was expelled for setting fire to the sports hall. At 13 years Stewart was given a supervision order for 12 months for arson. By the age of 17 he had amassed many convictions, mainly for burglary, joyriding and stealing from cars. In September 1997, Stewart entered the prison system and from that point on was almost continuously incarcerated in different institutions.

At no point did any of Stewart’s troubled past—including an early diagnosis that he had the makings of a personality disorder or a reported lack of care for his safety—reach his prison files. Letters were seen that were racist and threatening, but these were not monitored.

During his stay at Altcourse in 1999, Stewart was seen by a registered mental health nurse who noted, “In my opinion he has a longstanding, deep-seated personality disorder. He shows a glaring lack of remorse, feeling, insight, foresight or any other emotion. He has an untreatable mental condition and I recommend no further action. Only time will have any influence on his personality and behaviour.”

This conclusion was reached after a conversation with Stewart and without reading his security file detailing previous assaults on other prisoners and himself. Letters of Stewart were found after the murder written at the same time as he was interviewed by the nurse, referring to “niggers” and a “Paki bastard,” which also contained swastikas and the letters “KKK.”

Months later, during his first stay at Feltham, racist correspondence was found which should have been confiscated and the Race Relations Liaison Officer informed but which were instead given back to Stewart. He had a history of assaults on cellmates and had used cell furniture as weapons, but this had not been recorded.

In the search of Stewart’s cell after Zahid’s murder, weapons were found that Stewart had made from his table and bed. Some weapons had been found the day before the attack, but this was not reported and no further search was carried out, leaving Stewart at liberty to attack Zahid.

Feltham has been likened to a gigantic transit camp. Following a visit in December 1998, the chief inspector said, “This report ... is, without doubt, the most disturbing that I have had to make during my three years as HM Chief Inspector of Prisons. I have to disclose to the public [that] the conditions and treatment, of the 922 children and young prisoners confined at Feltham are in many instances totally unacceptable. They are, in many instances, worse than when I reported on them two years ago and reveal a history of neglect of those committed to their charge and a failure to meet the demands of society to tackle the problem of offending behaviour.”

The type of person attracted to a job that involves incarcerating young men, many of them mentally ill, and shunting them around like cattle is bound to include many right-wing and racist elements, people who have little or no empathy towards those with whom they are working.

The inquiry made a total of 88 proposals to tighten up procedures and establish responsibilities within the prison system. At the press conference given to launch its findings, Keith said, “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. They pointedly demand of government to think very carefully the point of prison and whether putting more people in jail achieves anything if nobody is prepared to put the money in too.”