Zahid Mubarek Inquiry

A non-statutory public inquiry into the murder of Zahid Mubarek at Feltham Young Offenders Institution on 21st March 2000

Terms of Reference:

“In the light of the House of Lords judgement in the case of Regina v Secretary of State for the Home Department ex parte Amin, to investigate and report to the Home Secretary on the death of Zahid Mubarek, and the events leading up to the attack on him, and make recommendations about the prevention of such attacks in the future, taking into account the investigations that have already taken place- in particular, those by the Prison Service and the Commission for Racial Equality.”

Chair: Mr. Justice Keith

Panel Members (advisers): Lutfur Ali, Bobby Cummines, Alastair Papps CB


Establishment: 29th April 2004

Hearings (including seminars held for brainstorming on key issues in advance of submission of
the final report): September 2004- October 2005

Link to download report:

Summary of report’s conclusions:

The report made 88 recommendations for reducing the risks of violence in cells:


A brief outline:


The principle which underpins the Prison Service’s decency agenda is that offenders go to prison as punishment, and not for punishment. Prisoners have to conform to so many rules regulating their behaviour when out of their cells that they need their personal space when in them. That is why the elimination of enforced cell-sharing should remain the goal of the Prison Service, and its achievement should be regarded as a high priority. The Prison Service should set a date for realising this objective, and further funds should be allocated to it to enable more inmates to have their own cells. But while prisoners continue to share cells, an unconvicted prisoner should never share with a convicted prisoner, unless the unconvicted prisoner specifically consents to do so. And attempts should be made to match prisoners with cellmates with whom they will be more at ease, recognising that many people will be more comfortable sharing with those who come from an ethnic or religious background they find it easier to identify with. The Prison Service should publish guidelines to assist officers in allocating those prisoners who have to share a cell and in handling requests by prisoners to share with a particular person.

Mixed wings

Some wings hold unconvicted and convicted prisoners together, and sometimes young offenders and adults as well. Wings holding convicted and unconvicted prisoners should be kept to a minimum, and should only be used when there is no operational alternative. But holding young offenders and adults on the same wing, as happens in some prisons, is an interesting initiative, and research should be done on whether the disadvantages outweigh the advantages.
Reducing risks in cells
The debate over bolted-down metal furniture, which cannot be broken up and used as weapons, and free-standing wooden furniture, which gives cells a feeling of homeliness, continues. The Prison Service is currently trialling bolted-down furniture made from white wood. Its popularity should be assessed. In addition, the opportunities for officers to find concealed weapons in cells need to be increased. That will require exploring the balance to be struck between less frequent fabric checks and more frequent full cell searches.
Although not limited to violence in cells, all establishments are now required to have their own strategy for combating violence. The strategy should be used as a vehicle to encourage prisoners to feel that they have a stake in making their prison safe – in particular, by encouraging them to think that they have let other prisoners down if they resort to violence, and by letting them have their say in the running of their prison through prisoner councils.

The flow of information

A new computerised system for the flow of information – the National Offender Management System or NOMIS – is due to be implemented shortly. It will eliminate many of the problems associated with the current procedures which are predominantly paper-based. Its most significant limitation is that it will not initially include security information. The report contains a number of recommendations for the sharing of security information, for training in the use of NOMIS, and for transitional arrangements until NOMIS is fully operational. Every establishment should appoint an officer not below the rank of governor to be responsible for the oversight of the flow of information. In addition, the handbook giving guidance on how to complete the prisoner escort record needs to be revised, and officers who are tasked to complete it should be instructed on how to do so.

Assessing risk

The cell-sharing risk assessment is the principal tool now used for identifying the risks which prisoners pose to any cellmate. The form has been revised since its introduction in the aftermath of Zahid’s murder, and the report makes a number of recommendations for improving and reviewing the assessment. Other tools have applications which can be used for assessing risk. They are OASys and MAPPA. The core function of OASys, which stands for Offender Assessment and Management System, is to identify how prisoners can best be managed in order to protect the community from them when they are discharged and to reduce the risk of them re-offending. MAPPA, which stands for Multi-Agency Public Protection Arrangements, requires the Prison Service to work with other agencies to manage the risks posed by dangerous offenders when they are released. OASys has a function for identifying the risk of harm which prisoners pose to others. And the Prison Service has introduced a risk management model for establishments to adopt for the management of those prisoners to whom MAPPA applies. The report contains recommendations for the wider use of these tools.
Skills in prison work

Two of the key attributes required of a prison officer were at the heart of the Inquiry’s work. The first is the officer’s ability to notice what is happening on the wing. Their antennae must be sufficiently attuned to the complex rhythms of prison life. They must be able to put themselves in the prisoners’ shoes and see things from their perspective. The second is the officer’s ability to earn the respect of prisoners on the wing. It is not enough for inmates simply to trust an officer to put them on report only as a last resort, not to be too rigid in their enforcement of rules, and to use their discretion fairly and humanely. Prisoners must also realise that they can confide in officers if they want to, knowing that they will get sound and disinterested advice and that their confidentiality will not be compromised. The report makes recommendations about the basic training officers undergo and about how the role of personal officer can be improved. The report also makes recommendations for building on the work which the Prison Service has already done to encourage officers to rise above misplaced loyalty to their colleagues and report wrongdoing when it occurs.

Mentally disordered prisoners

The care of prisoners with mental health problems was unacceptably poor at the time of Zahid’s murder. They were shuffled between the segregation unit if they misbehaved and the healthcare centre where they were dumped if they were difficult to manage. There they were housed alongside other inmates who had been classed as vulnerable, often in banks of cells with little or no recreational association. Two factors contributed to this state of affairs. The first was the high level of psychiatric morbidity in the prison population. The second was that mentally disordered prisoners did not represent a static group. Very many of them were serving relatively short sentences, and those serving longer sentences were often moved from one establishment to another in the hope that a change of scene might calm them down.
Much work has been done in the last few years to improve the lot of such inmates. All prisons now have multi-disciplinary mental health in-reach teams. The report contains recommendations for improving the ways in which mentally disordered prisoners can be identified, identifying the risks they pose, improving mental health awareness training for officers, managing such inmates on the wings, and improving the procedures for sharing information about such prisoners.

Racism and religious intolerance

It was not possible for the Inquiry to embark on an exercise similar to that carried out by the CRE to determine whether the scourge of institutional racism has now been eradicated from the Prison Service. A five-year action plan has been produced by the Prison Service working in partnership with the CRE, with the CRE monitoring the extent to which race equality is being implemented in prisons. And in December 2005 the Inspectorate published a review of race relations in prisons, in which it highlighted what it saw as the key areas which needed to be developed in order to implement the action plan effectively.
But the Inquiry was still able to make a number of recommendations of its own, relating to the training of officers to improve their awareness of how BME prisoners see things, the role of race relations liaison officers, the publication by each prison of a race equality scheme, and the investigation of complaints of racism. One of the Inquiry’s recommendations is that complaints of racism should follow the definition of a racist incident adopted by the Stephen Lawrence Inquiry. Another is that the Prison Service, the Inspectorate and the CRE should consider whether there is a need for the investigation of complaints of racism – and other serious complaints for that matter – to be carried out by an independent body, or at least to be carried out with a strong independent element built into the process.
The increase in the number of Muslim prisoners, and the suggestion that they are experiencing the backlash of what many observers believe to be an increased level of Islamaphobia in society in the wake of recent terrorist outrages, highlighted the fact that the definition of institutional racism adopted by the Stephen Lawrence Inquiry focused on discrimination and prejudice because of a prisoner’s colour, culture or ethnic origin. The definition did not refer to the person’s religion. Without suggesting in any way that the Prison Service should be regarded as institutionally infected with religious intolerance, thought should be given by the Home Office to recognising the concept of institutional religious intolerance, suitably adapting the Stephen Lawrence Inquiry’s definition of institutional racism. The report also recommends increasing the pastoral role of Imams in prison.


The focus of the Inquiry has been on violence in prisons, specifically attacks on prisoners in their cells. But one of the recurring themes throughout the report is that such attacks are more likely to occur in prisons which are performing badly. Many factors contribute to a prison’s poor performance, and it was, of course, not possible for an inquiry of this kind to address them all without becoming an investigation into a root and branch reform of the Prison Service, going far beyond its limited terms of reference. Having said that, the report considers the factors which contributed to Feltham’s degeneration into an establishment which was performing badly and in which prisoners were therefore more likely to be exposed to attacks by their cellmates. There are many lessons to be learned from Feltham’s decline, but the most important is that population pressures and under-staffing can combine to undermine the decency agenda and compromise the Prison Service’s ability to run prisons efficiently. When that happens, it is important for the Prison Service to tell ministers that, and they should listen very carefully to what the Prison Service has to say. The Prison Service will no doubt continue to strive to do the best it can with the resources it has. But if those resources are simply not enough, and the prison population continues to increase, ministers must find the extra money to enable it to deliver a proper regime for the prisoners it is required to hold. It may not be a vote-winner, but if more resources are needed to ensure that our prisons are truly representative of the civilised society which we aspire to be, nothing less will do.”