The Queensland coroner has found a young prisoner should not have been in the same facility as a murderous inmate, who savagely killed him in an unprovoked and apparently random attack.
Coroner Terry Ryan also found Leonard Raymond Gordon's death could have been prevented if equipment had not been left in a prison exercise yard.
Gordon, 22, was murdered in a Maryborough Correctional Centre exercise yard on October 9, 2012, in a surprise, violent attack with a metal handlebar just two days before he was due to be released.
That inmate, Gregory George Glebow, was already serving time for murder and told a prison psychologist he committed the violent act so as to be moved out of the MCC, where he had been involved in ongoing conflict with fellow prisoners.
An offer had been made to Gordon to be moved to a low-security facility, but he wanted to remain close to his family.
That, ultimately, proved to be a decision that had fatal consequences as he found himself in an exercise yard with Glebow as part of a routine prisoner movement.
Gordon, who suffered a fatal blow to his head from behind, was simply in the wrong place at the wrong time, Mr Ryan found in a report handed down this week.
It followed an inquest he held in June and August last year.
"The failure to remove loose items of metal exercise equipment was an oversight that led to a catastrophic result," Mr Ryan said.
Gordon was in jail after a positive urine test resulted in him breaching the conditions of his parole in relation to an intensive correction order.
He had previously served short periods in custody on property-related offences.
Glebow, meanwhile, was sentenced to life imprisonment after he bashed Brisbane father Michael Greer to death in March 2000, after mistakenly assuming he was gay.
While Gordon was a slender man, with a frame less than 60 kilograms, Glebow was a feared prison "head" who had beaten and raped fellow inmates, the inquest heard.
"It is less than ideal for a slightly built and young nonviolent prisoner like Mr Gordon to be accommodated in the same unit as a prisoner with a known history and potential for violence like Mr Glebow, who was free to associate with all other prisoners within the unit," Mr Ryan said.
It was during a routine search of cells, during which prisoners were housed in an exercise yard, that Glebow took the opportunity to follow through with his plan to kill a fellow inmate.
The attack was captured on CCTV. Gordon was struck at 2.43pm on August 15, 2012. Fourteen minutes later, the 22-year-old was declared dead.
"While (Glebow) clearly had the intent to carry out an act to avoid being moved to Unit S4, it appears that he acted in an opportunistic fashion and it is possible that the death might have been prevented if an officer was located in the exercise yard, and supervising a smaller number of prisoners," Mr Ryan said.
"I consider that the first aid Mr Gordon received after the attack was of a suitably high standard. Once he was found it is highly doubtful anything could have been done that would have prevented his death."
The inquest heard testimony from prison psychologist Samantha Newman, who interviewed Glebow in March and May last year about the circumstances of Gordon's death.
"Mr Glebow told Ms Newman that Mr Gordon was not in any way deliberately targeted by him in terms of particular selection as the chosen victim," Mr Ryan said.
"He had identified another prisoner that he could assault but that prisoner was not in the unit at the relevant time.
"This led to him ruling out other people that he was associated with, and it appears that Mr Gordon was simply a prisoner available to him to inflict harm upon at the relevant time."
Mr Ryan did not make any new recommendations as a result of his inquest, but did note several recommendations that rose from an investigation in to the incident from the Office of the Chief Inspector were "directly relevant" to the issues he considered.
One of those recommendations was that Queensland Corrective Services "take steps such that there are greater incentives for prisoners who do not wish to go to low-custody centres in order to continue to have contact with friends and family from the local area".