By 2014 things on the wings of Liverpool's privately-run Altcourse prison had gotten so bad the men serving their sentences there felt compelled to carry a weapon "at all times".
The volatile situation, especially tense in the troubled Valentines Green wing, exploded into tragedy on November 14 that year - claiming the life of 35-year-old dad-of-two Darren Ashcroft.
It is telling that when Mr Ashcroft was killed, stabbed to death in his cell by fellow inmate Keir Michael, he was carrying a knife in the pocket of his prison shorts.
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In the cell he shared with another man, Terry Roderick, police later found a knuckleduster and three razor blades.
Mr Ashcroft and Mr Roderick never had chance to get those weapons to defend themselves when Michael walked into their cell, asked for a bag of sugar and without warning plunged a metal spike into Mr Roderick's face.
Mr Ashcroft, who was around a week from release according to his family, tried to step between the two men to protect his cellmate only for Michael to plunge the spike into his chest.
Michael, then 41, was convicted of manslaughter and wounding with intent after a trial at Liverpool Crown Court, and was jailed for life with a minimum term of eight years in May, 2015.
During Michael's trial, lawyers for both the prosecution and defence painted a chilling picture of a dysfunctional, violent and lawless prison where weapon carrying was the norm.
After Mr Ashcroft's death, police searching the wing found 22 offensive weapons including knives, a broken grinder blade, razor blades melted into a Kinder Egg and sharpened rulers.
Ian Morley, defending Michael, told the court: "He habitually carried the spike, as did many, for self-preservation in the lawless circumstances of Altcourse prison.
“Even the unfortunate Mr Ashcroft had a knife in his pocket and there were three razor blades and a knuckle duster in Cell 28.
“The lawlessness was due to the extremely poor management of the jail, where unreported cuttings happened left, right and centre."
What the court heard was reflected in what Darren's heartbroken sister, Aintree Hospital nurse Kerry Ashcroft, found out after his death.
She told the ECHO: "The amount of weapons that were found there; when we heard the extent it was like wow; how do you miss that?
"What prisoners have told me was in there you're looking after yourself. Everyone had a weapon; Darren had a weapon.
"But he was not interested in getting into fights, it was never used.
"From what other prisoners who got in touch have told me, Darren was a lover not a fighter.
"Darren didn't do conflict. If trouble came to him he knew how to handle himself and he would look after himself but he was not the type of guy to go looking for it."
It is true that over the course of 2013 and 2014, something was happening in the UK prison system on a national level.
Synthetic psychoactive drugs, or 'legal highs', had been flooding jails, particularly the drug known as 'Spice'.
The effects of the drugs themselves are known to cause serious health problems, but more of a concern for the prison service was the secondary impact.
As one prison manager told a court, "drugs bring gangs, gangs bring debt and debt brings violence".
Despite these issues becoming a problem in most prisons, things were particularly pronounced at Altcourse.
It would take a further seven years for Mr Ashcroft's family to learn the full extent of how the situation was allowed to get so bad - too late for his mum, Vera Ashcroft, who died of cancer before an inquest could be held.
The option of a full jury led inquest was turned down, but the family applied for a judicial review and a High Court judge agree to overturn that decision.
The covid pandemic caused further delays, but proceedings finally got underway at Gerard Majella Courthouse last month where assistant coroner Joseph Hart presided over a nine day inquest.
What emerged was a picture of an overstretched, underdeveloped security set-up which failed to asses risks to the lives of prisoners.
It emerged Altcourse staff had received intelligence about 'shanks' being hidden around the wing by prisoners who were creating them in the prison's workshop.
Specific intelligence was also received about Michael, who had threatened to harm fellow inmates or staff and had reportedly walked into a younger prisoner's cell threatened to stab him if "drugs and phones" were not handed over.
Various security managers, the then deputy director of the prison Sean Oliver and then director Bob McCombe revealed how even a damning inspection by government watchdog HM Inspectorate of Prisons (HMIP) in June failed to stop the lawlessness plaguing the wings.
The HMIP report, which was made available to prison bosses shortly after the inspection, described how the prison "seemed calm" on first appearances.
But inspectors wrote: "However, under the surface levels of assaults against both prisoners and staff, bullying incidents and fights were high and rising sharply.
"There had been 38 serious assaults in just four months before the inspection.
"Gang issues and the availability of drugs, particularly new psychoactive substances (so-called ‘legal highs’ such as ‘Spice’ and ‘Black Mamba’), were a significant factor in much of the violence, and these had also been the cause of regular hospital admissions.
"The prison’s response to this was inadequate at both strategic and operational levels. The prison had been slow to react to the increasing levels of violence which, to some extent, had become normalised.
"The security strategy did not make the necessary links between drugs, gangs and violence and little had been done to address the disproportionate number of young adults involved in violent incidents."
Prison bosses told the inquest jury they had simply not considered expanding the prison's under pressure three strong intelligence analyst team - who were dealing with more than 70 security reports a month.
On February 3, the jury concluded that poor analysis of internal intelligence reports, lack of communication, staffing shortages and "unsatisfactory" assessments of threats to life "possibly contributed" to the fatal incident.
Jurors also concluded the prison was slow to react to concerns.
Mr Ashcroft's death was recorded as unlawful killing.
G4S said it had no further comment on the inquest.
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