Published last week, the commission's report refers to "systemic failures beyond useful interventions by individual members of staff" and "poor choices made by individual members of staff" at the west London institution.
Trevor Phillips, chair of the commission, said: "Each of the 20 failures allowed Robert Stewart to progress towards his murderous destination.
Had any of them been dealt with, this killing would probably have been avoided."
An internal inquiry had earlier recommended that no staff should face disciplinary action.
Phil Wheatley, director-general of the Prison Service, said he recognised that Mubarek's death was a result of a failure by the service.
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