The jury at the inquest into the death of Jean Charles de Menezes has returned an open verdict.
The coroner also asked the jury to answer a number of key questions.
THE FINAL MOMENTS
"Did firearms officer C12 shout armed police?" ANSWER: NO
"Did Mr de Menezes stand up from his seat before he was grabbed in a bear hug by officer Ivor?" ANSWER: YES
"Did Mr de Menezes move towards C12 before he was grabbed in a bear hug by Ivor?" ANSWER: NO
These three questions were focused on the final moments of Jean Charles de Menezes' life as he was surrounded by undercover police officers on the London Underground.
The police officers on the carriage all maintain that a warning was shouted before two of their number opened fire. But passengers who were sitting in the same carriage say they heard no warning.
Rachel Wilson and her boyfriend Ralph Livock were sitting opposite told the inquest nothing was said to alert the man before shots were fired. One of the police officers who was approaching the carriage seconds before the shooting told the inquest he heard several verbal warnings.
In his evidence, officer C12, the first of two to fire, told the jury that he had no preconceived ideas as to how he was going to apprehend the man. He said he decided on firing fatal shots because Mr de Menezes stood up and moved towards a gun pointed at his head. He concluded that the man was about to detonate a bomb and had to be killed to protect others. A surveillance officer says he pinned Mr de Menezes down before the shots were fired.
A majority of the jury disagreed with this account. They said that they accepted that Mr de Menezes had stood up - but they did not believe he had moved forwards into the path of a gun.
THE WIDER CIRCUMSTANCES OF THE OPERATION
The coroner also asked the jury to consider which of these other factors, if any, contributed to the death. The Jury were allowed to answer "yes", "no" or "cannot decide".
"The pressure on police after the suicide attacks in July 2005." ANSWER: CANNOT DECIDE
"A failure to obtain and provide better photographic images of failed bomber Hussain Osman to surveillance officers." ANSWER: YES
"The general difficulty in providing identification of the man under surveillance in the time available." ANSWER: NO
"The fact that the views of the surveillance officers regarding identification were not accurately communicated to the command team and firearms officers. ANSWER: YES
The Metropolitan Police had never been in a situation like this. Already reeling from the 7 July attacks, the city woke up on 22 July knowing that four more suicide bombers were apparently on the run. Resources were, to put it mildly, stretched - but the jury could not decide whether this corporate pressure on the Met played a role in the tragedy.
In the space of a few hours, the team linked one of the bombers to a gym card found at the scene - and then from there to the block of flats which was also home to Mr de Menezes.
During the inquest, the jury heard that some of the police staking out the south London flats did not have a picture of the real suspect they were looking for. Several of the surveillance officers watching the flat had only seen a poor image of would-be bomber Hussain Osman.
Some officers had seen a picture of Osman from the gym membership card. But it was indistinct and over-exposed, making him appear to have lighter skin. Another picture from his wedding day, also found at a bomb scene, was clearer but had not been circulated to the same extent.
A majority of the jury concluded that this lack of a decent photograph of the suspect was a more important factor in the tragedy than the fact that nobody could identify Mr de Menezes himself. Crucially, the jury said the confusion over exactly what the surveillance teams thought about who they were following also played a part.
The surveillance officer closest to the flat, Frank, says he was relieving himself as Mr de Menezes he left the property - so he could not help with the identification.
The Operation Room noted that the subject matched Osman's description - and one officer said he was "possibly identical". Another surveillance officer told the operation room that a request for a percentage certainty was "ridiculous". By the time Mr de Menezes reached the Tube, Commander Cressida Dick said he had to be stopped from entering the system.
In his evidence, Charlie 2, the second shooter, told the jury that he had heard the surveillance officers positively identify the man over the radio.
"A failure by police to ensure that Mr de Menezes was stopped before he reached public transport." ANSWER: YES
Commander John McDowell, now the national co-ordinator of counter-terrorism operations, set the day's strategy in the early hours of Friday morning.
Surveillance officers would surround the property and would be supported by firearms teams. According to his plan, anyone leaving the flats would be stopped and discounted a safe distance away.
The idea behind this was to isolate the property and its occupants - but not to alert any bombers, in case they had explosives with them.
The property was in a cul-de-sac, making a quiet stop outside the front door impossible. Crucially, the front door was a communal entrance - no officer knew who was coming from which flat.
When Mr de Menezes left the flat, the firearms teams were not yet in position to stop the possible suspect, as set out in the plan. Within minutes, the Brazilian was on a bus and heading through London, with officers chasing - and trying to work out whether or not he was a threat.
"The innocent behaviour of Mr de Menezes increasing suspicion." ANSWER: NO
Officers who were following Mr de Menezes reported that he was nervous and acting strangely, standing on the bus stairwell and being twitchy. The electrician was, it later emerged, probably late for a job in north London.
When Mr de Menezes' bus reached Brixton town centre, he got off and walked in the direction of the Underground before suddenly doubling back and getting back on a bus. Surveillance officers are trained to look for people suddenly changing direction as a means of shaking a tail. In reality, the Tube was closed amid the security chaos across London.
"The fact that the position of the cars containing the firearms officers was not accurately known by the command team as firearms teams were approaching Stockwell Tube." ANSWER: YES
"Shortcomings in the communications system between various police teams on the ground." ANSWER: YES
"Failure to conclude at the time that surveillance officers could have been used to carry out the stop on Mr de Menezes at Stockwell." ANSWER: YES
Detective Chief Inspector Greg Purser was one of the senior officers involved in the stake-out. He told the inquest that officers were under "undue pressure" and facing an "appalling dilemma".
Decisions had to be taken in seconds or minutes - rather than leisurely in hours like in other investigations.
"We put undue pressure potentially on surveillance officers and then potentially on firearms teams," he said.
"We had an enormous task that morning. To try and take the operation to the level we would have liked would possibly have taken a day. We were trying to do it in a short time. It's extremely difficult.
"We ask so much of our surveillance teams and we ask much of our firearms teams
The coroner also asked the jury to answer a number of key questions.
THE FINAL MOMENTS
"Did firearms officer C12 shout armed police?" ANSWER: NO
"Did Mr de Menezes stand up from his seat before he was grabbed in a bear hug by officer Ivor?" ANSWER: YES
"Did Mr de Menezes move towards C12 before he was grabbed in a bear hug by Ivor?" ANSWER: NO
These three questions were focused on the final moments of Jean Charles de Menezes' life as he was surrounded by undercover police officers on the London Underground.
The police officers on the carriage all maintain that a warning was shouted before two of their number opened fire. But passengers who were sitting in the same carriage say they heard no warning.
Rachel Wilson and her boyfriend Ralph Livock were sitting opposite told the inquest nothing was said to alert the man before shots were fired. One of the police officers who was approaching the carriage seconds before the shooting told the inquest he heard several verbal warnings.
In his evidence, officer C12, the first of two to fire, told the jury that he had no preconceived ideas as to how he was going to apprehend the man. He said he decided on firing fatal shots because Mr de Menezes stood up and moved towards a gun pointed at his head. He concluded that the man was about to detonate a bomb and had to be killed to protect others. A surveillance officer says he pinned Mr de Menezes down before the shots were fired.
A majority of the jury disagreed with this account. They said that they accepted that Mr de Menezes had stood up - but they did not believe he had moved forwards into the path of a gun.
THE WIDER CIRCUMSTANCES OF THE OPERATION
The coroner also asked the jury to consider which of these other factors, if any, contributed to the death. The Jury were allowed to answer "yes", "no" or "cannot decide".
"The pressure on police after the suicide attacks in July 2005." ANSWER: CANNOT DECIDE
"A failure to obtain and provide better photographic images of failed bomber Hussain Osman to surveillance officers." ANSWER: YES
"The general difficulty in providing identification of the man under surveillance in the time available." ANSWER: NO
"The fact that the views of the surveillance officers regarding identification were not accurately communicated to the command team and firearms officers. ANSWER: YES
The Metropolitan Police had never been in a situation like this. Already reeling from the 7 July attacks, the city woke up on 22 July knowing that four more suicide bombers were apparently on the run. Resources were, to put it mildly, stretched - but the jury could not decide whether this corporate pressure on the Met played a role in the tragedy.
In the space of a few hours, the team linked one of the bombers to a gym card found at the scene - and then from there to the block of flats which was also home to Mr de Menezes.
During the inquest, the jury heard that some of the police staking out the south London flats did not have a picture of the real suspect they were looking for. Several of the surveillance officers watching the flat had only seen a poor image of would-be bomber Hussain Osman.
Some officers had seen a picture of Osman from the gym membership card. But it was indistinct and over-exposed, making him appear to have lighter skin. Another picture from his wedding day, also found at a bomb scene, was clearer but had not been circulated to the same extent.
A majority of the jury concluded that this lack of a decent photograph of the suspect was a more important factor in the tragedy than the fact that nobody could identify Mr de Menezes himself. Crucially, the jury said the confusion over exactly what the surveillance teams thought about who they were following also played a part.
The surveillance officer closest to the flat, Frank, says he was relieving himself as Mr de Menezes he left the property - so he could not help with the identification.
The Operation Room noted that the subject matched Osman's description - and one officer said he was "possibly identical". Another surveillance officer told the operation room that a request for a percentage certainty was "ridiculous". By the time Mr de Menezes reached the Tube, Commander Cressida Dick said he had to be stopped from entering the system.
In his evidence, Charlie 2, the second shooter, told the jury that he had heard the surveillance officers positively identify the man over the radio.
"A failure by police to ensure that Mr de Menezes was stopped before he reached public transport." ANSWER: YES
Commander John McDowell, now the national co-ordinator of counter-terrorism operations, set the day's strategy in the early hours of Friday morning.
Surveillance officers would surround the property and would be supported by firearms teams. According to his plan, anyone leaving the flats would be stopped and discounted a safe distance away.
The idea behind this was to isolate the property and its occupants - but not to alert any bombers, in case they had explosives with them.
The property was in a cul-de-sac, making a quiet stop outside the front door impossible. Crucially, the front door was a communal entrance - no officer knew who was coming from which flat.
When Mr de Menezes left the flat, the firearms teams were not yet in position to stop the possible suspect, as set out in the plan. Within minutes, the Brazilian was on a bus and heading through London, with officers chasing - and trying to work out whether or not he was a threat.
"The innocent behaviour of Mr de Menezes increasing suspicion." ANSWER: NO
Officers who were following Mr de Menezes reported that he was nervous and acting strangely, standing on the bus stairwell and being twitchy. The electrician was, it later emerged, probably late for a job in north London.
When Mr de Menezes' bus reached Brixton town centre, he got off and walked in the direction of the Underground before suddenly doubling back and getting back on a bus. Surveillance officers are trained to look for people suddenly changing direction as a means of shaking a tail. In reality, the Tube was closed amid the security chaos across London.
"The fact that the position of the cars containing the firearms officers was not accurately known by the command team as firearms teams were approaching Stockwell Tube." ANSWER: YES
"Shortcomings in the communications system between various police teams on the ground." ANSWER: YES
"Failure to conclude at the time that surveillance officers could have been used to carry out the stop on Mr de Menezes at Stockwell." ANSWER: YES
Detective Chief Inspector Greg Purser was one of the senior officers involved in the stake-out. He told the inquest that officers were under "undue pressure" and facing an "appalling dilemma".
Decisions had to be taken in seconds or minutes - rather than leisurely in hours like in other investigations.
"We put undue pressure potentially on surveillance officers and then potentially on firearms teams," he said.
"We had an enormous task that morning. To try and take the operation to the level we would have liked would possibly have taken a day. We were trying to do it in a short time. It's extremely difficult.
"We ask so much of our surveillance teams and we ask much of our firearms teams