An inquest jury yesterday returned a verdict of lawful killing after hearing how two firearms officers opened fire on David Howell because they feared he was about to kill his hostage, the store manager.
The six-day hearing was also told that Mr Howell, 40, an out-patient, had missed his medication for two days, that hours before the shooting a locum GP had examined him, and that the hospital where he received treatment had been told of his unstable behaviour.
The family's lawyer, David Simon, of solicitors Glaisyers, said relatives were "concerned and angry" about events leading up to Mr Howell's death at the Co-op store in Washwood Heath, Birmingham, on 20 November last year.
"This was clearly an avoidable tragedy. It seems that there were some great bigs holes in the overall care that David Howell received," said Mr Simon. He and the family would be studying the evidence heard at the inquest and said there was a "distinct possibility" of civil action against one of the agencies involved, such as the doctor, social services or North Birmingham Mental Health Trust.
The dead man's mother, Marion Howell, said that her son should have been sectioned [under the Mental Health Act] hours before the tragedy after a doctor advised the hostel manager to have him taken into court.
Mr Howell first came to the attention of psychiatrists 1983 when he threatened his motherwith a knife. For the last 10 years he had lived in a hostel in Erdington, Birmingham, and been an outpatient at Highcroft Psychiatric Hospital.
After failing for two days to go for his medication, the hostel manager reported his disturbed condition to the hospital and said he needed treatment. He was examined by a locum doctor who tried to get him committed voluntarily, but the patient refused.
Mr Howell later barricaded himself in his parents' home in Ward End, Birmingham, but managed to escape after police were called. He then went to the store where he held manager Paul Murray hostage.
The jury saw a security video showing Mr Howell's last moments and heard evidence from the officers who fired a "simultaneous" volley of five 9mm rounds. Mr Howell was pronounced dead at the scene. Two separate inquiries by the Police Complaints Authority and the Metropolitan Police found no case to answer against either officer, PC Stephen Veal and PC Stuart Baker.
Birmingham Health Authority, which is holding an inquiry into the case, expects to publish its report within two weeks.