Taxi driver Derrick Bird unlawfully killed the 12 victims he shot dead before he committed suicide, an inquest jury ruled today.
The 52-year-old went on a 45-mile shooting rampage around West Cumbria on June 2 last year and then turned his rifle on himself.
A jury of six women and five men sitting in Workington, Cumbria, returned the verdicts after listening to four weeks of harrowing evidence.
Bird shot his own twin brother David several times, went on to gun down solicitor Kevin Commons, 60, and then drove to a taxi rank in Whitehaven town centre where he blasted taxi driver Darren Rewcastle, 43, at point-blank range.
The troubled father-of-two then randomly targeted strangers as he travelled out of town and killed mother-of-two Susan Hughes, 57; retired security worker Kenneth Fishburn, 71; retired Sellafield worker and part-time mole-catcher Isaac Dixon, 65; retired couple James and Jennifer Jackson, aged 67 and 68; farmer and rugby league player Garry Purdham, 31; estate agent Jamie Clark, 23; retired Sellafield employee Michael Pike, 64; and pensioner Jane Robinson, 66.
He repeatedly stopped his grey Citroen Picasso, called victims over as if to ask the time and then simply shot them in the face.
Bird also injured 11 others in his shooting spree in Lamplugh, Frizington, Whitehaven, Egremont, Gosforth and Seascale before he was found dead in woodland near Boot - more than three hours after police discovered his first known victim.
Days before, an increasingly agitated Bird, of Rowrah, near Frizington, was wrongly convinced he was going to prison because he owed up to £25,000 in unpaid tax.
That fear turned to paranoia as he believed David Bird and Mr Commons were conspiring to set him up to be arrested.
His obsession with going to prison developed amid a culture of backbiting and wind-ups at the taxi rank where he worked in Duke Street, Whitehaven.
Mental health experts told the inquests he was "accumulating the aggrievances" and never forgot a slight.
He was said to have become mentally ill over the preceding five weeks and had obvious delusional beliefs in the three days before June 2.
Psychologist Dr Adrian West said Bird was a "bitter, resentful and depressed man, blaming the rest of society for his failures".
His delusions enabled him to "enact vengeful, retaliatory fantasies" and to seek notoriety in causing grief to his community "believing that people would never forget him".
Weeks before the shootings, he was heard to comment that "Whitehaven will be as famous as Dunblane".
But he chose his victims discriminately and knew what he was doing was wrong, the jury heard.
An independent review of how Cumbria Constabulary responded on the day ruled that police could not have stopped Bird any sooner.
Luck was against them on several occasions but Bird was "incredibly difficult" to track with his extensive knowledge of country roads and amid the confusion caused by the random shootings miles apart in such a short space of time.
A similar review found there were no irregularities in how Bird obtained licences to use the 12-bore sawn-off shotgun and .22 rifle he used in the killings.
The jury came back with its verdicts within 90 minutes of being sent out to start its deliberations.
West Cumbria Coroner David Roberts praised the jurors for their hard work in listening to and processing the four weeks of evidence, "much of it heartbreaking".
Referring to the families of the victims, to whom he gave his personal condolences, he said: "I would like to express my appreciation to the families for the quiet dignity they have showed and the moving tributes to their loved ones who were snatched from them that sunny summer's morning.
"Their loss is beyond comprehension. I hope that in some small way this inquest, in examining the facts, can present some form of closure.
"We should also not forget the children of Derrick Bird who were caught up in the actions of June 2."
Mr Roberts used his discretion to raise concerns about three matters which he will address in letters to Home Secretary Theresa May and Health Secretary Andrew Lansley.
He said the inquest had heard of three problems involving the police and ambulance service on the day - the near-collapse of the police airwave system, communication problems between the police and ambulance service at strategic level, and the issue of ambulance staff and paramedics needing to wait for a scene to be declared safe before they could tend to injured parties.
He said: "I think it was clear during the course of the inquest the adequacy of the airwave system was thrown into doubt in relation to its capacity and the organisation of use.
"It was up to 97% capacity and it does not need a leap of imagination to think that may have crashed. It seems to me that is an area of national concern."
Mr Roberts added that there were problems at strategic level between both of the emergency services but he did not believe it was a local issue as such and that again it seemed to be of national importance.
Thirdly, he mentioned North West Ambulance Service's policy of staff going to a safe rendezvous point and waiting for a scene to be made safe before they attended a dangerous incident.
"We had a problem where the police did not know of the protocol," he said. "Clearly there are issues regarding the question of safe rendezvous points and whether these are going to be practicable in similar circumstances involving mass fatalities.
"The fact of this case is those who died did so almost immediately and no paramedic or ambulance support was going to save their life.
"Those who were injured had injuries which were not immediately life-threatening.
"It does not take a leap of imagination to see a situation where, if this incident was replicated, it may be the ambulance service or paramedic assistance would be needed for be someone to survive who otherwise would have died."
In summary of the evidence from mental health experts that Bird had accumulated his grievances over the years, Mr Roberts said: "What Derrick Bird's case does show is that our interaction with our fellow human beings and the way we behave can have consequences."
In a statement, Cumbria Chief Constable Craig Mackey said: "Our condolences and deepest sympathies are with the families and friends of the 12 victims and those who were seriously injured in such tragic circumstances on the 2nd of June last year.
"We welcome the coroner's decision to make three recommendations at a national level and look forward to contributing to these being addressed nationally.
"I commissioned two separate reviews into Cumbria Constabulary's actions both prior to and during the 2nd of June.
"You have heard the detailed evidence from the reviews completed by Assistant Chief Constable (Adrian) Whiting and Assistant Chief Constable (Simon) Chesterman, and we take on board all of their observations and recommendations.
"Both reviews have confirmed that there was nothing that Cumbria Constabulary, or any of our officers, could have done either before or during the events of 2nd June to stop Derrick Bird any sooner.
"The inquests have heard 18 days of harrowing and chilling evidence of what took place on the 2nd of June. It highlighted the scale and complexity of what happened in West Cumbria.
"Witnesses who gave evidence during the inquests recalled the outstanding response by members of the public who showed real community spirit. Thank you all for your support that day.
"I am reassured by the dedication and bravery of my police officers and staff who worked so hard to keep people safe.
"For some, lives will never be the same and I know that, as a constabulary, we will never forget.
"However, our focus will remain on providing support to the victims, their families and the people of West Cumbria and we will continue to do all we can to help the community to establish a new sense of 'normality' and try and move on from the tragic events of the 2nd June."
In a statement, director of emergency service for North West Ambulance Service Derek Cartwright said: "We cannot comprehend the feeling of loss experienced by the victims' families and we would like to express our sincere condolences during what must have been a very difficult time.
"Our thoughts also go to those who were injured and hope that they find the strength to overcome such a terrible event.
"The role of the ambulance service is to save life and I stand here proud of every one of the ambulance staff who were involved in this tragedy.
"It is my belief that the ambulance staff fulfilled their duties to the best of their ability, but we accept that, as often happens in cases such as this, there are lessons to be learned, albeit on a national level, and we need to reflect on the helpful comments made during this inquest."