As relatives quietly wept and survivors sat with heads bowed, a coroner yesterday ruled that none of the 52 victims of the 7 July bombings could have been saved by a faster response from rescuers, but MI5 and the emergency services need to improve their procedures as the terrorist threat continues.
Lady Justice Heather Hallett brought an end to five months of evidence on the worst atrocity on British soil by concluding that each of the dead had been unlawfully killed in a "dreadful act of terrorism" and no "failings on the part of any organisation or individual caused or contributed to any of the deaths".
The core findings, announced to a courtroom packed with 70 family members of those murdered by four Islamist extremists in a morning rush-hour in 2005, disappointed those who believed the testimony that was provided in systematic and often harrowing detail at the Royal Courts of Justice had justified placing some of the blame for the killings on the Security Service and the response of emergency services.
Instead, Lady Hallett paid tribute to the "quiet dignity" of the bereaved families, and outlined nine improvements in the protocols of MI5, the 999 services and London Underground which she said "may save lives". Despite testimony that the fatally injured victims of Mohammed Sidique Khan and his three co-conspirators waited in some cases for more than an hour before emergency workers reached them, the coroner said her "sad conclusion" was: "I am satisfied on the balance of probabilities that each of them would have died whatever time the emergency services had reached and rescued them."
The judge recorded her verdicts of unlawful killing and asked for the names of the victims to be read out. It was an act which served as a reminder of the diverse backgrounds, across many faiths and countries, of those killed: "James Adams", "Benedetta Ciaccia", "Shahara Islam", "Anat Rosenberg", "Laura Webb", "Gladys Wundowa".
Lady Hallett said the proceedings had provided answers to many of the questions about the events that led up to the 7 July attacks and what happened on the day, bringing to light new material about the bombings of three London Underground trains and a double-decker bus. But she said shortcomings, from the chaos caused at Kings Cross station by the lack of a rendezvous point for 999 workers to the lack of availability of stretchers, needed to be addressed.
A separate 65-page document, drawn up under the so-called Rule 43 which allows coroners to raise issues posing an ongoing risk to life, described in detail the MI5 surveillance operations and tip-offs prior to July 2005 that led to officers photographing Khan, the ringleader of the plot, and his 22-year-old second-in-command Shahzad Tanweer, at a motorway service station in February 2004.
Lady Hallett emphasised the massive burden the Securit Service faced at the time and said it had been right to prioritise the investigation of other plots, such as the successful interception of plans to build fertiliser bombs, rather than dedicate stretched resources to investigating Khan and Tanweer, who were recorded meeting those suspects.
But the coroner also criticised MI5 for some of its procedures, including the way in which in 2004 it showed a badly cropped picture of Tanweer to an informant, Mohammed Junaid Babar, who had met Khan in a terrorism training camp and might have identified the future bomber. Lady Hallett described the cropping as "dreadful" and said Witness G, the senior MI5 officer who gave evidence, had "no satisfactory explanation".
Marie Fatayi-Williams, whose son Anthony was killed on the bus, called for a public inquiry and said the inquest findings had "brought us only to the foothills of the issues we need to look at". But Lady Hallett formally ruled out re-opening the inquests into 30-year-old Khan, Tanweer and the two other bombers, Hasib Hussain, 18, and 19-year-old Jermaine Lindsay.
Outside the court, Rosemary Mayes, 67, whose son James was killed on the Piccadilly Line, said: "Every time the list is read out, the reality that he is dead hits us."
*Throughout the five months of evidence heard by the 7 July inquests, Lady Justice Hallett played the role not only of coroner but also arbiter of the stories of suffering and heroism recounted to her courtroom in forensic and harrowing detail.
The 61-year-old Court of Appeal judge provided not just the judicial rigour required for the proceedings but also a human response, as victims of the 2005 bombings broke down under the burden of their recollections and passengers-turned-rescuers described their selfless actions in coming to the aid of the dying and grievously injured.
Survivors and relatives praised her for ensuring each of the 309 witnesses felt they had contributed to the proceedings, thanking them for their testimony and ensuring they were given time whenever their emotions became overwhelming. On more than occasion, she paid tribute to those in the witness box.
Philip Duckworth, who was blinded in one eye by a shard from Aldgate bomber Shehzad Tanweer's shin bone as his device exploded just three feet from him, was told: "You have reduced us to silence. It is an astonishing story.
"The idea that you could be so close to the bomb, be blown out of the carriage and still be here to tell your story is amazing."
*Photos shown by MI5 to "human sources" must be high quality.
*Better recording by MI5 of decisions on assessing targets.
*Improved inter-agency training for 999 staff and London Underground.
*Overhaul of procedures to announce a major emergency on the Tube network.
*Establishment of rendezvous points at all Tube stations for 999 services.
*Improved procedure for informing 999 staff that electric current has been switched off.
*First aid kits to be considered for Underground train carriages.
*Better training for ambulance staff and medics assessing mass casualties.
*Public funding for the London Air Ambulance.