Stepping off the No 2 bus at 9.46am on 22 July 2005, Jean Charles de Menezes made the kind of decision that is second nature to Londoners used to the unpredictability of the city's transport network.
Realising the Tube station he was heading for was closed, he jumped back on the bus he had just alighted and carried on towards Stockwell. That split-second, seemingly innocuous decision cost him his life.
Unbeknown to Mr de Menezes, the officers tailing him thought the U-turn was a "typical anti-surveillance" technique. It convinced them that the Brazilian was a terrorist – one of seven deadly errors the police made as they tried to hunt down four men who had tried and failed to detonate suicide bombs the previous day.
If any one of these mistakes had not been made, Mr de Menezes would not have been pinned down and shot seven times in the head.
1 MISSING FIREARMS OFFICERS
The first came the moment the Brazilian left his block of flats at Scotia Road, Tulse Hill, which by sheer bad luck was also home to one of the failed bombers, Hussain Osman. The plan, according to John McDowall, who was in charge of the operation and is now deputy assistant commissioner at the Metropolitan Police, was that firearms teams would be outside the flats and would stop and question everyone who left. But the order was never communicated to the armed officers. Instead surveillance officers, with no training in stopping and questioning suspects, staked out the flats alone.
2 PHOTOGRAPH MIX-UP
The surveillance team, SO12, had not been shown a quality picture of Osman, the man they were hunting. All they had seen was a faded passport photograph at briefing at Scotland Yard at 5am and not all of them had a copy at the scene. The jury decided that the failure of the police to provide better photographs to the officers contributed to Mr de Menezes's death.
3 ABSENT FROM POST
But it should not have been a problem. The SO12 officers had a video with them to record those coming in and out of the flats. That could have been cross referenced to the photographs of Osman and the obvious differences established. But the SO12 officer, codenamed Frank, failed to film the Brazilian as he walked past his surveillance van because he had put down his camera so he could urinate.
4 BOARDING THE BUS
A fourth opportunity to stop Mr de Menezes – without the need for lethal force – came after he had boarded the No 2 bus. At that point officers told the control room at Scotland Yard that Mr de Menezes was not the suspect they were looking for. The decision was made to stop the bus and search and question him. That plan was abandoned when the surveillance officers changed their minds and sent a message to the control room saying they thought that Mr de Menezes was the man they were looking for. Again, this was highlighted by the jury, who said that the police's decision not to stop Mr de Menezes before he got on any public transport led to his death.
5 'ANTI-SURVEILLANCE TRICK'
It was shortly after this that Mr de Menezes got off the bus at Brixton, before boarding again. It was this decision which meant the Brazilian, according to the family's lawyer Michael Mansfield QC, was "virtually dead".
6 ENTERING TUBE STATION
As he arrived at Stockwell station another opportunity to stop Mr de Menezes before he went underground was missed. The gold commander in the control room, Cressida Dick, said that Mr de Menezes was to be stopped from getting on the Tube "at all costs", yet surveillance officers said they were never asked to stop and search Mr de Menezes outside – something they say they would have been able to do if asked. The jury said that the police's failure to use surveillance officers to intervene also contributed to his death.
7 COMMUNICATION BREAKDOWN
At this point in the operation there was confusion about whether Mr de Menezes was positively identified to CO19 firearms officers by the surveillance team or not and debate over what information, in terms of identification, was given to the firearms officers before they shot Mr de Menezes. That problem was compounded by the "awful" reception on the police radios.
Firearms officer C12 admitted he could have missed important messages over the radio and told the inquest that the signal was weak, faint and fuzzy and would sometimes cut out altogether. The other officer who shot Mr de Menezes, codenamed C2, said he heard a surveillance officer over the radio say "this is definitely our man". He was backed up by his firearms team leader, codenamed Ralph, who also insisted he heard that phrase. But the surveillance officer who had been tailing the Brazilian, codenamed Ken, denied making such a statement. The jury also said that shortcomings in the police's communication system contributed to the Brazilian's death.
THE FINAL MOMENTS
It was this confusion that led Mr Mansfield to accuse the firearms officers of deciding to kill Mr de Menezes as soon as they entered the station.
Denying this, they gave a detailed account of what they say happened in the seconds before Mr de Menezes was killed. The pair ran into the station and vaulted the barriers before pulling out their Glock handguns and running down the escalator towards the train Mr de Menezes had boarded.
Making his way along the platform with his gun hidden behind his right leg, C12 was the first inside the carriage and was alerted to Mr de Menezes's presence by a surveillance officer, codenamed Ivor, who pointed at the seated Brazilian and shouted "He is here". As Mr de Menezes stood up, Ivor pinned him back in his chair as C12 and C2 shot him dead.
Both firearms officers were adamant that they shouted "armed police" and C12 said he only decided to shoot the Brazilian when he continued to walk towards him after the warning was shouted. But six witnesses who were sat in the same carriage as Mr de Menezes said they heard no warnings. One, Anna Dunwoodie, said she was "very, very clear" that there were no shouts of "armed police" from the officers before they opened fire. Ms Dunwoodie also said she had no recollection of Mr de Menezes standing up and walking towards the officers.
Despite the horrendous sequence of errors which ended in experienced police officers killing an innocent civilian, perhaps one of Scotland Yard's most startling admissions during the inquest was that a similar tragedy could happen again.
Deputy Assistant Commissioner McDowall told the court that it was "entirely feasible" such a scenario could repeat itself. Cressida Dick, who has since also been promoted to deputy assistant commissioner, said: I pray it doesn't happen, but it is possible that an innocent member of the public might die in circumstances like this."
The key players
*Sir Michael Wright
The coroner, a former High Court judge, was brought out of retirement, but his conduct has been controversial. On the first day, he told jurors: "This is a fresh approach. No one can tell you what to decide." But he enraged the De Menezes family when he told the jury they would not be allowed a verdict of unlawful killing because that would suggest the officers who shot the Brazilian "had committed a very serious offence, murder or manslaughter". He also told the jury not to consider the feelings of Mr de Menezes's mother, Maria Otone, saying: "I know your heart will go out to her. But these are emotional reactions, and you are charged with returning a verdict based on evidence. Put aside any emotion."
The Police Chief
Sir Ian Blair
The then Commissioner of the Metropolitan Police resigned from the force after the Mayor of London, Boris Johnson, made it clear he did not want him to continue. One of the reasons for Mr Johnson's lack of faith in the police chief stemmed from the criticism he received over the De Menezes shooting.
The man police were hunting when they mistakenly shot dead Jean Charles de Menezes is now serving 40 years for the failed 21 July 2005 suicide bomb attempts. Osman was among four men who tried to detonate devices on underground trains.
He is currently serving a 40-year jail sentence.
The Gold Commander on the day of the operation, and therefore ultimately in charge, Ms Dick has since been promoted to Deputy Assistant Commissioner, a decision which the De Menezes family described as a "slap in the face" for them. During the inquest she said that she thinks about the tragedy every day but that she would not have done anything differently. Ms Dick also said that she could not guarantee that the same thing would not happen again.