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25 March 2011
Last updated at 11:55 ET
The 12 people shot dead by Cumbria gunman Derrick Bird were unlawfully killed, an inquest jury has found.
A verdict of suicide was given in the case of the 52-year-old taxi driver.
He shot himself in woodland on 2 June following a 45-mile rampage through west Cumbria, in which 11 people were also injured.
After the verdicts were delivered the coroner criticised the national policy which prevented ambulance crew entering a scene until it was cleared by police.
David Roberts said he would be writing to the home secretary about the issue.
The four-week hearing in Workington had heard details of the shootings and evidence about Bird's state of mind in the run-up to the day.
The deaths were examined in chronological order, with more than 70 witnesses giving evidence.
The jury of six woman and five men heard how Bird had become increasingly agitated in the days leading up to the shootings.
It emerged that he owed £60,000 back tax - relating to his years as a self-employed taxi driver - and had sought the help of his twin brother, David, and a solicitor friend.
However, he became convinced that they were "stitching him up" and he would end up in jail, the inquest was told.
He also felt that his taxi-driver colleagues were "winding him up" by playing practical jokes on him.
One of his friends told the inquest that Bird had said: "Whitehaven will be as famous as Dunblane, you'll see soon enough."
A consultant forensic clinical psychologist asked by police to work out Bird's motives, described him as "a bitter, resentful and depressed man, blaming the rest of society for his failures" and said he was suffering from a "delusional disorder".
The first victim was Bird's twin, who was shot 11 times.
He then killed 60-year-old solicitor Kevin Commons, whose help he had sought over back tax, before driving into Workington.
From there he shot colleagues and strangers he passed at random, sometimes calling them over to his car before shooting them, in many cases in the face.
The other victims were: Darren Rewcastle, 43; Kenneth Fishburn, 71; Susan Hughes, 57; James and Jennifer Jackson, aged 67 and 68; Isaac Dixon, 65; Garry Purdham, 31; Michael Pike, 64; Jane Robinson, 66; Jamie Clark, 23.
While the shootings were on-going, ambulance crews were ordered to stay away from the area and some victims had to wait hours before paramedics arrived.
West Cumbria Coroner Mr Roberts said: "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."
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A verdict of suicide was given in the case of the 52-year-old taxi driver.
He shot himself in woodland on 2 June following a 45-mile rampage through west Cumbria, in which 11 people were also injured.
After the verdicts were delivered the coroner criticised the national policy which prevented ambulance crew entering a scene until it was cleared by police.
David Roberts said he would be writing to the home secretary about the issue.
The four-week hearing in Workington had heard details of the shootings and evidence about Bird's state of mind in the run-up to the day.
The deaths were examined in chronological order, with more than 70 witnesses giving evidence.
The jury of six woman and five men heard how Bird had become increasingly agitated in the days leading up to the shootings.
It emerged that he owed £60,000 back tax - relating to his years as a self-employed taxi driver - and had sought the help of his twin brother, David, and a solicitor friend.
However, he became convinced that they were "stitching him up" and he would end up in jail, the inquest was told.
He also felt that his taxi-driver colleagues were "winding him up" by playing practical jokes on him.
One of his friends told the inquest that Bird had said: "Whitehaven will be as famous as Dunblane, you'll see soon enough."
A consultant forensic clinical psychologist asked by police to work out Bird's motives, described him as "a bitter, resentful and depressed man, blaming the rest of society for his failures" and said he was suffering from a "delusional disorder".
The first victim was Bird's twin, who was shot 11 times.
He then killed 60-year-old solicitor Kevin Commons, whose help he had sought over back tax, before driving into Workington.
From there he shot colleagues and strangers he passed at random, sometimes calling them over to his car before shooting them, in many cases in the face.
The other victims were: Darren Rewcastle, 43; Kenneth Fishburn, 71; Susan Hughes, 57; James and Jennifer Jackson, aged 67 and 68; Isaac Dixon, 65; Garry Purdham, 31; Michael Pike, 64; Jane Robinson, 66; Jamie Clark, 23.
While the shootings were on-going, ambulance crews were ordered to stay away from the area and some victims had to wait hours before paramedics arrived.
West Cumbria Coroner Mr Roberts said: "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."
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