- Police did not stop and question everyone leaving Mr de Menezes’s apartment block, despite orders to do so;
- Armed officers did not arrive at the apartment block in time to halt the Brazilian, despite the surveillance operation beginning four hours previously;
- Without the armed officers, there was no plan for how to deal with a suspect suicide bomber leaving the building. This uncertainty helped create the confusion about Mr de Menezes’ status that ultimately led his death;
- There was no plan for absence of certainty about identity;
- When one of the surveillance officers tried to clarify what they should do if forced to “contain” the suspect, “all he got was a shrug of the shoulders”,
- Senior officers believing that Mr de Menezes had been identified as a terrorist despite the fact that no surveillance officer had stated that to be the case;
- Police failed in their duty of care by letting a suspected suicide bomber board a packed bus (twice) and then a busy Tube train;
- The New Scotland Yard operations room was too noisy and chaotic for officers to accurately assess the information coming from surveillance officers outside Mr de Menezes’ block, to the extent that people couldn’t make themselves heard;
- Non-essential staff contributed to the noise and chaos by not leaving the room despite repeated requests to do so;
- Surveillance officers who identified Mr de Menezes to armed officers on the Tube train were unaware of orders that he should be “stopped”, ie killed, before he could board the train;
- Commander Cressida Dick, Gold Commander at Scotland Yard, issued a series of contradictory orders to the surveillance team following Mr de Menezes;
- Somehow the firearms team made a leap from being in pursuit of one terrorist suspect to a whole cell, which resulted in one officer pointing a gun at ‘Ivor’, a surveillance officer, and another firearms officer chasing the tube driver into the tube tunnel.
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