The father of twin babies drowned by their own mother says he can "finally grieve in peace" after a coroner rejected claims his estranged wife had been failed by mental health teams.
Samantha Ford was jailed for 10 years in 2019 for killing her 23-month-old children - Chloe and Jake - at their home in Margate on Boxing Day the year before.
The horrific crime was described as a "twisted act of vengeance" against her estranged husband when she appeared before the Old Bailey.
But it was claimed by her lawyers this week that there had been missed opportunities to prevent the killings through earlier and more thorough intervention by medical professionals.
However, coroner Christopher Sutton-Mattocks, who led an inquest into the deaths of the twins, ruled today that the devastating tragedy was an extremely rare event that no one could have foreseen.
He said no one - including Ford's family, friends and her estranged husband Steven - had "any inkling" the children's lives were at risk.
Instead, they believed that the toddlers had been a reason for the mum to carry on in the face of frequent suicidal thoughts.
"There was no forseeability that this tragic outcome was likely or possible - quite the opposite," the coroner said.
"Samantha Ford said the children were protective factors.
"Neither her family, friends nor Steven had any inkling the children's lives were at risk.
"They were concerned for her safety and it's arguable that people should have been more concerned about the welfare of the children in the event she did carry out her suicidal thoughts.
"But that is quite different to her being a risk to her children, let alone them being killed.
'Not one single person had the slightest suspicion that she would harm her children...'
"This was an extremely rare and unusual event."
He added that of all the witnesses giving evidence and statements, "not one single person had the slightest suspicion that she would harm her children, let alone kill them".
Mr Sutton-Mattocks made a ruling of 'unlawful killing' for both children and said he did not intend to make a prevention of future deaths report in any area flagged up by Ford's legal team.
Speaking after the hearing, a devastated Mr Ford welcomed the ruling, saying no one was to blame for his children's death but Ford herself.
"On Boxing Day 2018 my beautiful children Chloe and Jake were killed by their mother, Samantha," he said.
"The last two years have been agonising. I miss them so much and this is something I will never get over as long as I live.
"Samantha and her family have attempted to use the inquest process to point to failings in the NHS, which she says should have acted to prevent her from killing Chloe and Jake.
"I am disappointed that it has taken two years to reach this point. It was clear from the beginning that the health services did not fail my children or Samantha in any way."
Mr Ford says he is pleased the coroner "completely rejected the unfounded calls" of Ford's legal team to make a prevention of future deaths report.
"Having examined Samantha’s interactions with the NHS in great detail, the coroner found that there were no failings or faults on the part of the health services that could be said to have contributed to their deaths," he said.
"I do not consider this to be a win in any way. It is simply a prevention of additional injustice caused by Samantha’s continued attempts to find someone to blame for her actions.
"Samantha was to blame for the deaths of Chloe and Jake. No one else.
"I appreciate that this is a difficult outcome for Samantha’s family to hear. It is my sincere hope that they finally accept it."
The week-long inquest examined all aspects of Ford's interactions with healthcare professionals before her horrific crime. It was heard she spoke to 14 different health workers in November and December.
During proceedings it emerged the mum was struggling with the breakdown of her marriage, wasn't sleeping, was struggling to care for the twins and had frequent suicidal ideation.
Her lawyer, Brenda Campbell QC, argued that a prevention of future deaths report should be made by the coroner, claiming that the children's deaths could have been prevented and there were missed opportunities.
But this was rebuffed by barrister Jennifer MacLeod - representing the twins' father - who said the deaths of Chloe and Jake could not have been avoided by the actions of medical professionals or anybody else.
Instead, the tragedy was described by Mr Ford as an act of 'spousal revenge filicide' - when a parent kills their own child to cause harm to their ex-partner.
The former couple, who moved back to Kent from Qatar in 2018 after having their babies by IVF, had been married for 10 years, separating in August 2018 when she asked him to move out, before then begging him to come back.
The inquest was told she would not accept his explanation for the relationship breaking down and was using "emotional blackmail" to try to get him back.
During her trial at the Old Bailey, Ford was described as a narcissist by a psychiatrist, and it was said she was fixated on getting her husband back.
After he refused, she warned him in one message: “If this continues it’s going to lead down a horrible path.”
She also Googled how to drown someone in the weeks before she killed the twins and made chilling searches on the day of their death.
At sometime between 6.25pm and 6.52pm on Boxing Day 2018, just shortly after her parents left to go food shopping, Ford held the children under the water in the bath, dressed them in nappies and baby grows, and wrote a note saying "please forgive my crazy mind".
She then drove to Beachy Head, where she stayed for some time before attempting suicide by driving into the back of a lorry on the A299 Thanet Way.
'Samantha was to blame for the deaths of Chloe and Jake. No one else...'
She admitted manslaughter by reason of diminished responsibility and was jailed for 10 years, but is currently serving her sentence in a secure psychiatric facility.
It was heard how in the six weeks before she killed the twins, her mental health had deteriorated, she had been prescribed anti-depressants and had sought help from talking therapy service Insight Healthcare, her GP and out-of-hours service NHS 111.
Insight had raised concerns about her state of mind and frequent suicidal thoughts, but a letter it sent to her GP at Charing Surgery had not been read by the doctor when he next spoke to Ford, who had called to ask for more medication to help her sleep.
Instead, Dr Rob Immelman said the mum seemed calmer and more focused than she had been when previously seen by a colleague, who said she had seemed agitated.
Health workers from NHS 111, who Ford spoke to three weeks before her terrible actions, also said they did not feel there was an immediate risk to the children and she posed no threat of violence.
The inquest heard no one - including Mr Ford and Ford's own family - had thought her mental state severe, and had Mr Ford had serious concerns, he would not have left the children with her.
But Ford's barrister, Ms Campbell, argued the children were considered a protective factor by Ford, meaning they gave her a reason to live, which, she said, put them at risk, based on a 2016 report by the NSPCC.
She also argued there was a lack of early intervention by health professionals and an over-reliance on prescription medication rather than face-to-face consultations.
But Ms MacLeod said using one NSPCC briefing as the argument for the children being at risk was "very dangerous" and that it had not been appropriate in Ford's case to refer her for early help.
She added that not at any time had her medication been deemed inappropriate, or any risk to the children identified.
Mr Sutton-Mattocks says based on all his evidence, he did not find there were any failings by medical professionals that contributed to the children's deaths.
The inquest was told that before the twins were killed Ford's family had been concerned about her and were doing what they could to help her.
In a statement released after the hearing, her parents, Tony and Colette Emptage, said they remain concerned there were "missed opportunities" for Chloe and Jake.
"Although Samantha repeatedly sought help, she was only seen face-to-face on two occasions and the only solution appeared to be to prescribe her more and more medication," they said.
"We can only hope that the support networks that are in place to help people suffering the mental distress endured by Samantha will be strengthened to ensure that this can never happen to another family."
They added: "The deaths of our grandchildren Chloe and Jake was the worst pain that any family could ever endure. We will never recover from the loss of their precious lives.
"They were beloved and much-wanted children and evidence given to the coroner has shown that Samantha was a loving and devoted mother to them.
"She adored her children and looked after them as well as any mother could, even while she was struggling severely.
"We are grateful that events in the weeks leading to our grandchildren’s deaths and the serious mental illness that our daughter was suffering during that time has been made clear to the coroner."
They said Ford was "struggling severely" and suffering "intense mental distress".