ShareSaveAdd as preferred on GoogleJonny HumphriesNorth WestFamily photosBebe King, Elsie Dot Stancombe and Alice da Silva Aguiar were killed in the 29 July 2024 attack"Catastrophic" failures by the parents of the Southport killer and various agencies meant clear chances to prevent the 2024 child murders were missed, a public inquiry has concluded.
Axel Rudakubana, 17, should have been detained before he walked into the Taylor Swift-themed dance class and stabbed three girls, inquiry chair Sir Adrian Fulford found.
Sir Adrian said if his parents had done "what they morally ought to have" and reported his suspicious behaviour, he would not have been free on the day of the attack.
But a "merry-go-round" of referrals, assessments and "hand-offs" - and his autism being used as an "excuse" for past conduct - meant no agency understood the danger he posed.
Bebe King, six, Elsie Dot Stancombe, seven, and nine-year-old Alice da Silva Aguiar were killed in the attack while eight other children and two adults were severely wounded.
In a 760-page final report - following Phase One of the inquiry into how Rudakubana was able to carry out the attack - Sir Adrian called for the end of what he described as a "culture" of agencies passing responsibility between each other or downgrading their own involvement in cases like Rudakubana's.
He described it as the "single most important conclusion" of his report, adding: "This failure lies at the heart of why [Rudakubana] was able to mount the attack, despite so many warning signs of his capacity for fatal violence."
Those criticised included Lancashire Police, the government's counter-extremism service Prevent, various NHS mental health services, Lancashire County Council, elements of children's social care, youth offending services and a broader "multi-agency" approach.
Sir Adrian said: "Over a long period of time, [Rudakubana] had become an aggressive, near-total recluse, who bullied and threatened his family and unashamedly lied to officials."
He said the inquiry's evidence revealed a pattern of mental health services and social care treating the teenager's autism spectrum disorder as an "excuse" for his behaviour - rather than appreciating that in his individual case his condition increased his risk to others.
Sir Adrian also highlighted how different agencies had shown "scant regard" and a "lack of curiosity" over Rudakubana's internet usage.
"I have no hesitation in concluding that the degrading, violent and misogynistic material that [Rudakubana[ was viewing online contributed to and 'fed' his already unhealthy fascination with violence," he wrote.
The retired High Court judge singled out an attack Rudakubana carried out on a boy with a hockey stick at the Range High School in Formby in December 2019, a couple of months after he had been expelled for admitting carrying a knife, as a "watershed moment".
He said it proved "beyond doubt" that Rudakubana "was motivated by an ensuring desire to inflict severe harm on and possibly kill another pupil.
"Nothing occurred during the next five years to indicate that this level of danger had diminished."
The report also focused on another serious incident in March 2022, when the teenager was reported missing and found by Lancashire police officers on a bus with a knife.
Sir Adrian described that incident as the "most marked example of the consequences of poor information sharing".
He said an arrest would likely have led to his home being searched and "critical information" found about the ricin seeds he had bought and the terrorist manuals he had downloaded.
Instead, Rudakubana was simply taken back to his family home in Banks, West Lancashire, and no criminal action was taken.
In response, Lancashire Constabulary's Chief Constable Sacha Hatchett said the force accepted there was an "opportunity" to arrest the killer that day and added: "I am extremely sorry for this."
There was stark criticism particularly for his father Alphonse Rudakubana, who Sir Adrian said had deliberately withheld information about his son amassing a stash of deadly weapons including the biological toxin ricin.
Sir Adrian said if the parents had reported their true level of knowledge to the authorities before the attack, the killer would "undoubtedly have been taken into care or held in custody".
He did accept that Rudakubana had made his mother and father's lives "a nightmare" and parenting him had been "challenging".
Giving evidence during the inquiry last year, his father Alphonse Rudakubana tearfully apologised and said he regretted not contacting the police about his son following a range of troubling incidents in the months and weeks before the attack.
"The love I had for him overrode [my] good judgement," he said.
Sir Adrian said the killer's parents had failed to act out of a "misguided and irresponsible" desire to avoid him being taken into care.
Speaking after the report's conclusions were made public, Sir Adrian said: "Numerous systems that should have provided oversight, assessment and protection were ineffective or inadequately used. Some failed outright.
The Phase One report came after months of evidence from police officers, medical professionals, social workers and teachers - as well as witnesses, survivors and parents of the children both killed and wounded.
The 67 recommendations of the report call for a joined up approach with agencies able to share information more effectively.
Reacting to the report, Home Secretary Shabana Mahmood said the government was determined to "take the necessary action to reduce the risk of such an attack happening again".
Prime Minister Sir Keir Starmer added: "I'm determined to make the fundamental changes needed to keep the public safe."
Mahmood also announced the terms of reference for Phase Two of the inquiry, which will focus on the "adequacy of arrangements for identifying and managing the risk posed by individuals who are fixated with extreme violence".
Mahmood said this would include examining how agencies worked together, laws around knives and weapons and the influence of the internet and social media.
The second phase will begin immediately and report back in Spring 2027.
Earlier, solicitor Nicola Ryan-Donnelly, from law firm Fletcher's, which is representing 22 of the injured and traumatised children, said the findings were "disturbing and frankly depressing".
"These calls for organisational and individual accountability must be heard. They must be acted upon," she said.
Mark Wynn, chief executive of Lancashire County Council, said the authority was "deeply sorry" for the failures identified in the report and had made "substantial changes" - including a commitment to implement all recommendations in full.
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