Southport inquiry finds “fundamental failure” by any organisation or multi agency arrangement to take ownership of risk that perpetrator posed

On 29 July 2024, Bebe King, Elsie Dot Stancombe, and Alice da Silva Aguiar were killed by Axel Rudakubana (AR), at a Taylor Swift-themed dance class. Many other children and adults also suffered physical and/or psychological harm.

As part of its investigation into how the attack was able to happen, the Southport Inquiry heard evidence from a range of local and national agencies which had prior contact with its perpetrator.

The report made the following key conclusions:

• There was a fundamental failure by any organisation, or multi-agency arrangement, to take ownership of the risk that AR posed.
• Information management and information sharing between and within agencies was often poor.
• There was a repeated tendency on the part of multiple agencies to excuse AR’s behaviour (including his violence) on the basis of his perceived or, later, confirmed autism spectrum disorder (ASD).
• AR’s online behaviour, which provided the clearest indications of his violent preoccupations, was never meaningfully examined.
• AR’s parents did not provide boundaries, permitted knives and weapons to be delivered to the home, and failed to report crucial information in the days leading up to the attack.

The phase one report said: "Agencies repeatedly passing the risk to others and closing/downgrading their own involvement is not effective – or responsible – risk management. If, as a society, we are to avoid repetition of what happened in AR’s case, this culture
has to end. This is the single most important conclusion of Phase 1 of this report. This failure lies at the heart of why AR was able to mount the attack, despite so many warning signs of his capacity for fatal violence."

The report observed that following the attack, Merseyside Police’s criminal investigation gained considerable insight into AR’s online behaviour.

The inquiry found: “As well as having twice downloaded an academic article that contained the text of an Al-Qaeda training manual, AR had downloaded a wide range of vile and disturbing imagery, as well as articles and papers relating to a variety of conflicts and atrocities, both contemporary and historical.

“Although there is no evidence that this level of acutely inappropriate online activity by AR was known to any agency prior to the attack, there is a direct line back from it to reports of AR’s online behaviour between 2019 and 2021.

“At these earlier stages, AR was known to have searched his school computer for school shootings, he had asked about access to pictures of weapons or severed heads, and he had searched for information about terrorist attacks and global conflicts. Save for The Acorns School, this concerning aspect of his behaviour was never properly appreciated by any agency or by AR’s parents.”

The inquiry found there were also concerns raised with Lancashire County Council (LCC) at various stages about AR’s online activity, in particular in December 2019, October 2021 and March 2022.

Criticising the council’s response, the report said: “Overall, LCC’s approach to AR’s online activity appears to have been relatively cursory. Even when concerns were identified over AR’s behaviour online, these were not effectively followed up. On other occasions, the dilution or loss of important earlier information meant that there was not sufficient understanding or rigour in pressing AR as to his online activity, which might have led to further concerns being raised.”

It added: “LCC does not have any statutory powers that would have enabled them to investigate AR’s online behaviour. However, it would have been possible for them to discuss it with AR’s parents and make appropriate suggestions and recommendations – such as ensuring that parental controls were applied. Given how far short LCC fell in this area, across a number of teams and a significant period of time, I have made a recommendation that they review the approach to be taken in the future.”

Meanwhile, the report criticised the authority for repeatedly “stepping down” the perpetrator’s case to its non-statutory Early Help service.

The report made the following recommendations in relation to online harms:

• The Department for Education should review and strengthen its guidance to schools on monitoring and filtering systems, including ensuring that the systems used are appropriate and adequate from a technical perspective.
• Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms to children. It should include consideration of the risks associated with the use of Virtual Private Networks, which can enable children to bypass the safeguards established under the Online Safety Act 2023.
• The Department of Health and Social Care should consider whether reforms to national guidance, policy or training are required.

Turning to the issue of parental failures, the inquiry found that AR’s parents created “significant obstructions” to constructive engagement with AR by the various agencies that were involved.

However, the report added that relevant agencies “must be prepared to deal with parents who – through a mixture of inability, difficulty and unwillingness – are ill-equipped to address the risks of violent children”.

The inquiry therefore concluded that relevant agencies “did not sufficiently, or in some cases at all, make allowance for AR’s parents’ behaviours in their assessment of the risk that AR posed to others”.

Following the publication of the 760-page Phase One report, Phase Two of the Southport Inquiry will begin immediately and report back in Spring 2027.

Making recommendations ahead of Phase 2, the report said it should:

• consider what single agency or structure should be appointed or established to record, monitor and co-ordinate interventions for children and young people who present a high risk of serious harm.
• consider the development of a shared multi-agency risk-assessment tool that is clear, accessible and suitable for use across public sector services.
• consider whether there should be a further ability to restrict or monitor access to the internet on the part of children and young people, if a significant threshold is passed concerning the risk they pose to others.

Chair of the Southport Public Inquiry, Sir Adrian Fulford said: “Today is in recognition of Elsie, Bebe and Alice, of those who were physically and psychologically injured, and to the families whose lives have been irreparably changed. Our work has been to establish a clear, unflinching account of how such an appalling event occurred, and what must change to ensure it is never repeated.”

Mark Wynn, Chief Executive of Lancashire County Council, said: “Lancashire County Council acknowledges the Chair’s findings and thanks Sir Adrian Fulford for his thorough and rigorous examination of the events preceding this tragedy.

“[…] We are deeply sorry for the failures identified and for the part we played in the systemic shortcomings that preceded the attack in Southport. We know that no words can ease the grief of the families who lost loved ones, or the pain of those who were injured and traumatised.

“Since 2019, we have made substantial changes to our safeguarding practice, and the Chair’s findings will inform our continued improvement. We are committed to implementing all recommendations directed to us in full."

Wynn added: “We also welcome the Chair’s recognition that the current regulatory framework was not designed for cases like this. We will continue to work with government and partner agencies to advocate for the systemic reforms needed – including a dedicated multi-agency framework for managing individuals who may pose risk to others, and clearer statutory guidance on threshold decisions.

"We remain committed to cooperating fully with the inquiry as it moves into its next phase."

According to the BBC, the legal representative for the three murdered girls' families has now said those who failed to take action to try to prevent the Southport attacks will be named unless “suitable disciplinary measures are taken”.

Chris Walker of Bond Turner Solicitors told BBC Breakfast: “There are five particular state entities which are causing us most concern and we, frankly, find their behaviour unacceptable - Prevent, Lancashire Police, Lancashire Social Services, CAMHS, and FCAMHS."

"I know the names of those individuals," he added.

"If necessary, if we're not satisfied, I will be naming them publicly and I will be bringing out in the public domain once more their individual failings”.

CAMHS is the Child and Adolescent Mental Health Service while FCAMHs is the Forensic Child and Adolescent Mental Health Service.

Lottie Winson