Report reveals ‘systemic failure of state’ to prevent Southport murders, says home secretary
The Southport inquiry has revealed a “systematic failure of the state”, home secretary Shabana Mahmood has said.
She said in a statement:
The senseless killing of three young girls in Southport was a devastating tragedy that will leave a lasting mark on our national conscience.
Sir Adrian’s report is heartbreaking. It shows a systematic failure of the state to prevent a vile and sickening individual perpetrating this atrocity.
My thoughts and prayers are with the families and friends of Bebe, Elsie and Alice and all the victims of the Southport attack. They have shown immense bravery in taking part in this inquiry despite facing unimaginable grief.
This government has already taken action to prevent such an awful tragedy from happening again, and we won’t hesitate to do what is needed to protect the public. We owe victims nothing less.
Merseyside Police and Crime Commissioner Emily Spurrell said that the report “marks a crucial moment in fully understanding what happened and why”.
She said:
It is heartbreaking that there were so many missed opportunities to intervene. Each one was a moment where different decisions, stronger systems or better coordination could have changed the course of events and prevented this tragedy from unfolding.
That is why it is vital that every organisation or agency involved engages fully with the findings, faces them openly, takes responsibility where failings are identified, and commits to meaningful action, so that future families are never left asking the same questions.
She added that she would oversee how Merseyside Police responded to the findings.
She said:
The learning and recommendations in Sir Adrian’s report cannot stay on the page. They must be acted on in full and implemented nationally, with clear accountability and sustained oversight across all relevant agencies, to ensure that nothing like this can ever happen again.
As part of the inquiry’s phase two work considering whether more restrictions and monitoring of youngsters’ internet access should be considered, the use of virtual private networks (VPNs), used by the killer to get around age verification to order knives online, will be looked at
Rudakubana had deleted his internet history shortly before leaving to carry out the attack but had then searched social media site X for the Mar Mari Emmanuel stabbing, which led to video footage of Bishop Emmanuel being attacked while livestreaming a sermon in Australia.
At school Rudakubana was known to have searched computers for school shootings, had asked about access to pictures of weapons or severed heads, and he had searched for information about terrorist attacks and global conflicts.
At home, from 2019 until the time of the attack, the killer’s parents had no online parental controls set at their address.
There was “scant regard” and a “lack of curiosity” paid to the risks arising from his online behaviour, the report concluded.
And while there are “difficulties” over what powers are available to oversee and monitor online behaviour by children, Fulford said there would have been interventions available – such as after Rudakubana’s arrest after going to school to attack another pupil.
As Press Association reports, the inquiry heard evidence from X’s head of global government affairs, Deanna Romina Khananisho, who said it would be “tyrannical overreach” for the site, formerly known as Twitter, to remove the video of the attack on the bishop in Australia.
Rudakubana had a number of accounts on X, which required users to enter a date of birth to verify their age, but the content of his messages on the site would not be disclosed by the company without a legal order.
Fulford said “regrettably” X did not show “the same ready willingness to co-operate with the inquiry as almost all other organisations …”
The inquiry chair’s recommendations include the Department for Education reviewing its guidance to schools on monitoring and filtering online systems and the use of VPNs or other software to circumvent age-related protections.
Lancashire police chief sorry for failure to arrest Rudakubana in 2022
The chief constable of Lancashire Constabulary, Sacha Hatchett, said the force accepted there was an opportunity to arrest Rudakubana on March 17 2022, when he was found on a bus with a knife.
She said: “We did not adequately assess the risk he posed to others. I am extremely sorry for this.”
After his arrest on the bus, he told police he wanted to stab someone. He also admitted to thinking about using poison.
Instead of arresting the teenager as they should have done, the report said, Rudakubana was returned home by two rookie police officers, who advised his parents to hide their knives.
Had Rudakubana been arrested, his home would probably have been searched, leading to the discovery of ricin seeds he had bought and terrorist material on his computer, the report found.
“I fully accept all the recommendations made for Lancashire Constabulary these include, but are not limited to, record keeping and risk assessment, the better sharing of information between partner agencies, improvements in training, and improvements in the availability of effective technology for frontline officers,” Hatchett said on Monday.
“Whilst some recommendations sit with Lancashire Constabulary, there are more systemic issues for policing nationally to consider, along with partner agencies.”
In regards to the next steps, Fulford had recommended the second phase of the inquiry should consider a single agency or structure to be appointed to monitor interventions for children presenting a high risk of serious harm.
He said “degrading, violent and misogynistic material” viewed online by Axel Rudakubana fed his “already unhealthy fascination with violence”.
Downloads including an Al-Qaeda training manual, a history of Nazi Germany and documents on wars in Rwanda, Sri Lanka, Somalia and South Sudan, were discovered on tablets belonging to Rudakubana.
The inquiry chairman said the lack of exploration of the killer’s “online life” was a “significant failure” which prevented agencies from identifying and addressing his risk.
He recommended that the second phase of the inquiry should consider abilities to restrict or monitor access to the internet of children if they pose a risk to others.
As the home secretary has just set out, the next phase will look at the role of multi-agency management and influence of the internet on violent attacks.
Risks posed by people fixated with extreme violence to be examined in second phase of inquiry
The second phase of the Southport inquiry will look at how well the risk posed by people fixated with extreme violence is managed, the home secretary has said.
It comes after the first phase of the public inquiry found Axel Rudakubana had “clearly revealed” he was an extreme danger.
In a written statement to MPs, Shabana Mahmood said: “I have asked the chair in Phase 2, to examine the adequacy of arrangements for identifying and managing the risk posed by individuals who are fixated with extreme violence.
“The inquiry will consider the role of multi-agency management, the interventions needed to reduce risk to the public, the effectiveness of laws around knives and weapons, and the extent to which the internet and social media are influencing and enabling people to carry out violent attacks.”
This next phase of the inquiry will begin immediately and is expected to report in Spring 2027.
The chief constable of Merseyside police, Rob Carden, has welcomed the findings of the inquiry report.
He said:
The force accepts learning set out in the report in relation to the initial response on the day of the attack and will be considering the recommendations in the coming days. Importantly, the report does stress that the response as a whole was well managed…
There was criticism of the police, among other agencies, over missed opportunities to stop the attack and Carden acknowledged a recommendation in respect of communication between different forces, made by chairman Sir Adrian Fulford because of concerns about the system for reporting “cross-border offences” between Merseyside and Lancashire.
He also said he appreciated that the inquiry recognised the bravery of the first police officers and Police Community Support Officer who attended the scene.
Carden added:
Finally, I want to stress that our thoughts remain with the families of Alice, Bebe and Elsie, and those who were injured and traumatised by the events at the Hart Space on 29 July 2024.
Nicola Brook, a solicitor in the major inquests and inquiries team at Broudie Jackson Canter, representing the three adult survivors at the Southport Inquiry, said: “Our clients were heroes, each acting with great bravery to mitigate the consequences of the barbaric attack.
“They have, however, suffered a deluge of unjustified criticism on social media, and we hope these comments will now cease following the chair’s clear praise and confirmation that they did all they could.
“The report crystallises one of our key concerns throughout – that every organisation tried to shirk responsibility, and that there was a disturbing lack of leadership. This is not the first time we have heard this at an inquiry.
“It is evident, time and time again, that there is a culture within government agencies to place their own reputations above their fundamental duty to protect society, and a failure to properly reflect on their conduct once presented with clear evidence that they failed on multiple occasions.
“Of the 67 recommendations made by the chair, thoughts must now turn to what mechanism needs to be employed to make sure these changes are actioned in their entirety, and if they are not, how those who seek to sidestep their responsibility are held to account.”
Report reveals ‘systemic failure of state’ to prevent Southport murders, says home secretary
The Southport inquiry has revealed a “systematic failure of the state”, home secretary Shabana Mahmood has said.
She said in a statement:
The senseless killing of three young girls in Southport was a devastating tragedy that will leave a lasting mark on our national conscience.
Sir Adrian’s report is heartbreaking. It shows a systematic failure of the state to prevent a vile and sickening individual perpetrating this atrocity.
My thoughts and prayers are with the families and friends of Bebe, Elsie and Alice and all the victims of the Southport attack. They have shown immense bravery in taking part in this inquiry despite facing unimaginable grief.
This government has already taken action to prevent such an awful tragedy from happening again, and we won’t hesitate to do what is needed to protect the public. We owe victims nothing less.
Chairman of the Southport inquiry Sir Adrian Fulford concluded his statement at Liverpool town hall with a minute’s silence in memory of the victims of the attack.
He said:
Finally, and of the highest importance, we should conclude phase one of this inquiry by focusing our thoughts on the deceased, the other victims and all their families.
I ask we all stand for a minute’s silence to pay tribute to the three young girls who were killed, to all those who were physically and psychologically injured (some very gravely and with significant enduring consequences), and to their families whose lives have been irreparably changed.
Starmer: Southport report ‘truly harrowing and profoundly disturbing’
In a statement, prime minister Keir Starmer said that the “brutal, senseless murders of Bebe, Elsie and Alice marked one of the darkest moments in our country’s history”.
He said:
It is a tragedy we will never forget. I have been overwhelmed by the bravery and determination of their families, and as prime minister, I will do everything I can to honour their memory.
The report today is truly harrowing and profoundly disturbing. It sets out in stark detail the systemic failures over the five years that led to this terrible event, and the repeated missed opportunities that could have prevented it.
While nothing will ever bring three little girls back, erase the trauma from those injured, or undo the lasting impact on those who witnessed such horror, I am determined to make the fundamental changes needed to keep the public safe.
Josh Halliday
Nicola Ryan-Donnelly, a solicitor at the law firm Fletchers which represented 22 of the injured children at the inquiry, said: “It is clear there is a need for whole-scale system reform across health and social care, education and policing.
“As Sir Adrian Fulford has said, the findings of this inquiry are disturbing and frankly depressing. These calls for organisational and individual accountability must be heard. They must be acted upon.”
Ryan-Donnelly added:
The families we represent have shown courage, strength and honour in the darkest of days.
Their lives have been permanently altered by these heinous acts of violence.
The physical and emotional scars inflicted on them are a daily reminder of something that we now know could and should have been prevented.
Downing Street reiterated that the Southport killings must be a “line in the sand” after an inquiry found that Axel Rudakubana’s attack “could and should have been prevented”.
The prime minister’s official spokesman said:
The home secretary is going to respond to this report and its harrowing contents in the House shortly.
I won’t get ahead of her, but as the prime minister said last year, this terrible event must be a line in the sand for Britain.
We must get the families and people of Southport the answers they deserve.
This must be a moment of fundamental change for how we protect our citizens and our children.
That’s exactly why we launched the inquiry as soon as we could, once justice was served to the offender in question.
Mark Wynn, chief executive of Lancashire County Council, said he is “deeply sorry” for the failures identified in the inquiry report.
In a statement, he 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.
Our thoughts are with the families of Elsie Dot Stancombe, Alice da Silva Aguiar and Bebe King, with all those who were injured, and with everyone whose lives were changed by the attack in Southport on 29 July 2024.
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.
In a statement given at Liverpool town hall as the report was published, Fulford said he has “no doubt that if appropriate procedures had been in place and if sensible steps had been taken by the agencies and AR’s parents, this dreadful event would not have happened”.
He added:
It could have been and it should have been prevented.
He said the failure, at an organisational and individual level, to “stand up and accept responsibility” for managing the risk the killer posed was a “frankly depressing – and therefore urgent – matter requiring government attention”.
Fulford added:
Far too often, AR’s ‘case’ was passed from one public sector agency to another in an inappropriate merry-go-round of referrals, assessments, case-closures and ‘hand-offs’.
Josh Halliday
Fulford also criticised agencies for failing to investigate Rudakubana’s “chilling” internet use, finding that his interest in “degrading, violent and misogynistic” content fed his obsession with violence and led him to build an arsenal of weapons, including knives, a crossbow, petrol bombs and material to make the deadly poison ricin.
The judge said he would consider in the second phase of the inquiry whether there should be a new power to monitor or restrict the internet use of young people who are believed to pose a threat.
Fulford said the “pervasive failure to act on (Rudakubana’s) dangerous, with some notable exceptions, was a fundamental failure in this case”.
‘Missed opportunity’ saw rookie police officers tell Rudakubana’s parents to hide their knives
Josh Halliday
The most striking missed opportunity was in March 2022, when Rudakubana went missing from home and was found with a knife on a bus, telling police he wanted to stab someone. He also admitted to thinking about using poison.
Instead of arresting the teenager as they should have done, Fulford said, Rudakubana was returned home by two rookie police officers, who advised his parents to hide their knives.
Had Rudakubana been arrested, his home would probably have been searched, leading to the discovery of the ricin seeds he had bought and the terrorist material on his computer, the report found.
Fulford concluded: “Rigorously putting out of mind the so-called ‘benefits of hindsight’, I have no doubt that if appropriate procedures had been in place and if sensible steps had been taken by the agencies and (Rudakubana’s) parents, this dreadful event would not have happened. It could have been and it should have been prevented.”
Rudakubana was referred three times to Prevent, the counter-terrorism agency, over concerning remarks he had made or material he had searched online at school.
Prevent dismissed his case each time on the basis that he had no clear ideology such as jihadism or rightwing extremism. Counter-terrorism officers have accepted this was a mistake.
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