‘Fundamental failure’ by police and agencies to assess risk posed by Southport killer, inquiry finds

Inquiry chair Sir Adrian Fulford said there was “a fundamental failure by any organisation, or multi-agency arrangement, to take ownership of the risk that Axel Rudakubana posed”.

Rudakubana murdered the three young girls in a knife attack at a Taylor Swift-themed dance event in Southport on July 29, 2024 – Alice da Silva Aguiar, nine, Elsie Dot Stancombe, seven, and Bebe King, six.

Ten others were injured – eight children and two adults.

Rudakubana was jailed in January last year for a minimum of 52 years.

In Phase 1 of the Southport Inquiry, published on Monday (April 13), Sir Adrian said the number of missed opportunities for intervention with the killer was “striking”.

Among them, Lancashire Constabulary accepted that there was an opportunity to arrest Rudakubana on March 17, 2022, but did not adequately assess the risk he posed.

Sir Adrian said there was a “disturbing lack of clarity” as to who, if anyone, was the lead agency, which persisted through the Inquiry’s hearings.

Lancashire Constabulary’s Community Safety team took the view in December 2019 that as soon as a referral had been made to Prevent, it was Prevent which was to be the lead agency, he said.

Prevent declined to refer the case to a Channel panel on three occasions when, based on the information that should have been known to Counter Terrorism Policing North West (CTPNW), referrals ought to have been made, added Sir Adrian.

“Lancashire Constabulary repeatedly took the view that its role was complete so long as a referral had been made to the Multi Agency Safeguarding Hub (MASH), even when officers repeatedly attended at the same address,” Sir Adrian said. “This was compounded by the fact that the constabulary did not routinely receive any feedback from the MASH or other agencies as to what action was being taken;

“Information management and information sharing between and within agencies was often poor. Risk information was not adequately shared between agencies and was lost or diluted over time even within agencies. As a consequence, the significance of subsequent events was seriously underestimated and opportunities to intervene were lost.

He has recommended that Lancashire Constabulary should consider extending Operation Encompass to share automatically relevant information with schools in bordering areas. The Department for Education should consider national implementation. This is because children will not necessarily attend school in the same police force area as they live, Sir Adrian said.

He also highlighted “a persistent issue of ‘dilution’ of information as it went through multiple referrals from the police”.

Sir Adrian recommended Lancashire Constabulary, and the College of Policing nationally, should ensure that forms and training emphasise the importance of recording, as precisely as possible, the words and behaviour of individuals who may pose a significant risk to others.

“I am concerned that the system of reporting cross-border offences between forces has the appearance of being somewhat ‘hit and miss’,” said Sir Adrian. “Passing information to another force by email does not seem to reflect a clear and established procedure which ensures that the information will be handled appropriately on receipt.

“Lancashire Constabulary and Merseyside Police should review the effectiveness of their information-sharing systems and consider whether a more robust process is required. Findings should be shared with the National Police Chiefs’ Council and College of Policing for consideration as to whether national level guidance is appropriate.”

In response to the report, Lancashire Constabulary Chief Constable Sacha Hatchett said: “First and foremost, I continue to extend our sincere condolences to the families of the three children killed in the attack: Elsie, Alice and Bebe, and to those who continue to cope with the injuries they sustained on that terrible day. I cannot imagine the pain and suffering they must endure each day.

“I fully appreciate that they want answers and to understand the circumstances that led up to the attack.

“AR is responsible for his devastating actions on that day which inflicted such terrible pain, however, there is learning for all agencies involved with him over many years, including Lancashire Constabulary.

“Lancashire Constabulary approached the Inquiry with candour, humility, reflection and a genuine desire to learn and improve.

“In all their interactions with AR and his family, Lancashire Constabulary officers were motivated by a genuine desire to help, and this has been reflected in the Inquiry report.

“The Inquiry process enabled us to examine and reflect in depth about our involvement with him in the preceding years.

“Lancashire Constabulary accepts that there was an opportunity to arrest AR on 17 March 2022, and that we did not adequately assess the risk he posed to others. I am extremely sorry for this.”

She added: “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.

“Whilst some recommendations sit with Lancashire Constabulary, there are more systemic issues for policing nationally to consider, along with partner agencies.

“We will now take time to read the report in detail and to carefully consider its recommendations.

“I want to thank Sir Adrian Fulford and the Inquiry Team for their time and effort in reaching these conclusions today.

“Whilst today marks an important step towards finding the answers that the bereaved families and survivors have waited for, it cannot lessen the depth of their pain or the weight of their loss. My hope is that, in time, they find space for healing and moments of peace whilst facing life without their children.”

Merseyside Police Chief Constable Rob Carden said they “welcome and acknowledge” the findings of the Southport Inquiry Phase 1 report.

“The report assesses the response of a range of local and national agencies which had prior contact with the perpetrator,” he said.

“It also looks at the Merseyside Police response on the day of the incident itself.

“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 and displayed effective inter-agency liaison, and the matters raised for learning did not impact on the response provided on the day.

“Merseyside Police will always learn from incidents and take action to improve the service it provides to the people of Merseyside.

“In relation to major incidents and JESIP principles we have regular training sessions with our emergency service partners and will stress at all of these the need for clarity in communication between  partners, including the North West Ambulance Service, from control room to room.

“However, it is clear that emergency service resources (police and ambulance), on the ground on the day of the incident, were in attendance promptly, were updated on the current situation and knew it was safe for non-police emergency services to be in attendance.”

Mr Carden added: “In terms of the 2019 investigation following the arrest of AR at the Range High School, which resulted in him being charged, we acknowledge the recommendation in respect of communication –between different police organisations we will work together with other policing organisations to ensure this is resolved.

“We appreciate that the inquiry recognised the bravery of the first police officers and police community support officer (PCSO) who first attended at the Hart Space. The report states, ‘They did not know that he would surrender when challenged; they did not even know that he was alone. Their courage in entering a stairwell, against the advice of those who had seen how AR was armed and how he was behaving, is worthy of the highest praise.’

“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.

“It is incumbent on all the organisations referred to by the inquiry to act on the recommendations made to ensure everything possible is done to prevent this from happening again.

“Following the tragic incident the families of Alice, Bebe and Elsie found themselves facing unimaginable trauma and distress, but somehow they have managed to find the strength to ensure that their daughters’ names are recognised for good, and not solely associated with the tragedy.

“They have worked tirelessly to ensure that their daughters’ legacies live on as a result of the positive work they are doing to help others, and I commend them for making sure that others will be helped as a result of the work they are doing in their daughter’s names.”

​Senior National Coordinator for Counter Terrorism Policing, Deputy Assistant Commissioner Vicki Evans, said she “deeply regrets” that they contributed to the collective failure to manage the perpetrator’s risk.

“On 29th July 2024 Elsie Dot Stancombe, Alice da Silva Aguiar and Bebe King lost their lives in a senseless and abhorrent attack,” she said.

“Today myself, and everybody at Counter Terrorism Policing is thinking about the victims, families, and wider community affected. They have shown great strength and courage throughout this process.

“Elsie, Alice and Bebe deserved to live their young lives free of fear. They, those who were injured, and the people of Southport also expected that they would be safe that summer. Tragically, that was not the case.

“The chair has outlined in his report today, there were fundamental failures by multiple agencies.

“It is with my deepest regret that Counter Terrorism Policing contributed to the collective failure to manage the perpetrator’s risk.

“Following the tragic incident, Counter Terrorism Policing has not waited to act upon the urgent change needed to how we work and how we work with others. But there is still more to be done.

“We will continue with our unwavering determination to work with other partners to deliver critical change to ensure the right parts of the system are doing the right things to keep people safe.

“I would like to thank Sir Adrian Fulford, and his team, for their comprehensive work and scrutiny throughout phase one of the inquiry. We will continue to support them as we move into the second phase.

“We will now review every facet of the report and respond to the recommendations for the Prevent programme alongside the Home Office.

“All those affected have rightly demanded answers and accountability, and I hope today’s report has gone some way to providing that.

“They have also been clear that the inquiry must instigate change that will strengthen the systems that are meant to keep us all safe.

“Counter Terrorism Policing is committed to driving the necessary change, both now and in the future.”

Merseyside’s police and crime commissioner Emily Spurrell said: “Today will be another incredibly hard day for the families at the heart of the Southport tragedy who have lived with unimaginable loss. They deserve answers, accountability, and assurance that lessons will be learned.

“This report marks a crucial moment in fully understanding what happened and why – not just in relation to one organisation but across the range of agencies involved – and sets out the changes that are needed to ensure that we never see a repeat of that devastating day.

“It is heart-breaking 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.

“I will consider the report in full and in detail, and through my scrutiny role, will oversee how Merseyside Police responds to the findings and recommendations where they apply to the organisation.

“The report also recognises the response on the day itself, and the courage shown by Merseyside Police officers and PCSOs who were first on the scene, running towards danger and responding in the most harrowing of circumstances.

“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.”

Home Secretary, Shabana Mahmood, said: “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.”

Stephanie Roberts-Bibby, Chief Executive of the Youth Justice Board (YJB), said: “This report lays bare the devastating consequences when risk of harm and offending is not fully understood, owned or acted on across the system.

“This is an unimaginable tragedy. Three young girls lost their lives in an act of extreme and devastating violence, and many others – children, families, professionals and an entire community – will carry the impact of that day for the rest of their lives. No words can do justice to the loss felt by the families, or the harm caused to the survivors, but this Inquiry must be the catalyst for meaningful change and at pace.

“Today’s report sets out in stark terms how a child with a known history of concerning behaviour was able to reach a point of catastrophic harm, despite contact with multiple agencies. The Inquiry has exposed serious systemic issues, including failures in information sharing, risk identification and ownership and aligned objectives of agencies to manage, mitigate and reduce harm.

“What the Inquiry shows is not a failure of one agency alone, but a failure of the system to come together around a child who was clearly in need of intervention throughout years of contact with agencies that was all too often, “light touch”.

“I recognise the need for collective action across the system. Youth justice is one part of a local safeguarding and public protection landscape that includes education, health, social care and police. But I must be clear – contact with youth justice most often happens much later in a child’s journey. The report reinforces the need for earlier, more joined-up intervention long before a child reaches the point of entering the justice system. This is something we have long advocated for and strongly support.

“The YJB’s role in supporting the system with the evidence of what works remains and we will do everything in our power to provide national leadership to youth justice services and the broader system. One of the recommendations is for a lead agency to be considered as Phase 2 of the Inquiry. We fully support clearer ownership of risk but this must be reinforced by professional curiosity and responsibility.

“With any local service or agency that comes into contact with children there must be a culture that supports frontline practitioners to challenge, escalate and tenaciously persist where concerns remain. This should be underpinned by robust ownership of risk and firm collective leadership.

“The YJB is committed to ensuring this Inquiry is not just a moment of reflection but a turning point to prevent further tragedies. Through these recommendations, learnings must be translated into action, action that delivers safer outcomes for children, victims and communities.”