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The brutal murder of schoolgirls Elsie Dot Stancombe, Alice da Silva Aguiar and Bebe King in Southport shocked the nation in the summer of 2024.But it was not the first time the perpetrator, 17-year-old Axel Rudakubana, had come to the attention of the authorities, as the Southport Inquiry has made clear.Chairman Sir Adrian Fulford said the killings ‘could have and should have been prevented' if Rudakubana had been taken into care or custody before he could carry out the attack. They were due to ‘systemic failings' identified by multiple agencies and a failure by any of them to ‘take ownership'.Concerns around Rudakubana's behaviour arose from the age of 13 and he attended the Acorns School, a pupil referral unit in 2019. Soon afterwards he was referred to the Prevent anti-extremism programme and ultimately expelled after researching school shootings online during lessons and bringing a knife to class.In December of the same year, he carried out a random attack on a boy at Range High School with a modified hockey stick.Children's services at Lancashire had been restructured as result of national reforms between 2019 and 2021, resulting in qualified social workers dealing with more complex cases, with family support workers otherwise making decisions.Although spurred by national changes, Fulford took issue with how it was implemented locally, finding ‘a culture of institutional reluctance' to escalate the case and ‘lack of flexibility' in its handling.Rudakubana was referred to Prevent again in 2021, by when he had been diagnosed with autism spectrum disorder and he received support from special educational needs and disabilities (SEND) and early help services over the following three years.Fulford found concerns were raised with the council about his online activity in 2019, 2021 and 2022, but that there was ‘inadequate exploration or response even when significant concerns about online harms have been identified'.He added: ‘Given how far short Lancashire CC 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.'Children's services at Lancashire had been restructured as result of national reforms between 2019 and 2021, resulting in qualified social workers dealing with more complex cases, with family support workers otherwise making decisions.Although spurred by national changes, Fulford took issue with how it was implemented locally, finding ‘a culture of institutional reluctance' to escalate the case and ‘lack of flexibility' in its handling.The report was critical of the child and youth justice service, which ‘fell well short of the standard which was to be expected' in 2020-21, mitigated by the impact of the pandemic, and young adults team, whose assessments of Rudakubana were found to be ‘poor'.It has recommended in-depth, independent audits be carried out of both services by the autumn.Fulford accepted that ‘employees acted with an intention to do good' and were ‘undertaking difficult and pressured jobs in challenging circumstances'.He instead placed blame on a ‘framework that was illsuited to dealing with' cases such as Rudakubana.He wrote: ‘Those individuals are not to blame for the systemic issues that they had to grapple with: those were the responsibility of Lancashire CC and of national-level systems and culture.'While there are procedures and measures for safeguarding children from harm, there was – and remains – a lack of consideration of the potential of children causing harm to others.Fulford said consideration should be given to a specific multi-agency forum and a single agency to ‘record, monitor and co-ordinate interventions' for such children.The report conceded the situation is not necessarily straightforward, however. It noted the evidence of Lancashire's director of children's social care, Louise Anderson, who told the inquiry there are 140,000 UK children aged 13 to 17 believed to carry knives. If they were defined as ‘likely to suffer significant harm', it would ‘overwhelm the safeguarding system'.Among the other recommendations are that staff at Lancashire undertake training relating to the Prevent anti-extremism programme and how to approach cases of autism by October, and around record-keeping.Lancashire's chief executive, Mark Wynn said: ‘We are deeply sorry for the failures identified and for the part we played in the systemic shortcomings that preceded the attack in Southport.'He said the council had ‘made substantial changes to our safeguarding practice' and was ‘committed to implementing all recommendations directed to us in full'.But he also stated ‘the current regulatory framework was not designed for cases like this' and said Lancashire would ‘advocate for the systemic reforms needed'.The inquiry found Rudakubana's parents had presented authorities with ‘significant obstacles' to engaging with the family and were ‘too ready to excuse and defend' his behaviour.Fulford said the next phase of the inquiry should also look into whether legal reforms are needed to permit agencies to ‘override parental consent' to share information or access a child in cases like Rudakubana's.Chris Walker, a solicitor at Bond Turner representing the three bereaved families, highlighted findings that ‘the attack would have been prevented had agencies acted to a competent level'.He said that ‘reforms require urgent and full implementation', but also that they would be ‘seeking individual and systemic accountability'.Walker added: ‘We call for immediate action, clear accountability and real change – not simply reassurances that "lessons have been learned."'Following the publication of the recommendations, Prime Minister Keir Starmer said: ‘I'm determined to make the fundamental changes needed to keep the public safe.'Phase two of the inquiry, looking at the system for risks posed by people fixated with violence, is due to be published in a year's time.

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LEGAL

Southport Inquiry: a damning verdict

By Martin Ford | 23 April 2026

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