The Southport Inquiry has concluded that the Hart Street attack that killed three young girls was preventable, identifying systematic failures across police, social care, healthcare, education and counter-terrorism over a five-year period.
Sir Adrian Fulford’s Phase 1 report, published today at Liverpool Town Hall, makes 67 recommendations and delivers a formal finding of “unlawfully killed” for all three children, stating in each case that the attack could have been prevented had agencies shared information and acted on it.
Bebe King, six, Elsie Dot Stancombe, seven, and Alice da Silva Aguiar, nine, were killed when Axel Rudakubana attacked a Taylor Swift-themed children’s dance class at The Hart Space on Hart Street, Southport, on 29 July 2024.
Sir Adrian identifies five overlapping failures that he says “affected and indeed infected all dealings” with Rudakubana from 2019 onwards.
The first, which he calls “the single most important conclusion of Phase 1,” is that no agency took ownership of the risk Rudakubana posed. His case became “an inappropriate merry-go-round of referrals, assessments, case-closures and hand-offs.” Prevent closed three referrals without any reaching the Channel panel, social care repeatedly opened and closed his case, and CAMHS assessed his risk to others as “none” just five months before the attack.
The report also finds that critical risk information was “lost or diluted over time” between and even within agencies.
Multiple agencies used Rudakubana’s autism spectrum disorder diagnosis as an excuse for his violent behaviour, an approach Sir Adrian called “both unacceptable and superficial.” His parents maintained no parental controls on his internet access for the entire period from 2019 to 2024, during which he downloaded an Al-Qaeda training manual, researched weapons and atrocities, and viewed graphic stabbing footage on the morning of the attack.
Sir Adrian also found that Rudakubana’s parents obstructed involvement from key agencies and failed to report what they knew in the week before the attack. On 22 July 2024, Rudakubana’s father intercepted him attempting to take a taxi to Range High School to carry out an attack, finding a weapons cache including a knife, bow and arrows, and bottles of fluid.
“If the parents had reported their true level of knowledge to the authorities prior to 29 July 2024, AR would undoubtedly have been arrested,” the report states.
Sir Adrian identifies 17 March 2022 as the most critical missed opportunity. Rudakubana was found on a bus carrying a knife, told officers he wanted to stab someone, and mentioned making poison. Two probationary constables handled the incident with almost no knowledge of his risk history. He was not arrested.
Had he been, the report concludes, police would have searched his home and found ricin precursors and the Al-Qaeda training manual. “The attack on 29 July 2024 would probably not have occurred,” Sir Adrian writes.
The report finds no shortcomings at the venue or in the emergency response. Leanne Lucas, the workshop organiser, and the other adults present acted with professionalism “above average for such a small community venue.” The attack was “wholly unpredictable.”
The first police officer, PS Gregory Gillespie, arrived within 10 minutes. CI Andrew Hughes’s decision to deploy unarmed officers was described as “undoubtedly the right one.”
The report exposes serious failures in the online weapons supply chain. Rudakubana purchased the murder weapon, a 20cm kitchen knife, from Amazon using a VPN and his father’s details for age verification. Amazon’s vice-president conceded the verification system was “child’s play” to circumvent.
One retailer, Hunting and Knives, operated by Ageo Wholesale UK Ltd, shipped 2,811 bladed items without any age verification via Evri, which does not offer age-verified delivery. The inquiry recommends a criminal investigation.
X, formerly Twitter, refused to remove the Bishop Mar Mari Emmanuel stabbing video that Rudakubana probably watched before the attack. The platform quoted Benjamin Franklin in its refusal and did not express condolences to the victims.
Prime Minister Sir Keir Starmer called the findings “truly harrowing and profoundly disturbing” while Home Secretary Shabana Mahmood said the report showed a “systematic failure” of the state and confirmed the government will respond to all recommendations this summer.
Security Minister Dan Jarvis said the government would “respond as quickly as we practically can” but would not comment on calls for Rudakubana’s parents to face criminal charges, saying it was “a matter for the police.”
Solicitors representing the families of injured children, described the findings as “disturbing and frankly depressing” and called for “whole-scale system reform” across health, social care, education and policing. “We ask that where recommendations have been made, those individuals and agencies to which they are addressed take action now. Not tomorrow,” she said.
Nicola Brook, the solicitor for adult survivors Lucas, Heidi Liddle and Jonathan Hayes, said her clients were “heroes” who had faced “unjustified” criticism on social media. “Every organisation tried to shirk responsibility, and there was a disturbing lack of leadership,” she said, identifying “a culture within government agencies to place their own reputations above their fundamental duty to protect society.”
Merseyside Police and Crime Commissioner Emily Spurrell said it was “heartbreaking that there were so many missed opportunities to intervene” and that recommendations “must be acted on in full and implemented nationally.” Chief Constable Rob Carden accepted the learnings from the report but noted the emergency response on the day was “well managed.”
Lancashire County Council chief executive Mark Wynn said the council was “deeply sorry for the failures identified and for the part we played in the systemic shortcomings that preceded the attack in Southport.”
Southport MP Patrick Hurley said it was “vital that we confront these failings openly and honestly” and that the report’s recommendations must be treated with the “utmost seriousness.”