A Lancashire-led probe into the contact between local agencies and Southport killer Axel Rudakubana could be scrapped, the Local Democracy Reporting Service (LDRS) understands.
It comes after publication of the first of two reports from the national public inquiry set up in the wake of the murders, in July 2024, of Bebe King, who was six, Elsie Dot Stancombe, aged seven, and nine-year old Alice da Silva Aguiar.
Lancashire County Council and Lancashire Police were amongst several public sector bodies whose involvement with Rudakubana prior to his attack – at a Taylor Swift-themed dance class in the coastal town – has been put under the microscope as part of the inquiry process.
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A dozen recommendations have been made to the county council for actions it should now take in response to the findings of the first-phase report – which was published on Monday – while the police force has received seven.
In January last year – less than a week after the then 18-year-old Rudakubana, from the village of Banks in West Lancashire, pleaded guilty to the murders – it was announced that a local child safeguarding practice review (CSPR) was to take place.
The Prime Minister, Sir Keir Starmer, had already said – within 24 hours of the guilty pleas – that an independent public inquiry would be carried out into the atrocity.
As a result, Lancashire County Council had to liaise with the government over how – and whether – the national inquiry could affect the local review.
The LDRS can now reveal that the Lancashire CSPR was paused shortly afterwards, before fully getting under way.
While the review has not officially been cancelled, the expectation among the agencies spearheading the process is understood to be that the public inquiry will supersede the work that they had been planning to undertake.
However, a final decision on the future of the CSPR will not be made until the national inquiry concludes.
Inquiry chair Sir Adrian Fulford said on Monday that he expected its second phase to take roughly as long as the first, which lasted 12 months.
As part of CSPR – commissioned by the Lancashire Children’s Safeguarding Assurance Partnership – a trio of experts were set to examine the roles of the raft of services that dealt with Rudakubana in the years before he went on the rampage in Southport at the age of 17.
The partnership – made up of Lancashire County Council, Lancashire Constabulary and the NHS Lancashire and South Cumbria Integrated Care Board – exists to improve how agencies work together to safeguard and promote the welfare of children. It requests CSPRs in an attempt to learn from incidents in which children have been harmed – and to reduce the risk of similar cases happening in future.
However, that is also one of the primary purposes of the nationwide inquiry, which has been exploring the roles of the county council’s children’s social care and education services, the police, the NHS and the counter-terrorism strategy Prevent during the period from when Rudakubana’s behaviour began to “markedly deteriorate” in September 2019 through to the day of the killings on 29th July, 2024.
Speaking at Liverpool Town Hall on Monday, Sir Adrian said that “if the relevant agencies, individually and collectively, had properly managed and responded to the known danger that AR [Rudakubana] posed to others – from December 2019 onwards – it is highly likely that this event would not have occurred”.
“There would instead have been a range of entirely different outcomes, which would have included AR being taken into care as being beyond his parents’ control – which he was – or into custody, for instance, as a result of his production or attempted production of the poison ricin.
“History simply would have taken a different course,” Sir Adrian added.
The near 800-page report condemned the “failure of any organisation or multi-agency arrangement to take ownership of the risk that AR posed”, as reflected by the “disturbing lack of clarity as to who, if anyone, was the lead agency, which persisted through the inquiry’s hearings”.
“Witnesses in appropriate positions were asked who was responsible for AR’s risk. There was no consistent response,” the document explained.
Sir Adrian’s first recommendation is that the second phase of his own inquiry 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”.
His report also noted what were described as “significant parental failures” – notwithstanding the pressure that Sir Adrian acknowledged Rudakubana’s mother and father were under as a result of their son’s deteriorating behaviour.
What could Lancashire County Council have done differently?
Sir Adrian said the killings were an attack of “unparalleled cruelty” – and stressed that Rudakubana was “not suffering from any kind of mental illness”.
He also emphasised in his report that he “entirely” accepted all Lancashire County Council employees had “acted with an intention to do good”, while undertaking “difficult and pressured jobs in challenging circumstances” within a system that was “ill-suited to dealing with AR”.
Nevertheless, during the presentation of his findings, Sir Adrian said there was “a notable lack of appreciation by the local authority of the need to manage the risk which AR posed to others”.
He added: “Indeed, the enduring focus of those involved with AR was on the risks to him, rather than the need to protect the public from him.
“One of the key lessons from this terrible attack is that the present child protection system is imperfectly designed to cope with children and young people when it is apprehended there is a real risk that they may inflict serious harm on others.
“A consequence of this critically blinkered approach was that, on a number of occasions, AR’s case was closed by social care when that should not have happened – and, equally, there were times when his case was not escalated to a higher level, when this step was necessary.
“In both situations, AR’s dangerousness was given insufficient consideration,” said Sir Adrian.
His report recounts all the incidents of violence involving Rudakubana during the years he was on the radar of the authorities.
They began in early October 2019 when he contacted Childline on a number of occasions stating he wanted to kill another pupil whom he claimed was bullying him. He later admitted to police to having carried a knife to school around 10 times – and said he would have used it to kill “if things got to a certain point with the bully”, the inquiry report said.
Two months after his resultant expulsion from school, he returned with a hockey stick that had been modified for use as a weapon – and was also again armed with a knife – intending to attack his perceived bully. When confronted by staff, he set upon a completely random pupil instead.
Rudakubana was sent to a pupil referral unit and later a specialist school. However, Sir Adrian said as he presented his report that Lancashire County Council had “failed in its obligation over a substantial period of time to investigate AR’s prolonged absences from school, or to consider the best means of addressing his educational needs by way of alternative schooling”.
Elsewhere, the authority’s interest in Rudakubana’s online activity was criticised in the inquiry report for being only “cursory” when the teenager had, Sir Adrian said during his presentation, been viewing “a wide range of deeply inappropriate and disturbing” subject matter.
The report also noted that in spite of being referred in February 2022 to the team responsible for ensuring youngsters approaching the age of 18 – who have been involved with children’s social care – have “a smooth transition” to adult services, Rudakubana was not visited by that team until November 2023.
No write-up of that visit had been produced by the time of the killings the following summer and “no follow up was actioned”, the inquiry found.
It was concluded by the inquiry that had Rudakubana not committed the attack shortly before turning 18 – in August 2024 – there would have been no support in place for him beyond that date and “no proper consideration of what support would have been appropriate”.
However, Sir Adrian said in his report he had been “reassured that there have been extensive changes implemented by [the county council] in this area since 2023”.
Separately, during his presentation, he also noted “significant examples of poor record keeping and inadequate information sharing”.
What Lancashire County Council says
Mark Wynn, Chief Executive of Lancashire County Council, said in response to the inquiry report: “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 29th 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.
“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.
What Lancashire County Council should do
Of the inquiry’s 67 recommendations, 12 are directed towards Lancashire County Council:
Recommendation 22: 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. This review should ensure that all frontline staff have a consistent and up-to-date understanding of online risks and that they have access to effective tools and guidance to identify and respond to these risks. It should specifically 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.
Recommendation 40: Lancashire County Council should ensure that by 13th October, 2026 all its frontline staff have received suitable training, or refresher training, on Prevent.
Recommendation 41: Lancashire County Council should ensure that its arrangements for social workers provide appropriate support and supervision for family support workers handling Level 3 cases on the Continuum of Need.
Recommendation 42: Lancashire County Council should review its processes and training to ensure decisions regarding children and families are made on the basis of assessed need rather than inflexible criteria such as duration or ease of arranging services.
Recommendation 43: Lancashire County Council should ensure that its policies and training emphasise the significance of multiple referrals when considering the relevant risks relating to a child (including the risk to others).
Recommendation 44: 1) Lancashire County Council should ensure that frontline staff are required to familiarise themselves with full case information, with this being embedded through training and performance review. 2) Lancashire County Council should review its IT systems to ensure that there are adequate mechanisms to bring all relevant information speedily to someone’s attention. The warning markers visible on the front page should include markers relevant to risk of harm to others and use of or access to weapons, as well as factors relating to risk of harm to a child. 3) Lancashire County Council should conduct sampling audits to monitor record-keeping practices.
Recommendation 45: Lancashire County Council should ensure frontline staff receive appropriate training on autism spectrum disorder, emphasising that autism does not necessarily explain or excuse behaviour. The Department for Education should ensure this approach is applied nationally.
Recommendation 46: 1) Lancashire County Council should consider how to address repeated lack of consent or manipulation of consent within existing legislation. 2) Phase 2 [of the inquiry] should consider whether legal reforms are needed to permit agencies, when considering children and young people who pose a risk of violence to others, to override parental consent to share information, access a child or young person, or obtain information about their online activity.
Recommendation 47: Lancashire County Council, in consultation with the Youth Justice Board, should arrange for a comprehensive and independent audit to be undertaken of the Lancashire County Council Child and Youth Justice Service to report by 13th October, 2026. This should include assurance that the service is holding young offenders to sufficient standards and boundaries in referral orders, and that interventions are focussed and appropriate.
Recommendation 48: 1) Lancashire County Council should ensure that staff within Children and Family Wellbeing Service, and Children’s Social Care receive training on the services available through the Child and Youth Justice Service, including prior to any court or out of court disposals such as Prevention and Diversion. 2) Lancashire County Council should offer input on this topic to Lancashire Constabulary, Counter Terrorism Policing North West and any relevant Child and Adolescent Mental Health Service
Recommendation 49: Lancashire County Council, with the Care Quality Commission, should commission an independent audit of the Young Adults Team to ensure assessments for transition to adult care are timely, properly reasoned and take full account of the individual’s history. This should report by 13th October, 2026
Recommendation 61: Lancashire County Council should, by no later than 13th October 2026, carry out and report on an audit (preferably involving an experienced independent external member) to review: 1) The speed of response to cases where a need for alternative education provision is raised including for those over 16 with an Education, Health and Care Plan; 2) The effectiveness of its monitoring of (and action in response to) school attendance with particular attention being given to (i) children who live in Lancashire but attend school in neighbouring counties; (ii) the resourcing of home visits in appropriate cases; (iii) whether appropriate action is being taken where parents refuse to allow school attendance workers to see a child who is not attending school. 3) The effectiveness of the Education, Health and Care Plan portal approach which has been put in place.
Source: The Southport Inquiry Phase 1 report
Inquiry’s key findings
The report concludes that the Southport attack was foreseeable and avoidable and highlights five major areas of systemic failure:
- Absence of risk ownership: No agency or multi-agency structure accepted responsibility for assessing and managing the grave risk posed by the perpetrator.
- Critical failures in information sharing: Essential information was repeatedly lost, diluted or poorly managed across agencies.
- Misunderstanding of autism: AR’s conduct was wrongly attributed to his autism spectrum disorder, leading to inaction and a failure to address dangerous behaviours.
- Lack of oversight of online activity: AR’s online behaviour, which provided the clearest indications of his violent preoccupations, was never meaningfully examined.
- Significant parental failures: 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.
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