A report into the Southport attack on Monday found that it was a 'clearly signposted disaster waiting to happen'.

Sir Adrian Fulford, chairman of the public inquiry investigating the atrocity, said Axel Rudakubana, 17, would not have been free to murder three young girls at a Taylor Swift-themed dance class, in July 2024, had his parents reported his escalating violence and hoarding of weapons to police.

In a damning report, the retired High Court judge also criticised police, social services, mental health teams, youth justice services and other agencies who failed to take responsibility for his case.

Here Liz Hull and Duncan Gardham assess some of the key failings highlighted by Sir Adrian's report.

Prevent

Sir Adrian said he had 'grave concerns' that individuals, such as Rudakubana, who are 'fixated' on violence, do not currently come under the remit of the Government's de-radicalisation programme, Prevent.

The teenager was referred to the strategy three times but each time his case was dismissed because he didn't have a fixed ideology.

Last month the Home Affairs Select Committee said the Prevent programme was 'outdated' and 'inadequately prepared' to deal with 'the complexity of current extremist threats' and called for it to be 'reset' and overhauled.

Sir Adrian said: 'In my judgement, the events of July 29 2024 have exposed a significant gap in the mechanisms by which the public are provided protection, including by way of adoption by the Prevent programme.'

He pointed to a 'critical error' when Rudakubana's first Prevent referral was made, in December 5 2019.

The inquiry heard that, despite searching for information on American school shootings during a computer lesson and also asking to see a picture of a severed head, Rudakubana's case was not escalated for intervention.

Greater Manchester Police, the force responsible for overseeing Prevent referrals in the North West at the time, failed to ask for Rudakubana's browsing history, which would also have revealed that he had been looking for gory pictures of 'degloving injuries'.

'Any competent analysis of the browsing history would have identified the concerning searches,' Sir Adrian said.

Mental health and autism

Officials repeatedly used Rudakubana's diagnosis of autism to excuse his behaviour, including his violence, Sir Adrian found.

'This was both unacceptable and superficial' and left him 'unmanaged,' he said.

The chairman pointed to the 'insipid response' of the child and youth justice service who did not check his internet use and repeatedly closed Rudakubana's case when he refused to attend appointments.

Rudakubana's diagnosis was also used as an excuse for him accessing inappropriate content about school massacres when his case was dismissed by Prevent, the report found.

Sir Adrian said the condition also led to a 'collectively inadequate response' to reports of violence towards his parents and by police and social services when he was found on a bus with a knife, in March 2022.

According a police report into that incident, Rudakubana was suffering from a 'bad mh [mental health] episode' as regards 'multiple mental health issues'.

Despite indicating to officers that he wanted to stab someone, Rudakubana was not arrested for having a weapon in public but instead was treated as a 'vulnerable' person and simply taken home with more referrals to mental health teams and social care.

Officials never recognised that his autism 'significantly increased the risk that he posed,' Sir Adrian added, which also meant his obsession with violence and weapons 'escalated' to beyond what was normal.

Weapons

Rudakubana was able to accumulate a small arsenal of weapons, including knives, machetes, a bow and arrow and a sledgehammer, in the years before the attack – despite being under 18.

Sir Adrian was condemnatory in his criticism of online retailer Amazon for its inadequate age verification process. This allowed the then 17-year-old to order the eight-inch kitchen knife he used to murder by entering the name and date of birth of his father instead of his own.

Rudakubana also used a combination of fake identities and false information to buy three machetes, from three different online retailers, including one in Spain that used a delivery firm that wasn't even asked to check the recipient's age.

John Boumphrey, UK boss of Amazon, admitted the firm had 'got the balance wrong' and did not contest that it was 'child's play' for anyone to circumvent their supposed controls, in his evidence to the inquiry.

Although the firm has since made improvements, Sir Adrian said it was of 'profound concern that it took an incident of this magnitude to prompt Amazon into instituting new processes'.

'The consequences of these lax and inadequate safeguards contributed significantly to the profound and tragic consequences in this case,' he added.

Harmful online material

Sir Adrian found that 'degrading, violent and misogynistic' material Rudakubana viewed online 'fed' his unhealthy fascination with violence and prompted him to acquire a dangerous arsenal of weapons.

But the lack of exploration of his online activity was a 'significant failing' that 'hampered' agencies from identifying and addressing the risk he posed to others, Sir Adrian said.

Investigations by Lancashire County Council's children and family wellbeing service were 'highly limited and ineffectual' and amounted to little more than asking Rudakubana whether he was aware of the need to remain safe on the internet, the report said.

There was also a 'lack of curiosity' about how Rudakubana, who had not attended school for two years and was a near total recluse in the months prior to the attack, was spending his time.

Significantly, Sir Adrian said, his parents had not set any parental controls on his computer devices and 'more remarkably still' this went 'unnoticed and unchallenged' by all the agencies dealing with him.

Rudakubana set up accounts on X and Instagram, using fake dates of birth, and primarily followed young female influencers, the report revealed.

He had used his laptop, two tablets to view numerous images and articles relating to international conflicts in Gaza, Ukraine, Sudan, Korea, Iraq and the Balkans, as well as pictures of dead bodies, the Twin Towers in New York and the victims of torture and beheadings.

Other subjects focused on the enslavement of women, torture, death, weapons and genocide, including ethnic cleansing in Somalia and Rwanda, where his parents were born. He also looked at mass graves with naked bodies in Nazi Germany, killings in Chechnya, and the fight against ISIS in Mosul.

Sir Adrian said the materials were 'seriously and offensively demeaning to women and girls.'

The inquiry heard that, six minutes before he left the house to carry out his murder spree, Rudakubana used Elon Musk's X social media site to view a video showing a knife attack on a conservative Syrian bishop in Australia called Mari Mari Emmanuel by a 15-year-old teenager.

But X only revealed to the inquiry that Rudakubana had lied about his age to set up an account when they received a hard copy request for information from the inquiry at their European headquarters, in Dublin.

Sir Adrian said it was also 'deeply regrettable' that X, formerly Twitter, refused a Home Office request to remove the video and 'failed to express any condolences to the victims'.