The chairman of the Southport inquiry has demanded a change in culture after uncovering a series of damning failures ahead of the attack at a Taylor Swift-themed dance class.
Sir Adrian Fulford, who released his 700-page report today, used variations of the word "fail" 295 times as he set out 67 recommendations.
The inquiry was called after AR, who GB News has chosen not to name at the request of the victims' families, killed three girls who attended a dance class in the Merseyside town.
Alice da Silva Aguiar, nine, Bebe King, six, and Elsie Dot Stancombe, seven, were murdered when the 19-year-old entered the dance class armed with a knife on July 29, 2024.
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Alice da Silva Aguiar, nine, Bebe King, six, and Elsie Dot Stancombe, seven, were murdered when the 19-year-old entered the dance class armed with a knife on July 29, 2024
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The report sets out key failures that "overlapped and exacerbated" AR's ability to carry out the attack.
Sir Adrian identified Lancashire Constabulary’s Community Safety team's response to handing over AR's case to Prevent as a key issue.
Another failure centred around Prevent declining to refer AR to a channel panel on three occasions.
The report added: “Far too often, AR’s ‘case’ was passed from one public sector agency to another in an inappropriate merry-go-round of referrals, assessments, case-closures and ‘hand-offs.’
Sir Adrian Fulford released his 700-page report today
|GB NEWS
“This culture has to end. This failure lies at the heart of why AR was able to mount the attack, despite so many warning signs for his capacity for fatal violence.”
Other failures listed by Sir Adrian included poor information management and sharing, the excusing of AR’s behaviour on the basis of perceived or diagnosed autism spectrum disorder (ASD), the failure to oversee and intervene in AR’s online behaviour, and the role of the teenager's parents.
AR's parents were described as "too ready to excuse and defend AR's actions", adding: "They failed to stand up to his behaviour and set boundaries... and they ultimately failed to report the clear escalation in risk in the period July 22 to July 29, 2024."
Sir Adrian set out a total of 67 recommendations based on the findings of the Southport inquiry.
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Southport mourners paid their respects to the three young girls who were murdered last year | GETTYThe recommendations target key failures that allowed the attack to go ahead and the agencies that missed key details that failed to stop the attacker before his stabbing spree.
Sir Adrian included the Department for Transport, NHS England, the North West Ambulance Service, the Home Office, Lancashire County Council, Lancashire Constabulary, Merseyside Police, the Department for Health and Social Care, Counter Terrorism Policing North West, Prevent, and the Department for Education.
The inquiry advised establishing a single dedicated agency or structure with responsibility for monitoring and co-ordinating interventions for children and young people who present a high risk of serious harm.
Sir Adrian's recommendations will now be put forward as part of phase two of the Southport inquiry.
Sir Keir Starmer, who paid his respects to the children killed in Southport at the time, is vowing to implement Sir Adrian's recommendations
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Making a statement immediately after the release of his report, Sir Adrian said: "One of the most striking conclusions from this inquiry's extensive investigation is the sheer number of missed opportunities over many years to intervene meaningfully, which directly contributed to the failure to avert this disaster.
"Numerous systems that should have provided oversight, assessment and protection were ineffective or inadequately used.
"Some failed outright. The consequences were catastrophic.
"It is unrealistic to suppose that all violent individuals can be prevented from carrying out attacks on others.
"But when a truly grave risk is clearly identified, our society is entitled to expect, at the very least, that meaningful and substantive steps will be taken to avert the impending disaster. That conspicuously did not happen in this case."
In a statement published shortly after the inquiry's release, Sir Keir Starmer said: "The brutal, senseless murders of Bebe, Elsie and Alice marked one of the darkest moments in our country’s history.
"The report today is truly harrowing and profoundly disturbing. It sets out systematic failures that led to this terrible event.
"I’ve been overwhelmed by the bravery and determination of their families and while nothing will ever bring these three little girls back, I’m determined to make the fundamental changes needed to keep the public safe. I will do everything I can to honour the memory of Bebe, Elsie, and Alice."