The most striking missed opportunity was in March 2022, when Rudakubana went missing from home and was found with a knife on a bus, telling police he wanted to stab someone. He also admitted to thinking about using poison.

Instead of arresting the teenager as they should have done, Fulford said, Rudakubana was returned home by two rookie police officers, who advised his parents to hide their knives.

Had Rudakubana been arrested, his home would probably have been searched, leading to the discovery of the ricin seeds he had bought and the terrorist material on his computer, the report found.

Fulford concluded: “Rigorously putting out of mind the so-called ‘benefits of hindsight’, I have no doubt that if appropriate procedures had been in place and if sensible steps had been taken by the agencies and [Rudakubana’s] parents, this dreadful event would not have happened. It could have been and it should have been prevented.”

Rudakubana was referred three times to Prevent, the counter-terrorism agency, over concerning remarks he had made or material he had searched online at school.

Prevent dismissed his case each time on the basis that he had no clear ideology such as jihadism or rightwing extremism. Counter-terrorism officers have accepted this was a mistake.

Fulford criticised a repeated tendency of professionals to “excuse” Rudakubana’s increasingly violent and unpredictable behaviour on the basis of his suspected, and later confirmed, autism diagnosis. “This was both unacceptable and superficial,” he said.

Fulford said he accepted that professionals dealt with Rudakubana in good faith, despite many shortcomings.

But he added: “The frankly depressing – and therefore urgent – matter requiring government attention is this failure, at an organisational and individual level, to stand up and accept responsibility for managing the risk that [Rudakubana posed].

“Far too often, [the killer’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’.”

To avoid a repetition of the attack, Fulford said, this “culture has to end”, adding: “This failure lies at the heart of why [Rudakubana] was able to mount the attack, despite so many warning signs of his capacity for fatal violence.”

Publishing his 260-page report at Liverpool town hall, Sir Adrian Fulford said Britain’s multi-agency model for troubled young people had “completely failed” and that ministers should establish a new dedicated agency or structure to oversee complex offenders such as Axel Rudakubana.

He said there was a “fundamental failure” by any organisation to take ownership of the risk Rudakubana posed, including a “disturbing lack of clarity” about who, if anyone, was the lead agency.

Fulford added: “Numerous systems that should have provided oversight, assessment and protection were ineffective or inadequately used. Some failed outright. The consequences were catastrophic.”

The inquiry said he had “profound concerns” about the “misguided and irresponsible” actions of Rudakubana’s parents, Alphonse Rudakubana and Laetitia Muzayire, who discovered in the weeks before the attack that their son was building a lethal arsenal of weapons but failed to report it to police for fear he would be arrested or taken into care.

He said: “If the full extent of [Rudakubana’s] family’s concerns had been shared with authorities in late July 2024 – including on the day of the attack – it is almost certain this tragedy would have been prevented.”

Axel Rudakubana was able to carry out the Southport atrocity because of “catastrophic” failures by multiple agencies and the “irresponsible and harmful” role of his parents, a damning inquiry has found.

Sir Adrian Fulford condemned the “inappropriate merry-go-round” of state bodies passing the buck and their “frankly depressing” refusal to accept responsibility, saying: “This culture has to end.”

The inquiry chair said the murder of the three young girls – Bebe King, six, Alice da Silva Aguiar, nine, and Elsie Dot Stancombe, seven – and stabbing of 10 others was not “a bolt of lightning out of a clear blue sky”.

He added: “Instead, some form of grave violence … had been clearly, repeatedly and unambiguously signposted over many years.

“Indeed, several professionals who had direct contact with [Rudakubana] expressed serious fears, sometimes in stark terms, that he would go on to harm or kill.”

Rudakubana was jailed for life last year after his ferocious assault on young girls at a Taylor Swift-themed holiday club in the Merseyside town on 29 July 2024.

Ministers are “failing to learn the lessons” from the Southport attack and allowing violence-obsessed teenagers to remain a “catastrophic” threat to society, lawyers for victims of the atrocity have said ahead of the findings of an official inquiry.

A report on the July 2024 attack by the judge Sir Adrian Fulford, to be released on Monday, is expected to strongly criticise failings by a series of agencies, including the counter-terrorism programme Prevent.

The killer, Axel Rudakubana, was referred three times to Prevent but concerns were dismissed, partly because he did not express a clear ideology.

Counter-terrorism officials have since promised that those who are not clearly motivated by jihadism or other beliefs will now pass through Prevent if they have a clear obsession with extreme violence, like Rudakubana.

However, a Guardian analysis has found that barely one in 10 of the 3,400 cases highlighting these concerns in children and teenagers went on to receive anti-radicalisation support in the year to March 2025.

Chris Walker, the solicitor for the families of the three murdered girls – Bebe King, six, Elsie Dot Stancombe, seven, and Alice da Silva Aguiar, nine – said the system was “not fit for purpose and must undergo fundamental changes to reduce serious risks to society.”

Addressing whether the government would act on the recommendations of the Southport inquiry ahead of the findings being published on Monday, the prime minister told reporters: “I gave my word that we will get to the bottom of this and that’s why we’ve set up the inquiry.”

He added:

We will act on the recommendations, it’s really important that we do so. So obviously there will be the full report, there will be the recommendations, we can go through them in detail – but this, for me, is a matter of principle.

It’s absolutely right that we act on the findings of this, and we will act on those findings.

Questioned on whether organisations should be held accountable, Keir Starmer said:

There does have to be accountability, there should always be accountability.

The first most important thing is to look at what those recommendations are, what needs to change, and to be a government that says ‘we’re going to carry this, we’re going to do what we said’ – we gave our word on this and when we give our word, we’ll follow through on that.

Chairman Adrian Fulford, who will publish his report at midday, said the obligation was to provide answers to victims and their families.

Concluding the hearings in November, he said:

Our principal responsibility lies to them, to provide the best possible explanation as to why and how this terrible event occurred, and to be brave about suggesting the changes that ought to be made to prevent, if we can, a repetition.

A second phase of the inquiry will be informed by the findings of phase one and is expected to focus on the risk posed by young people with a fixation, or obsession with, acts of extreme violence.

The inquiry, held over nine weeks at Liverpool Town Hall last year, heard from more than 100 witnesses, including 67 who gave live evidence.

It covered topics including Rudakubana’s involvement with health services, social care and education, and the three referrals to anti-terror programme Prevent which were made, and closed, before he carried out the attack.

Solicitor Nicola Brook from Broudie Jackson Canter, who represent Leanne Lucas, John Hayes and another adult survivor, Heidi Liddle, said:

Sitting through the extensive list of failings exposed during the first phase of the inquiry provoked an understandably complex mix of emotions for our clients, who battle the daily consequences of survivors’ guilt.

We hope the report will expose every entity that failed to act in time to prevent this catastrophic attack, and any agencies that are found to be at fault are committed to not just learning lessons but demonstrating, publicly, that they are committed to taking every step to prevent such an atrocity from happening again.

We cannot look back on this inquiry in years to come and summarise it as another navel-gazing exercise for the government.

She added:

There is no regulatory mechanism to ensure that recommendations are properly considered and acted upon at the end of an inquiry, which is why we are strongly urging the chair to implement a process to monitor the progress of all recommendations and provide evidence to support them, as happened at the Manchester Arena Inquiry.

Since that harrowing day, our clients’ thoughts have remained with the bereaved and will remain so today.

The findings of the public inquiry into the Southport attack are to be published at 12pm.

The inquiry heard evidence about the attack and the involvement of state agencies with killer Axel Rudakubana, 19, in the lead up to it.

Alice da Silva Aguiar, nine, Bebe King, six, and Elsie Dot Stancombe, seven, were murdered when Rudakubana entered the Taylor Swift-themed dance workshop in The Hart Space, armed with a knife, on 29 July 2024.

The killer, then 17, also attempted to murder eight other children, who cannot be named for legal reasons, class instructor Leanne Lucas, and businessman John Hayes.