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The fatal stabbings that turned a Taylor Swift-themed dance class in Southport, Merseyside, into a nightmare on 29 July 2024 would never have happened if public bodies had done their jobs properly. Sir Adrian Fulford’s conclusion, at the end of phase one of the inquiry into the murders, was blunt. The deaths of Bebe King, six, Alice da Silva Aguiar, nine, and Elsie Dot Stancombe, seven, and injuries to 10 other people, were the result of grave failures by police and council officers, health professionals and the anti‑terrorism Prevent programme. The multi-agency systems that are meant to link them together turned out to have deadly flaws.

Sir Adrian prefaced his findings by stating that the responsibility of the perpetrator, Axel Rudakubana, is “absolute”. He also attached significant blame to Rudakubana’s parents, who knew about the 17-year-old’s stockpile of weapons. They ought to have alerted police, above all in the week leading up to the attack, when his father managed to prevent him from taking a taxi to his former school to carry out a violent attack.

While the report does not single out individual police or council officers in Lancashire, where Rudakubana lived, this does not make them any less culpable. On the contrary, their collective failure to take “ownership of risk” is the single most disturbing conclusion. Ministers must not wait for the inquiry’s second phase to explain how they plan to bring this dangerous culture of buck‑passing to an end. It is impossible to ignore parallels with the Nottingham inquiry into the killings carried out by Valdo Calocane in January 2024. Significant differences between the two cases include Calocane’s age (32) and severe mental illness. But both include alarming instances of serious threats to public safety going unaddressed.

The Guardian recently reported on warnings that Prevent risks being “overwhelmed” by referrals for teenagers who are obsessed with violence but lack the coherent ideology of political extremists. The inquiry’s next stage will consider the need for a new mechanism to manage this growing threat. It will also consider tighter regulation of social media use (which the inquiry says “fed” Rudakubana’s violent fantasies) and the online sale of weapons. But the findings so far point to the need for new policies, as well as tighter processes and increased resources. The failures went beyond missed communications and overstretched staff.

The inquiry, for example, found that Lancashire council was overly focused on “risks to” Rudakubana rather than “from him” – a cruel irony for his victims and their families. On two occasions, police did not arrest him for carrying knives because custody was viewed as a “last resort” for teenagers. There were also issues linked to his delayed autism spectrum disorder assessment. While Sir Adrian stressed that there is no general link between autism and violence, Rudakubana’s diagnosis was used to explain his behaviour by officials with a “poor understanding”.

Any changes to the law will need to be carefully considered. The specific circumstances of Southport will not be repeated and there are risks with making policy off the back of one case, however tragic. But this inquiry and its brave participants have performed a valuable public service. First, they have provided a clear account of the dreadful sequence of events leading up to the murders. Second, they have unearthed a large amount of material with broader relevance to the way that our society deals with – and fails to deal with – individuals with a disturbing interest in violence.