Victims at the heart of a damning inquiry – and a warning that must not be ignored
Editor of The Southport Lead, Jamie Lopez, reflects on the damning Phase One of the Southport Inquiry and what must happen next
As the dust settles after the publication of the findings of Phase One of The Southport Inquiry, what happens next is of the utmost importance – and the victims and their families cannot be failed again.
On Monday, inquiry chair Sir Adrian Fulford delivered a 700-page report, the culmination of months spent hearing deeply harrowing testimonies. As we reported in The Southport Lead, the families of the victims are steadfast in their belief that this must be a turning point.
During emotional hearings at Liverpool Town Hall, the surviving victims and relatives detailed their experiences of the attack and their lasting trauma in heartbreaking detail, as did emergency services and members of the public who witnessed – or were suddenly drawn into – the events of the day.
Conversely, representatives of the agencies and services which dealt with Axel Rudakubana before he carried out his attack exposed how he was able to slip through the cracks and avoid proper intervention. Online retailers who sold weapons to the teenager also revealed an alarming lack of curiosity and care for what happened with their products.
Sir Adrian’s conclusions are direct, damning, and deeply troubling. Across his report, versions of the word ‘fail’ appear nearly 300 times. Almost every agency or service which came into contact with Rudakubana was found to be in some way culpable for not doing more.
Presenting his findings on Monday, Sir Adrian said: “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 AR’s parents, this dreadful event would not have happened.
“It could have been, and it should have been, prevented.”
For those who have followed the inquiry, Sir Adrian’s conclusions will not come as a shock, but to see them all together, in black and white, is stark.
Sir Adrian delivered 67 recommendations and a clear message that he will be expecting action and demanding answers during Phase 2, which will also last for around a year and examine in detail the role of internet and social media on potential violent individuals and how they are monitored.
The families of Bebe King, Elsie Dot Stancombe, Alice da Silva Aguiar have been unimaginably brave and determined in their efforts to create legacies for their children. Each of the girls has a charity set up in their name – Bebe’s Hive, Elsie’s Story and Alice’s Wonderdance – as their families find ways to help other children live the lives theirs did not get to.
Whether it be for supporting children to be able to dance, creating a safe space for young people to talk about their grief or creating other opportunities, the charities work tirelessly to enrich the lives of other children. Their work is visible here in Southport and has been openly and widely embraced by the community.
But it is another goal which means so much to the families: stopping anyone else from suffering the same fate.
As Sir Adrian said in the report: “A consistent concern raised by the victims of the attack has been that recommendations from past reviews and inquiries have not led to meaningful change. It is therefore essential that they are informed, in concrete terms, of the action to be taken in response to the Phase 1 recommendations.”
For the families and for all those others affected by the heinous attack, it is essential that real change takes place and that another preventable atrocity like this does not happen again. We should see reform of those services identified and their cultures to ensure greater accountability; systemic changes such as greater information sharing and potential law changes to compel parents with similar concerns to report their child
That is the legacy they deserve. Not apologies – but change.
Chris Walker, the lawyer representing the three families at the inquiry, made clear they want to see action and accountability: “Let us be clear now these reforms require urgent and full implementation. On behalf of the families, we repeat the chair’s hope that this marks a genuine turning point.
“Our clients have endured unimaginable loss, and their priority has always been preventing this from happening to another family while seeking individual and systemic accountability.
“This fight does not end today. We call for immediate action, clear accountability and real change - not simply reassurances that ‘lessons have been learned’. The public deserves systems capable of identifying escalating risk, protecting the vulnerable and preventing acts of mass violence. We, alongside our clients, will continue to push for that change until it is achieved.”
Mr Walker went further when speaking to the BBC, saying he was “aghast” at the actions of five state entities –counter-terrorism agency Prevent, Lancashire Police, Lancashire social services, Child and Adolescent Mental Health Services, and Forensic Child and Adolescent Mental Health Services – and took the extraordinary step of saying he would publicly name individuals from these if disciplinary action, reform and job losses did not occur.
Vera Baird KC, a former victims’ commissioner, echoed those remarks as she said it is “pointless” to carry out such exercises if people are not held accountable.
She added: “You can’t be sure, if you’re living in Southport, that the people who made the mistakes won’t be making the same mistakes again today.”
Go deeper on this story with our In Conversation podcast (for paid subscribers only) and hear directly from Jamie Lopez about the Southport Inquiry and his coverage since 2024 in the town. Tap below to listen to the podcast.
Inside the Southport Inquiry
As the dust settles after the publication of the findings of Phase One of The Southport Inquiry, what happens next is of the utmost importance – and the victims and their families cannot be failed again.
In the background of these efforts, we can see attempts to attach very different meanings and responses to what happened. Robert Jenrick, former Conservative minister and Reform UK MP called for Rudakubana’s parents – who were granted asylum in the UK in 2002 – to be deported, arguing that “the fear of being smeared as racist is costing lives”.
The killer’s parents were condemned by Sir Adrian, after the report found that they bore “considerable blame” for the tragedy by creating “significant obstructions to constructive engagement” with authorities as their son’s behaviour was escalating, and were “too ready to excuse and defend his actions”.
Conservative leader Kemi Badenoch made similar overtures about deportation as an avenue to repeat her call for the government to withdraw from the European Court of Human Rights.
While there should be no effort to downplay the extent to which they failed their moral and parental duties, these comments smack of political opportunism, repeating party lines rather than truly focusing on the people at the heart of what happened.
This opportunism was evident in the days following the attack. As misinformation spread online about the perpetrator’s religion and immigration status, tensions escalated into racist violence: riots broke out, a mosque was attacked with fire and bricks and communities across the country felt the impact.
In total, 1,876 people were arrested for the violence, with over one thousand charged, and it took days to restore order. Nigel Farage, meanwhile, was all too willing to amplify the rhetoric that helped to fuel the unrest. At the same time, Elsie’s grieving mum felt compelled to beg people to stop rioting.
Almost two years on, it is again clear whose voices we should be listening to.
What happened in July 2024 will always be a part of Southport. The town’s MP Patrick Hurley, who was elected just weeks before the attack, said in Westminster this week: “The families affected do not want their lives to be defined by the attack, and we must not allow my great town to be defined by it either.”
In the nearly two years since, the aim has been clear: build a legacy that shows good can still triumph over evil. It is evident in the extraordinary work done by the charities; in Alice’s dad Sergio completing six marathons to raise funds, and in the planned £10m redesign of the Town Hall Gardens in their memory.
What will matter most though, is not words but change – change that ensures nothing like this can ever happen again. ■
About the author: Jamie Lopez is editor of The Southport Lead and a freelance journalist based in Southport.
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You are absolutely right that it is change, real change to make things better and to stop bad things happening again, that matters.
Time and time again we see huge amounts of time and money spent on inquiries into terrible failures and miscarriages of justice but many of recommendations get lost or forgotten.
Do we lack the means to improve the services and agencies which failed?