As a result, he recommended that a legal duty be established requiring parents, legal guardians, or bystanders to report criminal activity.
Chris Walker, a solicitor representing the three bereaved families, added that Rudakubana’s parents had “failed in their responsibility to society”.
“He had not left the house for two years except when armed or seeking to cause harm, yet they allowed him to leave on that day knowing he was likely carrying a weapon.”
Fulford’s report made 67 recommendations in total. Prime Minister Sir Keir Starmer and Shabana Mahmood, the Home Secretary, have both vowed to enact changes to address the findings.
Starmer said he was determined “to make the changes across the entire state that are so clearly necessary to honour the victims, the injured and the families of Southport”.
Mahmood said: “This Government has already taken action to prevent such an awful tragedy from happening again, and we won’t hesitate to do what is needed to protect the public. We owe victims nothing less.”
Rudakubana was jailed for 52 years in January 2025 for the murders of Bebe King, 6, Elsie Dot Stancombe, 7, and Alice da Silva Aguiar, 9. He avoided a whole life sentence because he was nine days too young.
Fulford’s report, comprising two volumes with a total of 763 pages, highlighted five areas of systematic failure, including a misunderstanding of autism, a lack of oversight of Rudakubana’s online activity and an absence of any agency accepting responsibility for him.
The killer was formally diagnosed with autism in February 2021, but Fulford concluded that Prevent, the police and the NHS had failed to understand the threat posed by the disorder and used the condition to excuse his violence.
Merseyside Police previously considered charges against Rudakubana’s parents, but in June 2025, a spokesman said the evidence had not met the required threshold.
In November, the couple gave evidence to the inquiry, prompting the force to confirm its detectives would examine their transcripts.
It is understood that Merseyside Police will be reviewing the newly published report.
Fulford concluded that, had Rudakubana’s parents reported their “true level of knowledge” to the authorities before the attack, their son would have been arrested.
Singling out Rudakubana, a taxi driver, for creating “significant obstructions to constructive engagement” with agencies involved, he said the couple were too willing to defend their son.
Both Rudakubana’s parents, who moved to the UK from Rwanda in 2002 to escape the genocide, gave evidence to the inquiry from remote locations.
In summarising their evidence, Fulford said it was “likely” that Rudakubana’s mother’s fear of knives was a result of experiencing the genocide in Rwanda, making it harder for her to confront her son’s interest in knives.
His mother, a laboratory worker, told the hearing: “There are many things that Alphonse and I wish we had done differently, anything that might have prevented the horrific event of July 29, 2024. [For] our failure, we are profoundly sorry.”
In the US, parents of children who carried out mass shootings have been prosecuted on at least three occasions.
In Georgia, Colin Gray, 55, was found guilty of murder and child cruelty in March this year. Prosecutors argued he was “the one person who could have prevented” his son Colt, 14, from shooting dead two teachers and two pupils at Apalachee High School in Winder in September 2024.
In a statement given at Liverpool Town Hall following the publication of the report, Fulford said the killer’s parents “bear considerable blame for what occurred”.
Key said his two “principal conclusions” were that Axel Rudakubana’s parents were at fault in not reporting his escalating behaviour, and that state agencies – including those in health, education and policing – failed to manage the risk the teenager clearly represented.
However, he said that Rudakubana had turned his parents’ life at home into “little short of a nightmare”, and urged the media not to use his conclusions “in order to vilify or unfairly attack” any individuals.
He added: “Their life at home must have become little short of a nightmare given, to use the words of his own father, [Rudakubana] had turned into a ‘monster’.”
Two of Key’s 67 recommendations addressed problems related to Rudakubana’s family and their actions in the lead-up to the attack.
One said that the Youth Justice Board should produce “clear practical guidance” for parents of children who have been found with a knife or another offensive weapon, including the “importance of informing agencies”.
Fulford also said that the Law Commission should be asked to review the merits of “legal reform concerning whether specific categories of persons ought to be under a legal duty to warn about, or a duty to report, the criminality of another”.
The Prime Minister said on Monday: “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.”
Fulford highlighted that no state agency had accepted responsibility for assessing and managing the grave risk posed by Rudakubana.
He wrote: “Far too often, [Rudakubana’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’.”
He added that various agencies had a fundamental misunderstanding of autism and how it affected Rudakubana’s behaviour.
Fulford said that they “regularly used his autism as an explanation or even excuse for his conduct, including his violence”.
The inquiry chairman added that autism spectrum disorder (ASD), even before its formal diagnosis, had been “a way for agencies such as the police, Prevent and social services to view any difficult behaviour by [Rudakubana] as a ‘mental health’ problem”.
“This reflected a poor understanding of both ASD itself and a misunderstanding of the ability of mental health services to ‘treat’ or address it.”
The first phase of the Southport inquiry heard evidence over nine weeks of hearings. A second phase is due to begin immediately and is expected to report in spring 2027.
The inquiry was told that the killer had been referred to Prevent three times before the attack.
Yet on each occasion, the Government’s anti-terror programme closed his case because he did not seem to have an identifiable terrorist motive.
The inquiry previously heard that the killer was discharged from mental health services six days before he carried out the murders.
Nicola Brook, a solicitor at Broudie Jackson Canter representing the three adult survivors, said: “Of the 67 recommendations made, thoughts must now turn to what mechanism needs to be employed to make sure these changes are actioned in their entirety, and if they are not, how those who seek to sidestep their responsibility are held to account.”
Rob Carden, the chief constable of Merseyside Police, said: “The force accepts the learning set out in the report in relation to the initial response on the day of the attack and will be considering the recommendations in the coming days.
“Importantly, the report does stress that the response as a whole was well-managed and displayed effective inter-agency liaison, and the matters raised for learning did not impact the response provided on the day.”
Lawyers representing the families of children who survived the attack praised their clients for showing “courage, strength and honour in the darkest of days”.
Nicola Ryan-Donnelly, a serious injury solicitor at Fletchers, said the “moral failure” of Rudakubana’s parents made “disturbing reading”.
“It is clear there is a need for whole-scale system reform across health and social care, education and policing.”
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