“One of the most striking revelations from this inquiry’s comprehensive investigation is the multitude of missed chances over many years to take meaningful action, which directly led to the inability to prevent this disaster,” stated Fulford.

“The consequences were catastrophic.”

At the age of 17, Rudakubana carried out an attack in northwestern England, resulting in a life sentence with no possibility of parole for 52 years. This sentence was given for the murder of Alice Da Silva Aguiar, 9, Elsie Dot Stancombe, 7, and Bebe King, 6, as well as for injuring eight children and two adults.

The incident in Southport sent shockwaves through the nation and incited days of unrest after far-right extremists manipulated erroneous reports that the attacker was a Muslim migrant who had recently entered the UK. In reality, Rudakubana was born in Wales to Rwandan Christian parents.

The inquiry’s report outlined 67 recommendations aimed at preventing such tragedies in the future. In response, British Prime Minister Keir Starmer vowed to implement changes addressing the “systematic failures that led to this terrible event.”

“Today’s report is truly harrowing and profoundly disturbing,” said Starmer.

“While nothing will ever bring these three little girls back, I’m determined to make the fundamental changes needed to keep the public safe.”

Police, social workers and educators were well aware of problems with Rudakubana.

At age 13, he was convicted in 2019 of assaulting another child at school with a hockey stick and placed under supervision of a local service for youth offenders.

He was referred to the government’s anti-extremism program, Prevent, three times between 2019 and 2021 for expressing interest in school shootings, the 2017 London Bridge terror attack, the Irish Republican Army and the Middle East. Each time, the case was closed because he was not considered susceptible to becoming a terrorist.

During that same period, local police were called to his home five times more than unspecified concerns about his behaviour. He was given mental health and educational support, but later appeared to have stopped engaging with social workers. He was expelled after bringing a knife to school and hardly ever showed up at a subsequent school.

Fulford highlighted an incident two years before the rampage when Rudakubana was caught on a bus with a knife in March 2022 and told police he wanted to stab someone and admitted trying to make poison.

Taken together, they should have sparked an arrest that would likely have led to a search of his house that would have discovered he had bought seeds to make the biological toxin ricin and downloaded terrorist material on his computer, Fulford said.

But he was not arrested and was released to his parents, who feared him and repeatedly failed to report the various knives he had purchased, his troubling behaviour and threats he had made.

After the July 29, 2024 rampage, police searched his home and discovered ricin and a document described as an al-Qaeda training manual.

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