Inquiry finds systemic failures and parental blame in Rudakubana case

Rudakubana “fell through the cracks” of a system where there was a “widespread but false assumption” that he was someone else’s problem, Fulford said. Despite the many agencies involved, no single body took a lead role which meant none carried out a comprehensive risk assessment.

Lancashire constabulary took the view that Prevent was in charge, the inquiry said, while the council repeatedly stepped down his case to non-statutory help. The forensic child and adolescent mental health services closed the case in March 2020 without carrying out an assessment of the risk he posed to others.

“This culture has to end,” the inquiry chair said, adding: “Agencies must not simply pass on the risk to others or assume others have taken on responsibility”.

There was an “alarming” failure to share information within and between the agencies, including Prevent, Lancashire constabulary, schools, councils and health services.

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

Had the agencies involved had a “remotely adequate understanding” of his history, the teenager would have been arrested and his house probably searched, where officers would almost certainly have discovered his preparations to attempt to make deadly poison and the terrorist material on his computer.

Instead of arresting him, Rudakubana was returned home by two rookie police officers, who advised his parents to hide their knives.

Fulford stressed that it was wrong to make a general link between autism and an increased risk of a person becoming violent. But in Rudakubana, he said, this condition manifested in a growing threat to others. It took 77 weeks for him to be diagnosed with autism after a GP referral in August 2019.

His worsening behaviour – including a fascination with extreme violence, appearing to condone terrorists and expressing murderous thoughts about fellow pupils and teachers – were too frequently “excused” by professionals on the basis of his autism.

Again, Fulford highlighted the “inadequate” response to the bus incident in 2022, which police put down to Rudakubana having a “bad mh [mental health] episode”.

The inquiry chair said: “Agencies regularly simply used autism as an explanation, or even an excuse, for his conduct including his violence. Strategies and interventions were needed in order to address the risk he posed and the causes of it.

“But instead, as a result of a significant lack of understanding, the problem was left both unmanaged and underestimated.”

By the morning of his carefully planned attack, Rudakubana had become a recluse. He had amassed a cache of weapons in view of his parents and left their house only a handful of times during the previous two years – and only then when he intended to harm school pupils.

Online, he festered in dark places, researching school shootings, terror attacks and ways to attack others. Occasionally, he did this in full view of other pupils and teachers, triggering the three referrals to Prevent.

Yet authorities showed only a “glancing interest” in his internet use, Fulford found. When limited questions were asked, the inquiry found, Rudakubana’s “false and self-serving replies were far too readily accepted”.

Over two days of astonishing testimony in November, Rudakubana’s father, Alphonse Rudakubana, admitted knowing that his son had amassed an arsenal of weapons – including knives, a bow and arrow and a sledgehammer, as well as a jerry can – and that he feared his son was planning to attack others.

However, he did not alert the police or any other agency because he worried his son would be taken away. Alphonse told the inquiry he was terrified, abused and repeatedly attacked by his teenage son, who had turned into “a monster”.

Despite the difficulties they faced, Fulford concluded, Rudakubana’s parents “bear considerable blame for what occurred”.

He added: “If [his] parents had done what they morally ought to have done, [Rudakubana] would not have been at liberty to conduct the attack and it would not therefore have occurred.”