Chapter 2: Overview chronology

¶1. Chapters 5 to 11 of this report each comprise a detailed assessment of particular themes (weapons and poisons, online harms) or agencies (policing, Prevent and Counter Terrorism Policing, social care, healthcare, education) followed by Chapter 12 which considers AR’s family. I have adopted this structure to facilitate close scrutiny of each agency or topic. I recognise the risk, however, that the chronological assessment of individual themes or agencies in this way may lose track of the overall picture or the sense of what was happening in parallel to the actions of one single agency.

¶2. Therefore, this chapter provides an overview chronology. It is not intended to be comprehensive but is designed to provide a sufficient introduction to the overall flow of events. While I have included some limited commentary on key events, my detailed findings including any criticisms or praise for the actions of those involved, should be taken from the relevant chapters.

Date/period	Detailed event summary	Inquiry reference
2002 and 2003	AR’s parents (Alphonse R and Laetitia M) are granted asylum.	IWS000058/§7
2004	Dion R (AR’s older brother) born in Cardiff.	IWS000056/§8
7 August 2006	AR born in Cardiff.	IWS000056/§8
December 2012	AR’s family moves to Southport; in 2017, they relocate to 10 Old School Close, Banks, Lancashire.	IWS000058/§§10-12
4 September 2017	AR starts at Range High School; initially quiet, no concerns.	RAN000036/§15
11 April 2019	AR’s GP makes first referral to mental health services, reporting that AR was suffering from nervousness at school and around crowds. Referral was rejected by Alder Hey Child and Adolescent Mental Health Services (CAMHS) the next day. Family signposted to Parenting 2000 for counselling sessions.	AHCH000297 AHCH000162/1 AHCH000095/1
30 May 2019	AR has the first of seven privately funded counselling sessions with Parenting 2000 in relation to symptoms of anxiety.	PAR2000018/§11 PAR2000005


Late year 8 (June to July 2019)	AR’s behaviour starts to deteriorate, with regular detentions, however nothing of major concern.	RAN000036/§18
18 June 2019	AR makes a concerning comment during discussions in a religious education lesson about jihad. He states that the Manchester Arena attack “was a good battle”, but when asked says he was saying this from the viewpoint of the attacker, not his own. The teacher’s concerns are passed to the designated safeguarding lead.	RAN000039/§§17-20 LCC001402
July 2019	Range High School assess AR for attention deficit hyperactivity disorder (ADHD). Survey results show poor behaviour traits rather than ADHD. Alphonse R disagrees with the result.	RAN000023, row 7
14 August 2019	AR’s GP refers him to Alder Hey’s Community Paediatric Service for autism spectrum disorder (ASD)/ADHD assessment. The first appointment is not until 2 July 2020 (46 weeks) and the assessment and diagnosis process not completed until 3 February 2021 (77 weeks).	AHCH000091 AHCH000339
Start of year 9 (September 2019)	AR’s behaviour markedly deteriorates, including fighting, and commenting – when given a detention – “That’s why teachers get murdered”.	RAN000036/§§30-32 RAN000006/2


5 to 8 October 2019	From 5 October, AR contacts Childline on a number of occasions stating he wants to kill another pupil whom he perceived as having bullied him. On 7 October, he refers to taking a knife to school for that purpose. Childline refer this to the National Crime Agency the same day, who inform Lancashire Constabulary. Police Constables Alex Wood and Alexander McNamee visit the family home that night. AR admits to carrying a knife to school around 10 times and said that he would have used it to kill “if things got to a certain point with the bully”. Police inform Range High School who search AR the next morning. They do not find a knife, but AR admits to carrying a knife previously, and says he would have used it. Police open a vulnerable child investigation and also make a high-risk safeguarding referral to Lancashire County Council’s (LCC) Multi-Agency Safeguarding Hub (MASH), who decide that AR’s case can be managed by LCC’s Child and Family Wellbeing Service (CFWS).	MERP000176 RAN000036/§37 LANC000065 LANC000144 LANC000041 LANC000018 LANC000066 LANC000067
9 October 2019	Range High School permanently exclude AR for carrying a knife to school.	MERP001170/1
10 October 2019	Range High School refer AR to CAMHS following AR’s disclosures to Childline of carrying a knife to school.	LCC000377
12 October 2019	CAMHS close the referral from Range High School after two days, stating AR was at risk of crime, but that no mental health issues were indicated in the referral. CAMHS suggest that a referral to Sefton Council’s Targeted Youth Prevention team would be suitable.	AHCH000162/2 LCC001390


17 October 2019	AR’s Parenting 2000 counsellor refers him to the CAMHS Crisis Care Team expressing concern that AR appeared very angry after being excluded by Range High School for taking a knife into school with the intention of using it. CAMHS maintained that a referral to the Targeted Youth Support team was appropriate. Parenting 2000 transfer AR’s counselling sessions to be funded under a Sefton Council project called Sunshine and Showers. This funds an additional 14 sessions of counselling with Parenting 2000.	AHCH000162/3 PAR2000005 PAR2000018/§§11-14; §§22-24
17 October 2019	AR starts at The Acorns School Pupil Referral Unit (PRU). On AR’s first day, during an admissions meeting with AR and his parents, deputy headteacher Mrs Joanne Hodson asks AR why he took a knife into his former school, Range High School. AR replies, “to use it”, showing no remorse or emotion.	LCC001773/§10, §13
28 October 2019	Alphonse R emails PC McNamee requesting his assistance at an appeal meeting to seek to reverse AR’s exclusion from Range High School. Police Constable (PC) McNamee declines to assist.	LANC000069
5 November 2019	Range High School’s governing board upholds AR’s exclusion.	RAN000039/§34
6 November 2019	Ms Lucy Parkinson (a family support worker in CFWS) conducts a home visit but is unable to see AR. Further attempts at contacting the family prove unsuccessful.	LCC002311/3-5


15 November 2019	AR researches US school shootings during an IT lesson and is told to stop by the teacher. The internet browser history for this day revealed, when later analysed by this Inquiry, that AR had also repeatedly searched for gory images of degloving injuries.	LANC000059/3 LCC001401
20 to 22 November 2019	The Acorns School escalates concerns to Lancashire CAMHS but they decline the referral due to AR’s GP being in Sefton; The Acorns School ask Alder Hey Community Paediatrics to place AR on the ASD pathway (for which he was already awaiting his first appointment after the GP referral in August 2019) due to their significant risk concerns.	LCC000775/3 LCC001421/3 LCC001773/§30
24 November 2019	PC McNamee requests the closure of the vulnerable child investigation but is told to ensure that Merseyside Police are aware that AR has taken a knife to school so that they can record a crime. PC McNamee asks Merseyside Police if Range High School has made a report to them and is told it has not.	LANC000269/§29 LANC000066 LANC000070
29 November 2019	AR punches a ceiling laminate very hard during a lesson at The Acorns School. In discussions about how to promote a local business, AR says “people don’t trust others they don’t know in case they get murdered”.	LANC000059/3-4


3 December 2019	During an art lesson AR asks why he is allowed to draw guns but not to view them on the internet and asks to have a picture of a severed head instead. The Acorns School send further information regarding AR’s behaviour and internet searching to Alder Hey to be added to the ASD referral. The Acorns School also contact PC McNamee at Lancashire Constabulary setting out their concerns. PC McNamee advises the school to call 999 if they feel unsafe.	LCC001417/2-3 LANC000059/3-4 LCC001773/§192
4 December 2019	The Acorns School email PC McNamee, worried that with a Lancashire address and a Sefton GP, AR would “fall through the cracks” and that “there is potential for a serious incident if we can’t access the right support”. Additionally, the Lancashire Constabulary Community Safety team become aware, from CFWS, of The Acorns School’s concerns. PC Paul Harrison contacts The Acorns School and seeks to facilitate a referral being made to the MASH.	LANC000059/2 LANC000060 LANC000097 LANC000099
5 December 2019 First Referral to Prevent	Emergency multi-agency agency review meeting between LCC’s CFWS, The Acorns School and Alphonse R, with AR present for part of the meeting. At the meeting, Alphonse R and AR dispute the concerns raised by The Acorns School and CFWS. The Acorns School make the First Referral to Prevent. This highlighted the knife carrying with intent to stab, the violent online searches and escalating behavioural issues.	LCC001346/67 LCC002311/6-7 CTPNW000154


9 to 10 December 2019	On the 9 December, the Lancashire Constabulary vulnerable child log is closed without any Merseyside Police crime reference numbers having been added. On the 9 and 10 December, AR attempts to override school IT restrictions to view restricted content.	LANC000066 LCC001346/67
11 December 2019	AR returns to his old school (Range High School) having booked a taxi the previous day. He is armed with a hockey stick that he has modified for use as a weapon, and carries a kitchen knife in his backpack, intending to attack the boy he perceived as having bullied him. When chased by school staff, he instead attacks a random pupil with the hockey stick. He is arrested by Merseyside Police and taken into custody. AR is assessed by Ms Stephanie Hallaron of Mersey Care Criminal Justice Liaison and Diversion Team (CJLDT) and states “I did want to kill him but I don’t think I would. Ideally, I wish I did it”. Following referrals to the MASH, LCC step AR’s case up from CFWS to Children’s Social Care (CSC) for assessment. The Acorns School make PC Harrison aware of what has occurred; he liaises between Prevent, Merseyside Police and CSC. As a result, a Merseyside Police search of AR’s home address recovers a number of electronic devices which are submitted for examination. In March 2020, it is reported that nothing significant has been found. AR is released on bail overnight.	MERC000026/4/§1 GMMH000004 AHCH000121/3 MERP002881 LANC000239 LANC000100 LANC000104 MERP002919/10


12 December 2019	AR is interviewed under caution by Merseyside Police following the attack. His mother is present as appropriate adult. He provides a misleading written statement denying intent to use the knife, and when interviewed denies searching online for inappropriate content, but otherwise refuses to answer questions. After the interview, he is released on bail conditions which, among other things, prevent him attending The Acorns School until social services or the appropriate authority clear his return. As a result, in conjunction with the first COVID-19 lockdown and The Acorns School’s concerns about the risk AR poses, he does not return to any face-to-face education until 6 July 2020.	MERP002919/3 MERP002927 MERP007527/§21 MERP000186/17 MERP002882/8 LCC001773/§113, §198
13 December 2019	PC Harrison visits 10 Old School Close to discuss supervision of AR with his parents and forms the view that AR’s parents are playing down the situation. He shares his observations with CSC. Ms Hallaron refers AR to Forensic CAMHS (FCAMHS) and CAMHS. FCAMHS accept the referral the same day, and CAMHS accept it on 16 December.	LANC000149 AHCH000121 MERC000010 AHCH000162/5
16 December 2019	Having gone through preliminary deconfliction checks, the First Referral to Prevent is passed to PS Carmen Thompson. Her rank at the time was police constable and she was a Prevent Counter Terrorism Case Officer (CTCO) within Counter Terrorism Policing North West (CTPNW). CSC visit AR at home. They observe AR to be a force in the household, and that his parents are struggling with boundaries, but find no concerns of neglect.	CTPNW000122 LCC000019/3


17 December 2019	LCC’s CSC hold a strategy meeting. CAMHS, CJLDT, Prevent, Lancashire Constabulary Community Safety team, Merseyside Police, Range High School and The Acorns School all attend. FCAMHS do not attend. The meeting concludes that there is a need for multi-agency support to the family, but that there is no evidence that either AR or his brother is at risk of significant harm. A follow-up meeting is planned, although Lancashire Constabulary Community Safety team are not invited as there are no open actions for them.	LANC000054 LCC000234 LCC000019 LCC001346/63 LANC000135 CTPNW000132
20 December 2019	AR has a face-to-face CAMHS assessment by case manager Mr Skott Morgan. He finds no indications of a serious mental health condition. In considering possible autism, he notes AR has atypical behaviours with a lack of empathy and rigid thinking.	AHCH000162/12
3 January 2020	PS Carmen Thompson and another Prevent officer visit AR at home. AR states his behaviour and online searching has been taken out of context by The Acorns School.	CTPNW000135


6 January 2020	CSC chair another multi-agency strategy meeting. LCC’s alternative provision of education team, CJLDT, Prevent, CAMHS, Merseyside Police, Range High School and The Acorns School all attend. FCAMHS do not attend. Prevent update that they have no concerns about radicalisation or of AR being led into criminality. The meeting agrees that neither AR nor Dion R were at risk of serious harm, but there was a risk to AR of further criminality and of his needs in respect of education and health not being met. CSC is to complete its Child and Family Assessment, running alongside the Merseyside Police criminal investigation, but otherwise the case is to be closed.	LCC000023/2 LCC001346/60-61 CTPNW000009 LCC000235 MERC000002/50 AHCH000162/13-14
8 January 2020	Mr Morgan completes a CAMHS risk assessment, although detail is lacking in the assessment.	AHCH000162/14
21 January 2020	FCAMHS host a case assessment meeting. CAMHS do not attend but The Acorns School, CJLDT and CSC attend. Discussion focuses on: balancing the need to get AR back into education against the risk to staff and pupils; AR’s wider care; the delay to the ASD diagnosis; and who was to conduct a risk assessment. It is suggested that unfortunately, The Acorns School had been left “holding the baby!”. No formal lead agency for supporting AR is identified.	LCC000020 LCC001346/61-62 GMMH000005/1-5 MERC000002/49


31 January 2020	The First Referral to Prevent is formally closed. PS Thompson had concluded that there were no Counter Terrorism/ domestic extremism concerns at this stage but AR was extremely vulnerable and needed support from other agencies that were in place and who had been advised to re-refer AR if appropriate. The closure is approved by her supervisor DS James Neale.	CTPNW000122/31
4 February 2020	As a result of the Merseyside Police investigation into the hockey stick attack at Range High School, AR is charged with assault occasioning actual bodily harm, possession of an offensive weapon in a public place, and possession of a bladed article on school premises.	MERP002914
11 February 2020	Mr John Hicklin of FCAMHS writes to Ms Hallaron further to the 21 January meeting, having now spoken to CAMHS. He notes the long waiting times for autism assessment and suggests a diagnosis will be fundamental in categorising AR’s high-risk behaviour. CAMHS were to discuss how escalation of concerns could be raised with the paediatric team. He advises that AR would benefit from psychologically informed interventions to address his high-risk behaviour, taking into account his likely diagnosis of ASD. The exact nature of those interventions was to be determined by CAMHS.	GMMH000006
14 February 2020	Mr Morgan of CAMHS writes to Ms Anna Jameson of LCC, highlighting AR’s likely ASD traits and how they related to his offending behaviour, but stressing that AR had not presented with any mental health concerns. No actions identified for further support for AR from CAMHS.	LCC000029/1


19 February 2020	AR pleads guilty in the Youth Court and receives a 10-month referral order, for which AR will be open to LCC’s Child and Youth Justice Service (CYJS) (sometimes known as the Youth Offending Team (YOT)). CSC complete the Child and Family Assessment. This focuses on the risks to, rather than from, AR. It concludes that AR should be treated as a ‘child in need’ (this was level 3 on the Continuum of Need as it applied at the time). A further meeting is planned for 4 March 2020 to “consider the future risk and further plan the assessment”.	LCC000027
2 March 2020	Alphonse R and Laetitia M write to Ms Jameson of CSC (the email being sent from Alphonse R’s email account, but signed by both parents). They express significant concerns over AR’s education at The Acorns School. They criticise the school’s focus on behaviour. They suggest that the school has an aggressive environment, going so far as to suggest that this contributed to AR’s return to Range High School to attack a pupil. They downplay AR’s actions, describing him as a good boy, and not a threat to himself or others.	LCC000482 LCC002310/21


4 March 2020	A child in need meeting is chaired by Ms Jameson of CSC, with FCAMHS, LCC alternative provision of education, CYJS, CJLDT, CFWS, Range High School and The Acorns School attending. CAMHS do not attend following Mr Morgan’s recent departure from that service. AR’s parents’ email is discussed. The Acorns School reject its characterisation of their provision for AR. Most of the focus is on risk assessments but no consideration is given to using a structured clinical risk assessment such as the Structured Assessment of Violence Risk in Youth (SAVRY). AR’s case is stepped down from child in need to Early Help from CFWS.	LCC001346/58 GMMH000007 LCC002310/22
8 March 2020	AR is closed to the CJLDT.	MERC000026/4/§1
9 March 2020	Mr Hicklin of FCAMHS writes again to Ms Hallaron of CJLDT with a summary to be shared with other agencies. Mr Hicklin notes that AR was now closed to CAMHS but he had hoped that CAMHS would advise on local service provision and support escalation of the autism assessment. He states the risk assessment will be complicated by AR’s likely diagnosis of autism and provides factors to take into account. He indicates that assessment by FCAMHS is not indicated as until the diagnosis was complete, they would not be able to contribute further to the understanding of risk. He notes that any professional can contact FCAMHS for clarification or if review is indicated because of a significant change in risk behaviour. AR is then closed to FCAMHS.	GMMH000007


24 March 2020	Ms Anna Croll of CYJS carries out an AssetPlus assessment of AR. It concludes AR’s risk of serious harm is ‘medium’. This is heavily based on the absence of opportunity or imminence. AR’s statements, in both October and December 2019, that he had intended to use the knives he had been carrying on each occasion do not appear to be known to CYJS.	LCC000447
9 April 2020	Ms Andrea Fontaine, AR’s new CFWS caseworker completes a Common Assessment Framework (CAF) form, although as there is already a Child and Family Assessment in place, this was limited to ensuring they were capturing the latest “voice of the family”.	LCC000283
April to May 2020	Ms Fontaine makes a number of attempts to contact the family but these go mostly unanswered. The Acorns School and CYJS express similar frustrations with contacting the family.	LCC002311/16-19 LCC001712/§81
1 May 2020	Dr Vicky Killen of Alder Hey writes to FCAMHS, LCC and CYJS confirming a new CAMHS case manager for AR, Mr Samuel Coppard. She provides healthcare input to AR’s education, health and care plan (EHCP) application (completing the forms on 14 May), and requests information on any other concerns. Dr Killen also requests sight of the FCAMHS assessments, which had not been shared with CAMHS. These are sent to Alder Hey and shared with Dr Killen and Mr Coppard. However, in error, they are not scanned onto the Alder Hey system or included in AR’s electronic patient record.	AHCH000234 AHCH000324/1 AHCH000003/2-3


19 May 2020	A Team Around the Family (TAF) meeting takes place, led by Ms Fontaine from CFWS. Ms Croll, Mrs Hodson and Alphonse R all attend. It is agreed that further work on the family’s social isolation would need to wait until COVID-19 restrictions are lifted.	LCC000061
20 May 2020	Mrs Hodson emails Ms Fontaine and Ms Croll stating that she needs to share her concerns following the TAF meeting. She stresses that Alphonse R still seems to perceive AR as the victim rather than the perpetrator of the hockey stick attack at Range High School, and that he was justified in carrying a knife because he was “frightened”. She feels the risk AR poses to The Acorns School has increased and stresses the duty she owes to both staff and pupils. Ms Fontaine responded to Mrs Hodson on 21 May stating that Alphonse R’s view of his son’s temperament and behaviour did not influence the risk level posed by AR and suggesting that no new or additional information had been provided that would suggest an increased risk. On 22 May, Ms Croll replied similarly, noting that she assessed AR as medium risk of serious harm. She provides an extract from the AssetPlus assessment but the full version is not shared.	LCC000998
May and June 2020	AR’s new CAMHS case manager, Mr Coppard, makes repeated attempts to engage AR, but AR largely fails to engage.	AHCH000289/§§36-54


9 June 2020	With Alphonse R’s consent, Ms Fontaine closes AR’s CFWS case given the challenges of the COVID-19 restrictions and his non-attendance at school: the plan is to re-open the case in September 2020 when it is anticipated AR will return to school. This decision is made notwithstanding detailed input from The Acorns School explaining why it would be beneficial for AR to remain open to CFWS over the summer.	LCC000284/1 LCC000998/2-3
June to September 2020	Mr John Fitzpatrick takes over the management of AR’s referral order from Ms Croll in the CYJS. He conducts three 30-minute in-person sessions with AR on: ‘No Knives Better Lives’, victim awareness and impact, and anger management. AR refuses a number of other regular contact sessions. Despite this, the frequency of CYJS contact is reduced in September 2020.	LCC000488/7-10 LCC001712/§128
2 July 2020	Face-to-face appointment between Mr Coppard, AR and Alphonse R. Alphonse R seeks medication for AR to help with his anxiety, but Mr Coppard advises him that Talking Therapy is indicated, emphasising the need for motivation in tackling anxiety through such therapy and behavioural work. A follow-up session is arranged for a week later.	AHCH000289/§§64-69
6 July 2020	Further (single agency) risk assessment of AR undertaken by The Acorns School, which allows him to return to face-to-face schooling, initially on a one-to-one basis.	LCC000707


9 to 23 July 2020	AR had inconsistent healthcare attendance, failing to attend several follow-up appointments with Mr Coppard, although he does attend on 16 July 2020. Alphonse R states that AR finds the appointments stressful. Discharge from CAMHS agreed shortly after this due to lack of engagement.	AHCH000289/§§72-76
4 August 2020	AR’s initial EHCP is finalised. This identifies requirements in understanding emotions, developing social skills, making positive choices and avoiding situations of risk to self/others.	LCC000073
11 August 2020	AR fails to attend a final CAMHS appointment. AR is not formally closed on the system, but there is no further engagement until February 2021.	AHCH000289/§78
28 August 2020	AR assessed by speech and language therapist from Alder Hey Community Paediatrics as part of an autism assessment.	AHCH000096/4-5
14 September 2020	Ms Fontaine of CFWS reopens their involvement with AR following the start of the autumn term. She starts another CAF assessment.	LCC001707/§49
27 October 2020	Community Paediatrics ASD Pathway report is completed and sent to AR’s parents. Report to be discussed at a multi-agency meeting.	AHCH000096/4-5
28 October 2020	Ms Fontaine completes the CAF form, with a focus on supporting AR with his return to school and social interactions. She assesses AR as being at level 2 on the Continuum of Need, having some unmet needs and being low risk.	LCC001707/§§53-57 and §60 LCC000306


2 November 2020	Alphonse R messages Ms Fontaine and stresses that he does not consent to any sharing of the CAF report with The Acorns School (save as necessary for AR’s education), CYJS or CSC. He describes the CYJS as being “in charge of punishing” AR. Ms Fontaine confirms that CFWS’ work is based on consent and she would not be sharing anything without consent.	LCC002311/32
4 November 2020	Ms Fontaine chairs a TAF meeting with The Acorns School and Alphonse R. It is agreed she will undertake sessions with AR to help with his anxiety, and with AR and Alphonse R on their communication with each other.	LCC000308
15 December 2020	Mr Fitzpatrick of CYJS updates the AssetPlus assessment of AR, whose risk of serious harm is now assessed as ‘low’.	LCC000449
30 December 2020	Community Paediatrics ASD multidisciplinary team meeting held. AR formally diagnosed by the panel with ASD.	AHCH000096/11
14 January 2021	Alphonse R contacts Ms Fontaine reporting that AR has assaulted him in the course of a domestic argument. Ms Fontaine gives Alphonse R advice about de-escalation.	LCC002311/36


19 January 2021	Mr Fitzpatrick of CYJS conducts final visit to AR under the referral order. At this meeting, AR states that Alphonse R had recently assaulted him. Alphonse R’s account is that AR threatened to break his laptop and had then kicked him, and Alphonse R had slapped AR in the face in response. AR had no visible injuries. Mr Fitzpatrick informs CFWS and The Acorns School. Ms Fontaine confirms that Alphonse R had texted her about the altercation earlier in the week. LCC teams decide that no referral to CSC was necessary in terms of any risk to AR arising from Alphonse R’s physical retaliation. No specific action is taken regarding AR’s own violence towards his father.	LCC000488/2-3
19 January 2021	Ms Fontaine chairs a TAF meeting with Alphonse R and The Acorns School. CFWS agrees to close the case and consider another referral to CAMHS.	LCC000310
21 January 2021	AR comes to the end of his referral order and CYJS close his case.	LCC000449 LCC001510
25 January 2021	Ms Fontaine conducts a home visit to see AR. Alphonse R confirms that AR kicked him in the earlier incident reported to Mr Fitzpatrick and that he hit AR back. AR does not show remorse and says he was not sorry.	LCC002311/37
1 February 2021 Second Referral to Prevent	The Acorns School make the Second Referral to Prevent following receipt from Range High School of Instagram posts made by AR praising Colonel Gaddafi’s Libyan regime. The Second Referral to Prevent is shared with CYJS and CFWS; neither take any action in response.	CTPNW000126 LCC001510/1


3 February 2021	CAMHS shares ASD diagnosis with AR. Alphonse R requests a re-referral to CAMHS and questions the status of the ADHD referral.	AHCH000100/40 AHCH000163/2
9 February 2021	Ms Lynsey Boggan (Interim Clinical Lead of Alder Hey’s ASD Pathway) responds to Alphonse R, explaining that for an ADHD referral to be progressed, The Acorns School would need to provide a referral as potential ADHD symptoms needed to be observed in two settings (e.g. school and home). Due to an administrative failure, the school are not informed of this. CAMHS are contacted to arrange a new appointment.	AHCH000163/1
15 February 2021	PS Thompson of Prevent carries out a Police Gateway Assessment (PGA) and closes the Second Referral to Prevent, concluding that AR was not the author of the posts. She concludes that the posts did not suggest that he holds any extremist ideology but rather an opposing opinion on Gaddafi’s regime, questioning the Western motivation for removing him. Her supervisor DS Treharne agrees with this assessment.	CTPNW000124/18
1 April 2021	Ms Samantha Steed takes over as AR’s new CAMHS case manager. She holds a video call with Alphonse R. AR is initially asleep and then refuses to join when awake. Five sessions are held with AR over the next six weeks.	AHCH000163/4-27


22 April 2021 Third Referral to Prevent	The Acorns School make the Third Referral to Prevent after AR was observed accessing material thought to relate to a London Bridge bombing and AR was involved in discussions around the IRA, MI5 and Israel/Palestine. This is again subject to a Prevent Gateway Assessment by PS Thompson (finalised 7 May 2021), which concludes that there are no Counter Terrorism/domestic extremism concerns at this stage, also noting that AR is awaiting an EHCP and a specialist educational placement which will help support him through his ongoing education.	CTPNW000137 CTPNW000143/3
7 May 2021	DS Rachael Treharne of Prevent reviews and approves the closure of the Third Referral to Prevent. She concludes AR is not at risk of radicalisation currently on the information provided, pointing to a lack of extreme views, the context of the comments having been the discussion of current affairs.	CTPNW000125/18-19
May 2021	There is a series of exchanges over revising the wording in AR’s EHCP between Alphonse R, The Acorns School, and CAMHS, which leads to marked redrafting in respect of a number of significant issues, including the risk AR poses to others.	LCC001773/§§107-109 LCC001346/29
May to June 2021	Ms Steed holds five meetings regarding AR, two with him, one with his parents and two with Sefton CAMHS multidisciplinary team. AR continues to struggle with anxiety around leaving the house and tension around support from his father. A routine referral to a psychiatrist was made to consider medication options. When AR’s presenting anxiety worsened, this was escalated to the urgent waiting list.	AHCH000163/29-41


24 June 2021	Alphonse R requests an assessment by CSC in respect of both AR’s and Dion R’s disability needs. CSC conduct multiple interviews over the next two months, including with Ms Steed and The Acorns School (who consider approximately 12 months’ consistent support is required for AR to be ready to access social activities), as well as the whole family. In August, CSC are informed by CAMHS that AR is alleging that Alphonse R has domestically (physically) abused him and his brother; AR repeats this allegation to CSC when asked about it. When not backed up by the family, AR states everyone is lying and pours milk over his parents’ bed. AR’s allegations are investigated as part of the assessment and found to be unsubstantiated. AR refuses to partake in a substantive meeting.	LCC000247 LCC002310/27
1 July 2021	AR has his first telephone consultation with Dr Lakshmi Ramasubramanian (CAMHS consultant child psychiatrist) to consider his chronic anxiety. She did not have the complete picture of AR’s history regarding risk to others. She deems him not to have a serious mental disorder, but prescribes him propranolol, a beta-blocker for his anxiety.	AHCH000163/42


2 July 2021	Ms Steed holds a video appointment with AR, who engages well, and Laetitia M. Ms Steed emphasises that behavioural activation work should accompany the new medication. Over the following days, Alphonse R contacts Ms Steed on several occasions setting out AR’s desire for different medication following online research he had conducted. Following Ms Steed consulting with Dr Ramasubramanian, the advice remains that AR should try propranolol for a period.	AHCH000163/49-51
August 2021	Further meetings are held by Ms Steed with wider CAMHS professionals, AR and Alphonse R. Alphonse R requests a new case manager. (It is in one of these meetings on 17 August that AR makes the allegations of domestic abuse against Alphonse R referred to above, which were found to be unsubstantiated.)	AHCH000163/59-94
30 August 2021	AR downloads a document containing an Al-Qaeda training manual. He downloads the same document a second time on 4 September 2021.	MERP000323/12
September 2021	AR refuses to attend The Acorns School in September, only returning intermittently from November.	LCC001773/§115
7 September 2021	CSC’s disability needs assessment is completed. It recommends considering funding a carer to support AR to attend social activities. This is not supported by a manager, who considers that AR’s needs would be better met by increased school participation. The case is stepped back down to CFWS and a new case worker, Ms Louise Lewis, is assigned.	LCC000247 LCC000115


10 September 2021	Ms Steed meets with Alphonse R who again requests a new case manager. He is conflicted, wanting Ms Steed involved but does not like the way she works in that she listens to AR too much and takes AR’s side. Alphonse R declines family therapy and does not want to consider parent support groups, but says he would accept a key worker.	AHCH000163/92
15 September 2021	AR and Laetitia M have a consultant psychiatric review. Dr Aesha Aseri (standing-in for Dr Ramasubramanian who is off work with COVID-19) prescribes sertraline, an anti-depressant. She agrees a follow up in four weeks.	AHCH000163/96-98
4 October 2021	Home visit by Ms L Lewis and Ms Sharon Barrett of CFWS. AR refuses to let his parents speak and mentions he makes money on the internet but refuses to expand on how (although it is now known he ran an online genealogical research business). AR is vocal on politics, including in relation to the Taliban, and the perceived powers of the intelligence services to access his data.	LCC002311/42 LCC000321
12 to 14 October 2021	Following the 4 October meeting, Ms Barrett emails Ms L Lewis flagging information about proscribed groups that should be discussed with AR’s parents. Ms Barrett also initiates a referral to the Targeted Youth Support team within CFWS, which includes mention of concerns about AR having extreme views and the risks that these could pose, which may need to be reported to Prevent. However, CFWS do not make a Prevent referral.	LCC000977


13 October 2021	Follow up psychiatric appointment. Dr Ramasubramanian notes no improvement, with AR still not leaving the house or attending school. She increases the dose of sertraline.	AHCH000163/107-109
15 October 2021	Multi agency meeting organised by The Acorns School to discuss AR’s lack of attendance. Alphonse R attends. CAMHS review AR’s medication and referrals made to youth support and transition teams.	LCC002311/42-43
27 October 2021	Another home visit by LCC. AR refuses to leave his room but speaks with Ms Barrett. A further visit scheduled for the week after.	LCC002311/45
1 November 2021	Ms L Lewis completes a CFWS Early Help assessment which notes concerns in relation to AR’s extreme thoughts and his vulnerability to being involved in “left wing extremists behaviours and his thoughts being said in the wrong environment may make him vulnerable”. It identifies other needs including online social media safety, relationship breakdown within family and AR’s poor school attendance.	LCC000321
3 November 2021	A further CFWS home visit takes place to introduce AR to his new targeted youth support worker, Mr Carl Coughlan. AR agrees to meet Mr Coughlan at a youth centre the next week. After Mr Coughlan leaves, AR’s behaviour escalates following Laetitia M’s request to speak to Ms Barrett in private and he has an argument with his father.	LCC002311/46
November 2021	AR reaches the top of the waiting list for a CAMHS key worker and is assigned Ms Michelle Warner. She has seven sessions with AR over the next four months.	AHCH000261/§13


5 November 2021	Laetitia M calls 999 regarding AR ‘trashing’ the house. Lancashire Constabulary do not attend following further call with Laetitia M where she states that AR has calmed down, but they make a safeguarding referral to the MASH.	LANC000024 LANC000076
8 November 2021	AR attends The Acorns School for the first time this term and meets Mr Coughlan at the Youth Zone for his first session. They discuss AR taking knives to school and his interests and look to find activities he would be interested in to help him develop social skills. A further meeting takes place on 18 November and AR fails to attend one on 2 December.	LCC002311/48-49 LCC001708/§§40-54
15 November 2021	AR meets with Dr Ramasubramanian, who notes some improvements (AR is attending school and anxiety has improved). Neither AR nor his parents mention the incident on 5 November.	AHCH000163/113-115
21 November 2021	Alphonse R contacts CAMHS regarding two further incidents over the preceding weekend. AR had made verbal threats to Alphonse R and poured milk over him. CAMHS alert CFWS.	LCC000975
30 November 2021	There is another 999 call by AR’s parents, regarding a further incident with AR, who got angry during dinner and threw a plate at a rental car, damaging the windscreen. Lancashire Constabulary officers attend late in the evening. Alphonse R confirms that AR kicked him. AR is not arrested and Alphonse R did not support a criminal investigation. A further safeguarding referral is sent to the MASH.	LANC000079 LANC000025 LANC000080


7 December 2021	Agreement reached between AR’s parents and LCC for AR to attend a specialist school. EHCP amended accordingly. TAF meeting chaired by Ms L Lewis (CFWS). Alphonse R and AR both attend. Meeting is deemed positive, including complementary education options, and the meetings with Mr Coughlan are moved to the afternoons to encourage AR’s attendance.	LCC001524 LCC000130
10 January 2022	Sessions restart between AR and Mr Coughlan. Six are planned but AR refuses to attend one. Mr Coughlan reports general progress. AR is more used to leaving the house and is positive about continuing to make progress.	LCC001708/§66-102
11 January 2022	LCC contacts Presfield High School to consider a place for AR in September 2022. TAF meeting; family therapy is recommended, for which the family are already on the waiting list. The meeting notes record that CFWS support will close once the sessions with Mr Coughlan finish.	PRE001809/§9 AHCH000164/5-6 LCC000137
18 to 25 January 2022	AR orders castor beans (the precursor to ricin), chemicals and chemistry equipment from Amazon suitable for crude ricin production. He specifies the next-door neighbour as the delivery address for some of the orders. Some of the items, none of which require age verification, are therefore delivered to a neighbour, including the castor beans. The neighbour is in contact with Alphonse R by WhatsApp asking him to sort out AR getting packages delivered to the wrong address.	AMA000096, rows 26, 33, 34, 39-46 MERP001255 MERP000164


20 January 2022	Presfield High School Head of Sixth Form, Mrs Hayley Dawson visits The Acorns School to discuss AR’s transfer. Mrs Dawson recalls no concerns were raised by The Acorns School at this particular meeting, and Presfield High School offer AR a place the next day.	PRE001809/§§12-13 PRE0001807/§§5-7
21, 25 and 26 January 2022	AR makes references in lessons to the Holocaust, the death of Princess Diana, and the London Bridge attacks, while stating that violence is sometimes necessary. The Acorns School challenge these comments and record them but following a discussion do not pass the comments onto Prevent.	LCC001346/12 LCC001773/§171
24 January 2022	Dr Ramasubramanian conducts telephone review with AR and Alphonse R. AR is positive, stating his anxiety settles down once he manages to get outside, and he is working well with Ms Warner, enjoying going to a local shop with her.	AHCH000164/22-24
8 February 2022	Ms L Lewis refers AR to the LCC Adult Social Care Transitions team, which works with young people who are approaching their 18th birthdays to ensure a smooth transition from child to adult services. However, the Transitions team assessment visit does not occur until 9 November 2023.	LCC001810 LCC000438/3-6
10 February 2022	Ms L Lewis chairs a further TAF meeting. AR attends and is quiet. AR’s parents report he is starting to show an interest in community-based activities and is looking forward to joining Presfield High School. Case still heading towards closure to CFWS.	LCC000144


21 February 2022	Mr Coughlan completes the final (eighth) direct youth work session with AR.	LCC002311/80
24 February 2022	Presfield High School agree to take AR before September 2022, following his further drop in attendance at The Acorns School and an understanding AR wants to start at Presfield High School. Sefton agree funding for a start date of 19 April 2022. Presfield High School put a transition plan in place to assist AR with school visits in March.	LCC001346/8-9
28 February 2022	AR attends The Acorns School for the last time.	LCC001773/§115
4 March 2022	AR orders conventional archery equipment from Amazon, which he later cancels.	AMA000096, rows 49-51
14 March 2022	At a further TAF meeting, CFWS close AR’s case as had been foreshadowed in previous TAF meetings in January and February 2022. Ms L Lewis cites the end of the sessions with Mr Coughlan, and that AR is calmer. The case is closed notwithstanding that AR is about to change schools.	LCC000155
15 March 2022	AR has his final (of seven) session with CAMHS Keyworker Ms Warner.	AHCH000261/§13


17 March 2022	AR is due to visit Presfield High School for an orientation session. Instead, he goes missing with a kitchen knife. Alphonse R reports AR missing to Lancashire Constabulary, who initiate a missing person investigation. AR is later found on a bus with the knife by Lancashire Constabulary officers. He informs police while being returned home that he intended to stab someone so his social media profiles would be deleted. AR mentions making poison to police. The police discuss matters with Laetitia M and Alphonse R once AR is returned home. As AR has returned home, a missing child referral is generated to LCC’s Missing from Home team. A criminal investigation into the offensive weapons offence is begun but rapidly closed on the basis that AR’s conduct was explained by his mental health. AR is neither arrested nor charged.	LANC000045 LANC000082
18 March 2022	Ms Steed meets with AR and Laetitia M. They discuss his reasons for going missing the previous day. He reiterates the desire to get arrested to have his social media accounts deleted, but does not mention taking a knife. CAMHS do not follow this up, and Ms Steed ends the assessment by recording no change to risk status and no current risk identified. PC Eve Rhodes of Lancashire Constabulary (one of the attending officers for the 17 March incident) makes a high-risk safeguarding referral to the LCC MASH.	AHCH000164/43-44 LCC000157


21 and 22 March 2022	The Acorns School share significant information with Presfield High School regarding AR. This includes information about the recent knife incident and a full Child Protection Online Management System (CPOMS) report. Presfield High School do not open the CPOMS report until after the attack on 29 July 2024. The LCC MASH try to contact Laetitia M but with no response. They close the case with no identified supporting needs that would require CSC or CFWS intervention. Ms Amanda Chapman of the Missing from Home team visits AR at home on 22 March to conduct a Return Home Interview. She has little information about the incident. AR gives a confused account, and lies by suggesting that he did not have a weapon on him.	LCC001346/4 PRE001806/§8 LCC000157/6 LCC000159
28 March 2022	AR enrols at Presfield High School. He barely attends. AR orders a bow, arrows, and a duffel bag from a number of sellers via Amazon. After the attack, these are found under his bed.	PRE001809/§§14-18 AMA000096, rows 58-59
7 April 2022	Dr Ramasubramanian conducts a review with AR. She is aware of the bus incident and AR carrying a knife but does not ask questions about it; CAMHS is not told that AR spoke of wanting to stab someone or that he mentioned poison. There is no re-referral to FCAMHS or re-assessment of AR’s risk by CAMHS. AR is keen to try new medication but this is not agreed to. Instead, Dr Ramasubramanian prescribes a slightly higher dose of sertraline for two months.	AHCH000164/50-52


26 April 2022	Following AR stopping taking medication and complaining of heartburn (which is not a common side effect of sertraline), Dr Ramasubramanian shares her concerns with Alphonse R that AR manages his own medication and is seeking reasons to change to a new medication. She remains firmly opposed to new medication, and says AR should not restart sertraline.	AHCH000164/58
30 April 2022	AR orders 12 glass swing top bottles and a 5L jerry can from Amazon.	AMA000096, rows 63-64
3 to 5 May 2022	AR contacts two archery retailers enquiring about discreet packaging and age verification for orders of crossbows. AR does not place an order. It is unlawful to sell a crossbow to someone aged under 18.	TAC000003 MERA000002
4 May 2022	Presfield High School teacher Mr James Berry undertakes a home visit to AR to encourage attendance. Alphonse R will not let him in due to the concerns that AR might get angry and attack him.	PRE001805/§§16-17
13 May 2022	A planned session with Ms Steed does not go ahead. Alphonse R mentions to her that AR had started retaking sertraline but had stopped again. Ms Steed clarifies that AR should not be in possession of his own medication but Alphonse R’s response is that AR would not harm himself with his medication. Alphonse R requests an urgent meeting with Dr Ramasubramanian. She calls him and offers an in-person meeting.	AHCH000164/62-65


14 May 2022	AR’s family call 999 again following a violent episode at night where AR attempts to flood the house and throws food after being denied access to a computer in the middle of the night. Lancashire Constabulary attend and make a high-risk safeguarding referral to the LCC MASH reporting that AR’s parents “are struggling to cope with him. They are going to contact CAMHS and his GP. Any help would greatly assist the family”. AR’s parents do not contact CAMHS or their GP, despite telling the attending police officers that they would do so.	LCC000170 LANC000093 LANC000094 LANC000167
16 May 2022	Presfield High School contact LCC MASH requesting details of AR’s previous contact with social services. LCC responds stating the history cannot be provided unless consent is obtained from a parent, or there is an immediate safeguarding risk. Appropriate attempts by Presfield High School to follow these referrals up with LCC did not lead to any change of position and AR remained closed to all forms of social care services.	LCC000165/4 LCC000168 LCC000170
23 May 2022	Following the request on 13 May 2022, Dr Ramasubramanian holds an in person review with AR, Alphonse R and Ms Steed. AR is gaunt and thin. Agreement that AR will restart sertraline. Dr Ramasubramanian is concerned about lack of parental supervision of AR’s medication. Dr Ramasubramanian suggests Alphonse R should give him one strip of tablets at a time. A follow up clinic letter on 25 May 2022 sets out AR’s poor eating and sleep habits and the concerns over medication monitoring.	AHCH000164/69-70 AHCH000095/24-26


26 May 2022	Alphonse R calls CAMHS to complain about Ms Steed and requests a new case manager. Ms Steed agrees that the situation is untenable and that she does not feel comfortable continuing.	AHCH000164/73, 77
31 May 2022	Alphonse R contacts Ms Steed to complain about the contents of the 25 May clinic letter and setting out a number of “corrections”. He demands an amended letter be sent. Dr Ramasubramanian refuses to amend the letter in the absence of evidence that its content was incorrect and maintains the concerns about medication monitoring which are long-standing.	AHCHC000164/83-86
1 June 2022	CAMHS Multi-Disciplinary Team (MDT) meeting where Ms Steed states both she and Dr Ramasubramanian find Alphonse R to be aggressive and rude, and Ms Steed queries if any case manager will be able to work with Alphonse R in the present situation.	AHCH000164/88-90
14 June 2022	Dr Ramasubramanian and Ms Steed attend a meeting with Presfield High School to provide the latest information on AR to help facilitate attendance at the school. For the only time in her career, Dr Ramasubramanian requests to be removed from a case, on account of Alphonse R’s behaviour.	AHCH000239/§66 AHCH000169
23 June 2022	Dr Ramasubramanian and Dr Killen attend a meeting with AR’s parents. They remind the parents of appropriate behaviours and discuss that the letter of 25 May 2022 will not be changed. AR’s adherence to a regular sertraline regime was also requested.	AHCH000164/104-110


28 June 2022	Mr Coppard begins a course of family therapy with a video appointment. Alphonse R states that AR does not wish to participate. Family therapy sessions continue until 23 April 2024, none of which AR attends.	AHCH000289/ §§124-125; 185
14 July 2022	Mrs Dawson of Presfield High School writes to Iain Calderbank, Senior Special Educational Needs Officer at LCC, stating that the school is withdrawing AR’s place for September due to his “devastatingly low” attendance. She notes LCC failed to attend AR’s annual review meeting on 7 July.	LCC000178/19-20
28 July 2022	Dr Anthony Molyneux, consultant child psychiatrist at Alder Hey, who has taken over from Dr Ramasubramanian, conducts a home visit. AR remains upstairs but he spends time with AR’s parents. Dr Molyneux prescribes AR a low one-off dose of diazepam, to act as a mild sedative to help AR attend the appointment planned for 1 August 2022.	AHCH000253/§§11-12
1 August 2022	Dr Molyneux sees AR and Alphonse R, observes AR is very slim but not unwell, and presents as “stable in terms of his mental health”. He notes “no evidence of any thoughts of harm to self or others”. He prescribes a low dose of fluoxetine for AR’s anxiety. Dr Molyneux is not aware of most of the past relevant history of AR’s risks and violence to others.	AHCH000253/§§19-20


5 September 2022	Alphonse R writes to Presfield High School requesting they keep AR on their student roll despite the significant non-attendance. The school reply confirming that they cannot meet AR’s needs, and the placement has been withdrawn. However, subsequently LCC refuses Presfield High School’s request to remove AR from the roll. Ms Kathryn Morris becomes AR’s CAMHS case manager and stays in that role until AR is discharged from CAMHS on 23 July 2024.	PRE000117 PRE001809/§21 AHCH000278/§1, §§224-229
20 October 2022	Ms Morris has a video appointment with Alphonse R and AR. AR will not appear on camera and is not interested in the discussion. Alphonse R indicates AR is eating and seems happier but is still struggling to leave the house.	AHCH000164/124
7 November 2022	Ms Morris has a face-to-face appointment with AR. They discuss his knife carrying to Range High School, but further discussions of police incidents are abruptly shut down. AR does not attend the next session scheduled for 28 November.	AHCH000278/§§33-36
1 December 2022	Dr Molyneux conducts a telephone review with Alphonse R and AR. AR has stopped taking fluoxetine some weeks previously. Dr Molyneux asks if AR has tried sertraline before. AR lies and says no, and sertraline is prescribed. Two weeks later, Dr Molyneux recognises that AR has been previously prescribed sertraline having re-reviewed the notes.	AHCH000164/130


29 December 2022	Dr Molyneux sees AR alone at the clinic and observes he is healthier and mentally stable. His impression is AR does not want to attend but is doing so “on a transactional basis” as he hopes that Dr Molyneux will provide “pharmacological intervention” for anxiety symptoms.	AHCH000253/§32
8 January 2023	AR orders a pack of four orange smoke “grenades” from Inevitable UK, a company selling them on Amazon. Such items are not for military/police purposes but do qualify as fireworks that should not be sold to anyone under 18. Although there is a legal disclaimer stating that the product is not for sale to people under the age of 18, neither Inevitable UK nor Amazon have any kind of age verification checks for the order of these items.	AMA000096, row 76
16 January 2023	Ms Morris has a face-to-face session with AR. His sole interest is to stay open to CAMHS to get medication. This is the last appointment with a CAMHS nurse case manager which AR attends.	AHCH000278/ §§53-58, §§63-64
31 January 2023	Alphonse R raises the issue of ADHD with a general paediatrician who is seeing AR about his nutrition. She requests that either AR’s GP or CAMHS progress a referral for ADHD assessment, but the request is not actioned.	AHCH000096/27


3 to 10 February 2023	Presfield High School email LCC regarding AR’s place at the school. LCC respond on 6 February stating that AR is on Presfield High School’s roll and named on AR’s EHCP, and the school must prove it cannot meet his needs. The school reply confirming LCC failed to attend the annual review and have not responded to the school’s letters and calls. Concern raised that LCC are a barrier and that the school is not able to meet AR’s needs.	PRE000152
6 February 2023	AR refuses to attend Dr Molyneux’s clinic. Alphonse R states he has lost weight and is experiencing adverse side effects from the sertraline. Dr Molyneux is concerned that AR is self-administering the medication without parental oversight.	AHCH000253/§§35-38
27 February 2023	AR attends Dr Molyneux’s clinic with Alphonse R. He appears well and stable but there seem to be tensions with Alphonse R and AR. AR adamant that he wants to go back on sertraline, and Dr Molyneux agrees to re-titrate it. This is the last time AR sees Dr Molyneux in person.	AHCH000253/§§39-40
2 March 2023	Ms Morris attends a professional review with AR’s parents, LCC and Presfield High School. Ms Morris states that AR has told her that he does not want to go to school. Laetitia M disagrees with this view, and does not want it shared with the school, in case they use it to remove AR’s place.	AHCH000164/141-142


20 March 2023	Presfield High School asks Sefton Council to conduct a visit to AR’s house after he fails to turn up to school. Ms Angela Maguire visits to see AR and is refused entry by Laetitia M. Sefton recommend Presfield High School contact Lancashire Constabulary.	LCC000186 PRE000210 PRE000216
21 March 2023	Presfield High School requests a welfare check from Lancashire Constabulary. This is declined under the Right Care, Right Person (RCRP) policy. Presfield High School seek assistance from Merseyside Police instead.	PRE000223
22 March 2023	Presfield High School seek assistance from the LCC MASH because they have not seen AR in 10 months and Ms Maguire’s attempted visit of 20 March had failed. LCC MASH respond stating the matter will stay closed as the case does not meet the threshold for section 47 intervention (significant harm), parents are not responding despite “numerous attempts” and no parental consent has been obtained. They do however write to AR’s parents.	LCC000186/5
4 April 2023	Alphonse R seeks support from the LCC MASH and AR reopens to CFWS with new lead family support worker Ms Ashleigh Williams.	LCC000187
11 April 2023	Ms Williams and Ms Barrett visit AR at home. He is calm but does not make eye contact. They see evidence of violence with a hole in the wall but are assured by Alphonse R that this is no longer happening.	LCC002311/103-104
14 April 2023	Ms Williams visits AR again at home. She focuses on AR’s online activity, which he claims is limited to YouTube and states that he is safe online.	LCC002311/104-105


2 May 2023	Ms Williams accompanies AR on a short walk. He was uncomfortable being outside but had made efforts to re-attend school. Ms Williams felt there was some progress. AR refuses to engage on two further attempted visits by Ms Williams on 9 and 18 May 2023.	LCC002311/105-106
15 May 2023	Review due to take place with Dr Molyneux. Email previous day from Alphonse R saying AR would only attend school if allocated a less boring teacher. Dr Molyneux and Ms Morris describe the case as a combination of overaccommodation, gaslighting and safeguarding. Meeting cancelled in any event due to AR staying up all night and being asleep. Dr Molyneux prescribes melatonin.	AHCH000185 AHCH000253/§49
25 May 2023	TAF meeting takes place chaired by Ms Williams to discuss AR’s progress. AR did not attend. Dr Molyneux, Ms Morris, Presfield High School and AR’s parents present. Dr Molyneux interprets Presfield High School’s observations about AR’s mental health as positive. Dr Molyneux states that as AR’s weight loss issues have resolved, he no longer met the criteria for mental disorder and was only being kept open by Alder Hey as a gesture of “goodwill”. It is agreed Mr Coughlan will try and re-engage AR as he requested anxiety support. It is noted that AR’s parents were unable to enforce even basic steps like getting AR to take his medication at the appropriate time.	LCC000359 AHCH000253/§58
June and July 2023	On five occasions Ms Williams and/ or Mr Coughlan visit the family home to meet AR, but he refuses to engage each time. A joint visit with Ms Barrett, requested by Alphonse R, is unable to take place due to sickness.	LCC002311/113-118


5 June 2023	Ms Morris writes a care plan for AR, noting he had been referred to CAMHS for “low mood, radicalisation, bringing knife to school and attacking peers, police involvement”. Mentions that AR does not want a case manager but wants to remain open to psychiatry.	AHCH000164/155-156
10 June 2023	AR orders a Bushcraft Survival Machete and sharpening stone from Springfields of Burton Ltd using a driver’s licence belonging to a woman called Alice (born 1991). The items are delivered by an age verified delivery through DPD and subsequently hidden by Alphonse R on top of the parents’ bedroom wardrobe. AR also orders a 2.7 kg sledgehammer from a company via Amazon (which is not subject to any age restriction), and a pack of fire lighters, duct tape, and hurricane matches. The latter are found taped to swing top bottles in the living room of 10 Old School Close following the attack.	SPRB000002 DPD000010 AMA000096, rows 85-88
20 June 2023	Presfield High School make a referral to Community Paediatrics for AR to be assessed for ADHD. This was rejected in February 2024 as the referral did not contain sufficient evidence of ADHD (although Presfield High School had been unable to complete several sections of the form because of AR’s minimal school attendance).	IWS000055 AHCH000250
3 July 2023	Very shortly before the scheduled time, AR refuses to attend another appointment with Dr Molyneux. One final prescription of sertraline is prescribed.	AHCH000253/§61


17 July 2023	Another TAF meeting takes place chaired by Ms Williams. CAMHS not in attendance. AR’s parents report AR has not been taking his medication for some time. Presfield High School reported on AR’s very poor attendance and said that they could not offer any more therapeutic support than was already being provided.	LCC000363
18 July 2023	PC Stephen Baker of Merseyside Police visits the family home with a member of the Presfield High School safeguarding team to encourage AR to attend school. Engagement is limited, and further visits in September, November and December prove unsuccessful.	MERP008318/§§29-39
6 September 2023	Ms Barrett and Ms Williams carry out a joint home visit. AR refuses to engage, but they meet with Alphonse R.	LCC002311/120
13 September 2023	TAF meeting held, chaired by Ms Barrett. AR’s parents, Mrs Dawson and Ms Morris attend. CAMHS and CFWS report no engagement, and Presfield High School confirmed that if his attendance continues to be so poor they will seek advice about offering his place to another student. Parents remain keen for AR to attend school and receive support. Presfield High School agree to continue to try to encourage attendance but cannot mandate this given AR is above compulsory school age. CFWS indicate their intention to close the case as AR is indicating that he is not consenting to any support, parents have declined parenting support and there are no safeguarding concerns.	LCC000365


25 September 2023	Following another cancelled meeting, Dr Molyneux attends the family home. AR is in his bedroom and refuses to meet with him. Alphonse R informs Dr Molyneux that AR has not taken sertraline for two months. He considered that the sertraline prescription should cease. Following this, Dr Molyneux recommends discharging AR from CAMHS. The outcome of subsequent discussions within CAMHS is that AR would remain nominally open to CAMHS psychiatry.	AHCH000253/§63
29 September 2023	AR’s CFWS case formally closes. The main reason given is AR’s refusal to engage and his parents not wanting additional parenting support.	LCC000355
3 October 2023	AR orders a Black Panther Machete from Knife Warehouse using a driver’s licence belonging to a man called Samuel (born 1961). Delivered by Royal Mail through an age verified delivery. Alphonse R takes delivery of this order.	KWAW000009 RMG000002


14 October 2023	AR orders a black coloured Kukri Machete Congo from Huntingandknives. co.uk using the driving licence details for ‘Samuel’. Hunting and Knives is a trading name of Ageo Wholesale UK Ltd. The delivery, which is not age verified, is contracted by Ageo Wholesale UK Ltd through a supply chain involving SJ Henderson Fulfilment/Ruach Music, Whistl and Evri. It is ultimately delivered by Evri on 26 October 2023. As Ageo Wholesale do not require any age verification measures, this parcel is delivered to AR (who is underage) and after the attack, this machete is found under his bed. [The Inquiry has discovered that over 2,800 other packages (the overwhelming majority of which were knives/bladed items) were sold by Ageo Wholesale to different customers and delivered through SJ Henderson Fulfilment/Ruach Music without any age verification protections.]	HKAW000032/§11
9 November 2023	Ms Suzanne Walmsley, a social worker within LCC Adult Social Care Transitions team, visits the home address following the referral from CFWS in February 2022. AR declines to engage, but Ms Walmsley speaks with AR’s parents. The notes of the visit are not written up until after the 29 July 2024 attack, and there is no plan for AR’s transition to adult services in place. This is the last contact from any form of social care/CFWS services with AR prior to the attack.	LCC000438
11 December 2023	Alphonse R emails Dr Molyneux saying AR is struggling to sleep, but otherwise well. Dr Molyneux again offers a prescription for melatonin.	AHCH000253/§93


22 February 2024	Ms Morris reviews the Risk Assessment and Management Tool and Child and Young Person Current View documents. She answers the question, ‘Poses risks to others’ with the entry ‘none’.	AHCH000155 AHCH000154
20 March 2024	AR’s EHCP is rescinded (on the grounds that he had not been in education for two years) and funding formally withdrawn for his place at Presfield High School. Alphonse R appeals, asking that AR remain on the Presfield High School roll and that his EHCP remain in place to his 19th birthday.	PRE001298
16 April 2024	Dr Molyneux formally discharges AR from CAMHS psychiatric team. AR remains open to CAMHS support due to ongoing family therapy.	AHCH000253/ §§101-105
23 April 2024	Final family therapy session takes place with Mr Coppard. Alphonse R notes that he has found them useful, whereas Laetitia M has developed a mistrust of CAMHS.	AHCH000289/§181, §§185-189
21 June 2024	AR places an order for a 20cm kitchen knife from Huntingandknives.co.uk, from whom he had successfully purchased the third machete. He chases the order on 11 July asking why it has not been delivered. Hunting and Knives respond stating the order is pending as he has not paid. The knife is never delivered.	HKAW000032/§§16-17 HKAW000009 HKAW000012
27 June 2024	AR is formally removed from Presfield High School’s roll after 0.7% attendance over two years.	PRE001808/§37, §52


13 July 2024	AR orders an Apollo chef knife from Amazon. He then cancels the order, and re-orders two of the same knives from Amazon, this time using a Virtual Private Network. He uses Alphonse R’s details for the online age verification. The package containing the knives is delivered on 15 July by Mr Hamza Ali, a contracted delivery driver for Condor Carriers, with age verified delivery. The year of birth of the person taking delivery was recorded as 1978 and the name was recorded as ‘Ax’ (the same name used for the delivery). This Inquiry finds that it was Alphonse R who took the delivery, and that Alphonse R then failed to prevent AR from taking custody of the two knives. AR goes on to use one of these knives in the attack on 29 July 2024.	AMA000096, row 98 HMA000002 COND000033
22 July 2024	Alphonse R intercepts AR preventing him from travelling to Range High School to carry out some kind of attack on the last day of their summer term. AR asks Alphonse R when Range High School has their morning break. Alphonse R tells him that it is the last day of their term. Alphonse R notices AR appears restless and in some kind of crisis. He sees a large bottle of fluid in AR’s room which AR says is alcohol. Alphonse R also sees a bow and arrows, as well as a Tupperware container with a liquid in it and a residue that looked like blue ink. AR allowed Alphonse R to pour the contents down the lavatory. AR asks Alphonse R to buy him petrol. He also produces a knife which was identified by Alphonse R after the attack as one of the newly delivered kitchen knives from Amazon.


22 July 2024 (continued)	AR demands from Alphonse R the knife/ machete that Alphonse R had hidden following the delivery on 14 June 2023. AR starts to lightly stab the bed near Alphonse R. Alphonse R deceives AR into leaving the bedroom first suggesting that the knife (machete) was downstairs. Alphonse R then shuts AR out of the bedroom. Alphonse R hears AR make a telephone call. AR makes a taxi booking to Range High School using the false name, ‘Simon’. Alphonse R attempts (unsuccessfully) to find out from a local taxi company where AR has booked to travel to. Alphonse R hears the front door close and, running outside, he spots AR entering a taxi with a rucksack. Alphonse R believes that the rucksack contained the knife that AR had used to threaten him. Alphonse R begs the driver not to take AR to Range High School which the driver states was the destination booked. AR comes back inside the home. Alphonse R calls Laetitia M to come home from work early. They wait outside the front door for over an hour. Once AR’s parents are inside the house, the Inquiry finds that they clean AR’s room with AR’s permission and see a number of the concerning items which AR had purchased. They are shocked by what they see and Alphonse R’s impression was that his wife, Laetitia M, was “petrified”.


22 July 2024 (continued)	AR threatens Alphonse R by saying “[n]ext time, next time if you stop me there will be consequences”. That night, Alphonse R texts Laetitia M saying “Our child needs to be protected. Imagine how those things [meaning AR’s behaviour] have faded away and he could have been killed of imprisoned for good/for life”.
23 July 2024	CAMHS case formally closed by Ms Morris as AR has been discharged by CAMHS psychiatry and family therapy has concluded. There was a final risk assessment.	AHCH000160
26 July 2024	Dion R returns home from university. Alphonse R tells Dion R that AR had done something bad recently. Dion R sent a message to a friend the next day indicating that his father had said “your brother is dangerous, he can kill you”.	IWS000060/§108, §§111-112 IWS000057/3 MERP001217/4
29 July 2024	AR commits the attack 09:51 – Timestamp on five files on AR’s tablet suggest he viewed material at home during the morning relating to violence and conflict, including excerpts from Kamikaze Death Poetry. 10:00 – The dance class starts at the Hart Space, 34A Hart Street in Southport. 10:50 – AR uses the chrome browser on his tablet to search for a podcast about Bishop Mar Mari Emmanuel who was stabbed in Sydney in April 2024. 10:55 – AR deletes his browser history on his laptop. 11:04 – AR searches for the “[M]ar [M] ari stabbing” this time on Twitter/X. The Inquiry finds that AR probably then viewed the actual footage of the stabbing which was posted on X.	IWS000058/§§227-250 MERP000216/1 IWS000056/§§235-241


29 July 2024 (continued)	11:10 – AR leaves the house on foot and walks round the corner. Alphonse R hears AR leave the house and shouts to Laetitia M who sees AR leaving their road on foot. Alphonse R asks Laetitia M if AR was carrying anything and she replies that he did not have a bag with him. The Inquiry concludes that Laetitia M had found the empty packaging for a knife and Alphonse R and Dion R are aware of this. AR’s parents do not call the police. 11:13 – From Hoole Lane, AR makes an aborted taxi booking attempt then one minute later successfully orders a taxi to 34A Hart Street (with One Call Taxis). 11:17 – AR returns to Old School Close and remains near the house. 11:31 – The taxi arrives and AR enters the taxi, which is driven by Gary Poland. There is no conversation between them during the journey. 11:44 – The taxi arrives in the vicinity of 34 Hart Street. AR asks if this is 34A. He exits and heads towards Masters Auto Repairs without paying. Mr Poland follows him in his taxi, asking him to pay the fare. AR refuses to pay and heads back to Hart Street, still on foot, then turns left into the Norwood Business Centre Car Park and walks towards the Hart Space. Mr Poland follows him in his taxi continuing to demand payment. Mr Poland parks outside the building. 11:45.30 – AR tries to enter the downstairs studio which is locked. 11:46:06 – Sounds of screams are heard on Mr Poland’s dashcam. 11:46:15 – The first child exits as Mr Poland starts to drive away believing (erroneously) that shots had been fired. Other children fleeing are visible to Mr Poland as he drives away.


29 July 2024 (continued)	11:46:28 – Alice da Silva Aguiar leaves the building. She is the 19th child to exit the building. She subsequently collapses, resuscitation is attempted and she is transferred to hospital. 11:46:31/33 – The first 999 call is made by Leanne Lucas. Her call connects as she is running across the car park having herself been seriously injured in the attack. 11:47:08 – Ms Lucas’ 999 call is connected through to Merseyside Police Force Control Room. 11:51 – The Merseyside Police Force Incident Manager directs that firearms officers were to make their way to the scene but that unarmed patrols should approach with caution, assess the situation and deal with it if safe to do so. 11:56:53 – The first police officer (Police Sergeant Gillespie) arrives on scene. 11:57:25 – The first paramedic, Senior Paramedic Team Leader Paul Smith, arrives at the scene. 11:57:50 – PS Gillespie has been joined by Acting Police Sergeant (A/PS) Holden and Police Community Support Officer (PCSO) Parry. 11:57:56 – PS Gillespie (armed with a baton) and A/PS Holden (armed with Taser) enter the Hart Space and confront AR on the upstairs landing. AR drops the knife and is physically restrained. PCSO Parry enters the building to assist on hearing that a knife is involved. 11:58:39 – AR is arrested.


29 July 2024 (continued)	12:04 – Elsie Dot Stancombe is formally declared life extinct at the scene. 12:36 – Mr Poland calls 999 approximately 50 minutes after the attack. 13:03 – Bebe King is formally declared life extinct at the scene.
30 July 2024	01:20 – Alice da Silva Aguiar is formally declared life extinct at Alder Hey hospital. AR is interviewed by police for the first time. He remains silent.	MERP007551/§42, §97
31 July 2024	AR is charged with three offences of murder, ten offences of attempted murder, and one offence of possession of a bladed article.
31 October 2024	AR is further charged with production of a biological toxin (the ricin found under his bed), and possessing a PDF document likely to be useful to a person committing or preparing an act of terrorism (the article containing the Al-Qaeda training manual).
20 January 2025	AR pleads guilty to all charges on the first day of his trial at the Crown Court at Liverpool.
23 January 2025	Mr Justice Goose sentences AR to detention at His Majesty’s pleasure for each count of murder, to life imprisonment for each count of attempted murder, and imposes additional sentences for the other counts. The minimum term is set at 52 years.