Conclusions and recommendations concerning the immediate circumstances of the attack

Responsibility

¶196. The responsibility for the dreadful attack was established by the criminal process.

¶197. On 20 January 2025, on the first day of his Crown Court trial, AR entered guilty pleas to three counts of murder, 10 counts of attempted murder, offences of having a bladed article, production of a biological toxin, and possession of a document likely to be useful to a person preparing an act of terrorism. He was sentenced by Mr Justice Goose on 23 January 2025 to detention at His Majesty’s pleasure for each count of murder, and to custody for life for the counts of attempted murder. The minimum term was 52 years. If it had not been for his age, he would have received a whole life term. The judge set out when passing sentence:

¶“I am sure that [AR] had a settled and determined intention to carry out these offences, and that had he been able to, he would have killed each and every child, all 26 of them, as well as any adults who got in his way. It was only because some managed to escape that prevented many more from being murdered.”

The deceased: Alice, Bebe and Elsie

¶198. Given the role of this Inquiry regarding the matters that are conventionally addressed at the conclusion of a Coronial Inquest, the Terms of Reference require me to include within the account of the attack the facts and circumstances of each individual death to reflect the purposes of section 5(1) of the Coroners and Justice Act 2009.

¶199. Sections 5(1) and (2) of the CJA 2009 provide as follows:

¶“5(1) The purpose of an investigation under this Part into a person’s death is to ascertain—

¶a. who the deceased was;

¶b. how, when and where the deceased came by his or her death;

¶c. the particulars (if any) required by the 1953 Act to be registered concerning the death.

¶(2) Where necessary in order to avoid a breach of any Convention rights (within the meaning of the Human Rights Act 1998 (c. 42)), the purpose mentioned in subsection (1)(b) is to be read as including the purpose of ascertaining in what circumstances the deceased came by his or her death.”

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¶200. It is neither necessary nor appropriate for this report to go into unwarranted detail as to the injuries sustained by the three murdered girls. The following findings are sufficient.

¶201. Elsie Dot Stancombe remained where she had been found in the Hart Space dance studio. She was formally declared life extinct at 12:04 by Senior Paramedic Team Leader Paul Smith. This was confirmed at 13:53 by Dr Eimhear Quinn.

¶202. Bebe King was taken out from the Hart Space by Mr Verite as I have already described. She was formally declared life extinct at 13:03 by Advanced Paramedic Gary Fitzpatrick. She was moved from the back of an ambulance to a guarded cordon.

¶203. Dr Cieka concluded in two full post-mortem reports dated 19 September 2024 that the deaths of Bebe and Elsie had been caused by “Multiple Stab Wounds” and that their injuries “would not have been amenable to emergency medical treatment however rapidly this intervention occurred”. This conclusion has not been questioned.²⁷⁷²⁷⁷ First Witness Statement of DCI Pye MERP007551/§§40-41.

¶204. Alice da Silva Aguiar managed to run out of the Hart Space as I have already described. She collapsed by the white BMW in the car park and was carried by Mr Verite to outside 34 Hart Street. There she was treated initially by Mr Tyjon and Mr Batchelor, and then by the attending paramedics aided by police officers and the off-duty Mr Lawler. Alice was transferred by road ambulance initially to Southport and Formby District General Hospital, and later on 29 July 2024 to Alder Hey Hospital. After all treatment options had been attempted, Alice died at Alder Hey Hospital and was declared life extinct by Dr Jessica Green at 01:20 on 30 July 2024. Forensic pathology evidence was provided by Dr Jonathan Medcalf, first in an interim post-mortem report dated 1 August 2024 and thereafter in a full report dated 6 November 2024. Dr Medcalf concluded that the cause of Alice’s death was “Multiple Stab Wounds”. Dr Medcalf indicated that “With regards to the potential ‘survivability’ of the injuries, this probably would be best addressed by a suitable qualified clinician”.

¶205. Alice’s family, entirely understandably, wanted to understand whether her injuries might have been survivable and whether all appropriate interventions were taken to try to save her. The Inquiry therefore arranged for the entirety of the relevant medical records to be considered by one of the leading experts in this area, Professor Richard Lyon MBE, who is a Consultant in Emergency Medicine and Pre-Hospital Care.

¶206. Professor Lyon provided a full expert report which was provided to Alice’s family and to the Core Participants who were entitled to see it. The legal representatives for Alice’s family did not seek to challenge Professor Lyon’s conclusions. Since the full detail of the expert report inevitably contains detail that is deeply distressing, Counsel to the Inquiry produced a summary of that report which was agreed by Professor Lyon and the legal representatives of both Alice’s family and the organisations involved in her treatment. This summary was presented to the Inquiry on day 11, 23 September 2024.²⁷⁸²⁷⁸ T/S: 11/42/9-54/5.

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¶207. Professor Lyon notes that Alice sustained critical internal injuries as a result of being stabbed. Alice was bleeding internally into her chest from several different sites. The type of bleeding this caused was slower than arterial bleeding which is why – for a short period of time – Alice was able to run from the scene, before collapsing from critical blood loss. Alice, following her collapse and loss of consciousness, would then have gone into cardiac arrest. The cardiac arrest most likely occurred when Alice was still at the BMW. Professor Lyon concluded that it would not have been possible to have prevented this from happening at the scene.

¶208. Once this had occurred, the probability of meaningful survival for Alice would have been <2%. She would have suffered irreversible brain injury from lack of oxygen to the brain due to the period during which she was in cardiac arrest. The lack of heart movement on the ultrasound scan taken at Southport Hospital in Professor Lyon’s view indicated a virtually zero chance of survival.

¶209. Therefore, given the context of this incident, the timing and location of Alice’s cardiac arrest and the available emergency medical resources, it would not have been possible for Alice to have survived her injuries. Professor Lyon was clear that the immediate response by the lay bystanders was commendable but there was nothing more that they could have done. Alice received rapid care, with both Merseyside Police and NWAS being on scene within a small number of minutes. Professor Lyon commends the NWAS paramedics for providing rapid medical care following their dynamic risk assessment.

¶210. Professor Lyon paid tribute to the efforts made by bystanders, the NWAS crews and the Southport and Alder Hey Hospital teams in what he describes as their outstanding response to this terrible incident and for the commendable attempt to give Alice the best possible chance of survival, despite her catastrophic injuries.

¶211. In summary, Alice’s heart had stopped beating and she was in cardiac arrest at the scene, resulting in brain damage. Although the doctors when she was at hospital were able to establish a pulse and they carried out emergency surgery, her bleeding remained uncontrollable. In essence her wounds were simply too grave for her to have been able to survive. Neither a pre-hospital resuscitative thoracotomy nor being provided with blood/blood products by the first Helicopter Emergency Medical Service (HEMS) resources on the scene, would have changed the tragic outcome for Alice.

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Conclusion on the section 5(1) facts and circumstances

¶212. I find the following facts and circumstances in relation to the three deceased. The reasons for my wider narrative conclusions are apparent from the later chapters of this report.

Alice

¶Name of the deceased: Alice da Silva Aguiar.

¶Medical cause of death: Multiple Stab Wounds.

¶How, when, and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by her death: On 29 July 2024, shortly after 11:45 am, Alice was the victim of a deliberate mass knife attack carried out by a 17 year old violence-fixated male on a group of innocent girls attending a dance and yoga event at the Hart Space, 34A Hart Street, Southport. Alice was able to flee the studio where the event was held but collapsed outside and went into cardiac arrest. Despite extensive and appropriate medical treatment by bystanders and then emergency responders at the scene and later in hospitals, Alice died at Alder Hey Children’s Hospital, Eaton Road, Liverpool at 01:20 on 30 July 2024.

¶Conclusion as to the death: Alice was unlawfully killed.

¶While the sole immediate cause of Alice’s death was her unlawful killing by the perpetrator, the attack that led to her death was preventable. There was a serious failure by a number of relevant agencies over the preceding years to share risk information about the perpetrator, assess the risk he posed, and act on that information in an effective multi-agency way so as to mitigate the risk. More effective earlier intervention would probably have led to the perpetrator’s fascination with violence being recognised earlier and more clearly. This in turn would have revealed earlier criminal acts committed or in preparation by the perpetrator leading to significant criminal justice and counter-terrorism interventions. The perpetrator’s violent behaviour was difficult for his parents to manage in the family home. However they had knowledge that he had purchased some weapons, and they knew he had tried to leave the house to carry out some form of attack at his old school just one week prior to the fatal attack, when there was a real risk that he was armed with a weapon. They also knew of empty knife packaging once the perpetrator left the family home on the day of the fatal attack. They failed to report this to the police or any other agency.

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Bebe

¶Name of the deceased: Bebe King.

¶Medical cause of death: Multiple Stab Wounds.

¶How, when, and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by her death: On 29 July 2024, shortly after 11:45 am, Bebe was the victim of a deliberate mass knife attack carried out by a 17 year old violence-fixated male on a group of innocent girls attending a dance and yoga event at the Hart Space, 34A Hart Street, Southport. Bebe suffered extensive and unsurvivable injuries which would have caused rapid death within the upstairs of the Hart Space. She was later formally declared life extinct at 13:03 on 29 July 2024.

¶Conclusion as to the death: Bebe was unlawfully killed.

¶While the sole immediate cause of Bebe’s death was her unlawful killing by the perpetrator, the attack that led to her death was preventable. There was a serious failure by a number of relevant agencies over the preceding years to share risk information about the perpetrator, assess the risk he posed, and act on that information in an effective multi-agency way so as to mitigate the risk. More effective earlier intervention would probably have led to the perpetrator’s fascination with violence being recognised earlier and more clearly. This in turn would have revealed earlier criminal acts committed or in preparation by the perpetrator leading to significant criminal justice and counter-terrorism interventions. The perpetrator’s violent behaviour was difficult for his parents to manage in the family home. However they had knowledge that he had purchased some weapons, and they knew he had tried to leave the house to carry out some form of attack at his old school just one week prior to the fatal attack, when there was a real risk that he was armed with a weapon. They also knew of empty knife packaging once the perpetrator left the family home on the day of the fatal attack. They failed to report this to the police or any other agency.

Elsie

¶Name of the deceased: Elsie Dot Stancombe.

¶Medical cause of death: Multiple Stab Wounds.

¶How, when, and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by her death: On 29 July 2024, shortly after 11:45 am, Elsie was the victim of a deliberate mass knife attack carried out by a 17 year old violence-fixated male on a group of innocent girls attending a dance and yoga event at the Hart Space, 34A Hart Street, Southport. Elsie suffered extensive and unsurvivable injuries which would have caused rapid death within the upstairs of the Hart Space. She was later formally declared life extinct at 12:04 on 29 July 2024.

¶Conclusion as to the death: Elsie was unlawfully killed.

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¶While the sole immediate cause of Elsie’s death was her unlawful killing by the perpetrator, the attack that led to her death was preventable. There was a serious failure by a number of relevant agencies over the preceding years to share risk information about the perpetrator, assess the risk he posed, and act on that information in an effective multi-agency way so as to mitigate the risk. More effective earlier intervention would probably have led to the perpetrator’s fascination with violence being recognised earlier and more clearly. This in turn would have revealed earlier criminal acts committed or in preparation by the perpetrator leading to significant criminal justice and counter-terrorism interventions. The perpetrator’s violent behaviour was difficult for his parents to manage in the family home. However they had knowledge that he had purchased some weapons, and they knew he had tried to leave the house to carry out some form of attack at his old school just one week prior to the fatal attack, when there was a real risk that he was armed with a weapon. They also knew of empty knife packaging once the perpetrator left the family home on the day of the fatal attack. They failed to report this to the police or any other agency.

Safeguards regarding taxis: duty to impart information and report crime

¶213. The evidence heard by the Inquiry revealed that taxi drivers may at times be the first or only members of the public to witness indications of serious criminal activity. Their actions in such moments can materially influence the speed and effectiveness of an emergency response. The events of 29 July 2024 have highlighted the importance of ensuring that all licensed taxi drivers clearly understand their safeguarding obligations and the expectation that they report serious criminal behaviour immediately. The following recommendation seeks to strengthen this understanding across the sector.

Recommendation 4: The Department for Transport should require local authorities to ensure that all licensed taxi drivers have a clear duty promptly to report any significant criminal activity they witness while working. This duty should form part of mandatory training, and a failure to report such activity, subject to individual circumstances, should place the driver’s licence at risk. Local authorities should implement practical measures to ensure that drivers have read, understood and acknowledged this requirement.

¶214. I am concerned that on the day of AR’s earlier attack on Range High School in December 2019, The Acorns School called the taxi company that usually brought AR to school but that firm refused to give out any information about where AR was going to in the alternative taxi that he had booked, when he should have been in the school taxi (see Chapter 11: Education).²⁷⁹²⁷⁹ This was not One Call Taxis.

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Recommendation 5: The Department for Transport should ensure that local authorities establish effective arrangements between licensed taxi companies and schools. These should enable school safeguarding teams to access taxi booking information where relevant to a legitimate safeguarding or risk concern relating to a child who should be at school.

¶In this context, I note that Alphonse R experienced similar difficulties on 22 July 2024 (and to some extent on 11 December 2019) when trying to get information from taxi firms about where AR was heading. There may be safeguarding concerns around whether parents should similarly be able to access such information from taxi firms: parents who are a risk to their own children might use this information for malign purposes and it may prevent children at risk accessing places of safety. Therefore, my formal recommendation above is limited to school safeguarding teams, but I make the following observation.

Observation B: The balance of risks around parents being able to access information concerning the destination of taxis booked directly by their children might also warrant consideration.

Lessons from the emergency response

¶215. Before setting out my recommendations in relation to the police and paramedics, it is important to note the situation faced by the emergency services on 29 July 2024. The events unfolded at speed and were complex. First responders made decisions under extreme pressure and in the face of significant uncertainty. The recommendations below are made recognising both the commendable bravery and professionalism shown by the responders, but also the importance of strengthening emergency service responses in future no-notice, life-threatening incidents. They are intended to support clearer decision-making, enhance resilience, and ensure that emergency services personnel have the training, structures and resources needed to respond as effectively and safely as possible.

¶216. The evidence heard by the Inquiry demonstrated that rapid and informed decision-making by Force Incident Managers is critical in responding to attacks where a threat to life is ongoing. In this case, the decisions taken by Merseyside Police — particularly CI Hughes’ willingness to take a measured degree of calculated risk in deploying unarmed officers — were decisive in preventing further loss of life. However, CI Hughes suggested that the matters included in the Manchester Arena Inquiry learning and briefing were not reflected in formal policy or guidance. I recognise that the police use overarching principles of decision making which address the question of calculated risk in threat to life situations, in particular the National Decision Making Model, and that these themes are addressed in many elements of police training, including the Force Incident Manager course and via Stay Safe training. Nevertheless, in my view it is important that these specific issues, which arose in the Manchester Arena Inquiry and this attack, are appropriately embedded. The following recommendation is therefore intended to ensure that all police forces adopt clear, structured guidance on how calculated operational risk should be assessed and managed in such circumstances.

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Recommendation 6: All police forces should ensure that their policies, guidance and training address taking on a calculated degree of risk in recognition of the immediate need to protect the public from an obvious risk to life. This may involve the decision to deploy unarmed officers with caution.

¶217. The Inquiry also heard compelling evidence of the pressure placed on a single Force Incident Manager during the early stages of a rapidly developing major incident. In Merseyside Police, the availability of a second Force Incident Manager provided essential support and contributed to effective command decision-making. As this practice is not yet universal across forces, I make the following recommendation to promote consistent resilience in incident command capacity nationwide.

Recommendation 7: All police forces that have not implemented a model providing immediate and direct support to Force Incident Managers, ideally through a second Force Incident Manager, should consider adopting such arrangements to strengthen decision-making during critical incidents.

¶218. The Inquiry examined in detail the ambulance service response to the attack. Notwithstanding the evident professionalism and courage of the individual clinicians who deployed, certain structural issues had the potential to impede clarity and the speed of response during the early stages of the incident. In particular, the absence of clear, consistently understood procedures for declaring a Major Incident or Major Incident Standby created avoidable uncertainty. I stress again, however, that in this attack, this had no impact on the survivability of the injuries that were suffered by the victims. Additionally, the Inquiry heard that NWAS, in common with other ambulance services, does not currently have the funding capacity to allow all frontline staff to participate in regular major incident exercises, despite the clear value of such training and ongoing work in this area. The following recommendations seek to address these issues so that ambulance services are better supported, better prepared and better able to co-ordinate effectively with partner emergency responders.

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Recommendation 8: NHS England should review funding, and consider providing additional resources, to enable all emergency response ambulance staff to participate in appropriate training exercises.

Recommendation 9: North West Ambulance Service should review its procedures for declaring a Major Incident or Major Incident (Standby) to ensure clarity in how declarations are made and how they are communicated internally and to other emergency services.

Wider lessons regarding the medical response

¶219. Professor Lyon was asked to comment on whether there are lessons to be learnt for the benefit of the future from what occurred on 29 July 2024. While Professor Lyon has not identified any failings in the response to this incident by the first-responders or the medical services, nonetheless his detailed consideration of the treatment of Alice has led him to highlight a few general areas that he suggests should form part of any consideration of how the number of fatalities might be reduced should similar incidents occur.

¶220. First, Professor Lyon suggests that there may be a need to secure a greater degree of “situational awareness” of a complex scene when multiple 999 calls are received from the public. This is an important observation by Professor Lyon, but the difficulty for the Inquiry is that no practical steps have been identified which would have improved what was a highly successful reaction by the emergency services to this incident.

Observation C: The relevant bodies and agencies (North West Ambulance Service, Merseyside Police, the College of Policing and the National Ambulance Resilience Unit [NARU]) may wish to consider this observation by Professor Lyon when considering any improvements to the ways in which major tragedies of this kind are handled and in their training exercises.

¶221. Second, it is self-evidently right for Professor Lyon to observe that it would be helpful if chest seals and bleed control kits, usable by those who are not medically qualified, are more readily available. However, as Professor Lyon pointed out, there will always be a challenge as to the location of these kits and ensuring that sufficient kits are immediately accessible. Mr Daniel Ainsworth’s evidence was that both of these are useful tools for clinicians but that there needs to be considerations around the practicalities of how they would be used – by comparison, there is a network of defibrillators which are registered, at locations and with codes visible to 999 call handlers.

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Observation D: The efforts which I am told are presently underway to place such kits in high-risk locations for penetrating trauma (e.g. pubs and night clubs) are important and should be prioritised. But it would be unrealistic to suggest that such a kit should be located in a building such as the Hart Space. I suggest this would be a disproportionate expectation, given the low likelihood of an event of this kind occurring.

¶222. Third, Professor Lyon has suggested that there was an apparent delay in declaring a major incident in the present case, potentially because of a lack of urgency or a sense of reluctance to take this step. I have addressed the issue above.

¶223. Fourth, Professor Lyon suggests that there could be an earlier deployment of HEMS and Consultant-level Pre-Hospital Emergency Medicine responders to the scene of an incident such as the present, to aid in clinical decision making and to provide more immediate enhanced care, including critical interventions such as a thoracotomy. Mr Ainsworth provided a detailed explanation of the arrival time of the HEMS resources in response to the attack.²⁸⁰²⁸⁰ Witness Statement of Mr Ainsworth NWAS001083/§§126-134. In short, at the time of the incident, many of the HEMS resources were deployed on other incidents. North West Air Ambulance resource H08, crewed by a double critical care paramedic, arrived at the scene at 12:23. Due to the allocation of other resources to other incidents, the Complex Incident Hub contacted the Great North Air Ambulance Service and resource H58, crewed by a doctor and a critical care paramedic, flew from the Penrith area and were transported from the landing site to the scene. They are timed as being with a patient at 12:40. A BASICS doctor was allocated to the event at 12:01 but required to travel from Manchester. I am satisfied from Mr Ainsworth’s evidence that these resources were appropriately managed.

¶224. Fifth, Professor Lyon suggests that improvements could be made as regards the interoperability of the police and the ambulance services, including the ways in which they communicate and in M/ETHANE reporting. I agree with this observation and have set out the confusion that appears to have arisen through the different terminology used by Merseyside Police and North West Ambulance Service above. This was also a feature of the Forbury Gardens Inquests for which I was Judge Coroner.

Recommendation 10: Merseyside Police and North West Ambulance Service should review the terminology used in their systems and procedures to ensure shared understanding and interoperability. The College of Policing and the National Ambulance Resilience Unit should undertake a national review to ensure that police and ambulance services across the country operate with consistent terminology and mutual understanding.

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¶225. Sixth, Professor Lyon proposes that more potentially needs to be done to ensure rapid and effective role allocation at the scene. As to this proposal, Mr Ainsworth noted that this would have assisted, for example by the allocation of an equipment officer. However, he noted that the allocation of such roles would have taken clinicians away from initiating care and treatment. He stated that there is a balance between allocating roles and providing treatment which would depend on the incident. He stated that allocating all roles would, in this case, have been the wrong decision given the condition of the patients and he thought that the right balance was taken.²⁸¹²⁸¹ T/S: 12/160/14-162/1. While there was some evidence that there were issues with equipment, these were not fundamental issues and did not have any causative impact, and I therefore do not consider that I need to make a recommendation in this respect.

¶226. Finally, the possibility is raised by Professor Lyon of making blood products available earlier following an incident of this kind. This would be especially important when they occur in remote or rural areas, with lengthy journeys for the injured to hospital. Mr Ainsworth stated that, since the attack, North West Air Ambulance Critical Care Paramedics now have the ability to provide pre-hospital blood transfusions. As a result, there are now four HEMS resources that can administer blood products, rather than one.²⁸²²⁸² T/S: 12/166/1-17. If in place at the time of the attack, it would have meant that blood products could have been administered by the crew of H08 which was on scene at 12:23, rather than waiting for the arrival of a doctor on H58 at 12:40. Mr Ainsworth was also asked about whether NWAS Advanced Paramedics should be able to administer blood products. He explained that blood products are incredibly beneficial but only to a very specific presentation of clinical need and NWAS did not believe that it is appropriate to widen the provision of blood products. Noting the improvements already made at the local level, I was satisfied by his explanation, and I do not consider this warrants a formal recommendation, but I make the following observation:

Observation E: The capacity for getting blood products to the scene in response to major and critical incidents is worthy of ongoing consideration by ambulance trusts and helicopter emergency medical services nationwide.

Venue security

¶227. I readily understand why it is felt that the children present on 29 July 2024 should have been provided with a greater degree of protection. It would be wrong to criticise the parents who sought to have these issues scrutinised in this Inquiry’s Phase 1 hearings. Painful though I know it has been – particularly for Ms Lucas and Mrs Scholes – these were necessary questions.

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¶228. Having considered the matter with care, for the reasons I have set out above, I find that in terms of the organisation of the class and the security of the venue there were no shortcomings or failures on the part of:

¶a. Ms Lucas as the main class organiser (and this also extends to Mrs Liddle);

¶b. Mrs Scholes as the leaseholder;

¶c. JGH Developments Ltd as the landlord (this also extends to Mrs Hayes as director, and Mr Hayes who had day-to-day operational control).

¶229. The level of risk and the protections that need to be in place for a community event or class will need to be assessed on an event-by-event basis. The present attack was wholly unpredictable and there were no grounds for suspecting that the children at this dance class were at risk of violence, particularly of this extreme kind. I do not consider that those listed above can be faulted for not anticipating this kind of eventuality.

¶230. I have considered whether I should recommend change to the OOSS guidance so as to mandate greater security of access points for community venues. In considering this issue, I take account of the strength of feeling among some of the victim families that there should be change in this area. I am keenly aware, given the appalling actions of AR, of the strong temptation to suggest this protective step.

¶231. However, after careful deliberation I have concluded it would be disproportionate and potentially counter-productive for me to recommend that all community events of this kind must take place behind a securely locked door.

¶232. In reaching this conclusion, I have had regard to essentially the same issues highlighted by Ms Dixon. Imposing particular physical security arrangements on the huge range of community providers risks (through both cost and practicality) deterring small-scale community events from being organised. Such events are a major benefit and contribution to communities. I have also taken into account that, under the Terrorism (Protection of Premises) Act 2025 (‘Martyn’s Law’), certain premises and events are required to ensure that steps have been taken to prepare for potential terrorist attacks and get ready to help keep people safe in the event of an attack. Notably, under that Act, in order to be a qualifying premises, 200 or more individuals (including staff) must, at least occasionally, be reasonably expected to be present at the same time in connection with one or more uses specified in that Act. I consider this reflects the importance of not imposing disproportionate burdens on small premises and providers. I also take account of the fact that, as considered below, this was an essentially unprecedented event in the history of the United Kingdom. An occurrence of such rarity should not, in my view, lead to a profound change in the way that valuable classes of this kind are organised. The wholly exceptional nature of the present violence tends, therefore, to indicate that requiring ad hoc children’s gatherings such as the present to be held behind securely locked doors which cannot be opened from the outside by unauthorised individuals would be an unjustified step.

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¶233. I found it informative that Mrs Scholes, having since moved to new premises, has refused an offer from Sefton Council to install a quick release door because she fears that should there be a fire it may not be safely navigated by small/ young children attempting to flee the building.

¶234. I wish to stress, therefore, that the security measures needed, for instance, at school premises (as to which there is more demanding guidance in place) are unlikely to be applicable – at least as an appropriate mandatory measure – for informal and occasional classes such as the one on 29 July 2024. I recognise, however, that circumstances which are dissimilar to the present may call for a more cautious approach, if a notable level of risk is apparent.

¶235. There is, however, no recorded history of attacks, still less serious attacks, in the United Kingdom on small and informal gatherings of young children outside of a school setting. The closest events in gravity to the Southport attack are in truth attacks on schools with firearms. Those have been historically mercifully rare in the UK. Nothing similar has occurred for nearly 30 years, since the devastating Dunblane attack in March 1996 which led to The Firearms (Amendment) (No. 2) Act 1997 banning .22 calibre handguns.

¶236. For reasons that I understand, Mrs Scholes and Ms Lucas have suggested that organisers of events such as the present should be warned if a dangerous individual poses a risk. This would include maintaining a central register and the police being in a position to warn all those responsible for holding events such as this dance class. Even with recent technological advances, this would be an expensive and labour-intensive undertaking and organisers of informal events of this kind would need to be aware of this responsibility. Moreover, although there were strong reasons to suspect that AR harboured a violent grievance directed at Range High School, there was no basis for appreciating that a Taylor Swift themed dance and yoga class for young girls might instead become the focus of his attention. I consider it unlikely, therefore, that a register of the kind suggested would have afforded protection to the victims in this case.

¶237. In all the circumstances, I make a more limited recommendation in this area.

Recommendation 11: The Department for Education should update the out-of-school settings guidance by reviewing the health and safety section to ensure terminology is clear and consistent, particularly regarding emergency plans and fire/evacuation plans for smaller providers. The guidance should also be updated to include a non-binding cross-reference to school entrance security guidance, emphasising that while out-of-school settings may differ from schools in terms of what is necessary, appropriate or proportionate, providers should still consider appropriate entrance and exit security measures.

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