Chapter 1: Fundamental problems

Introduction

¶1. As part of its investigation into how the attack on 29 July 2024 was able to happen, the Inquiry heard evidence from a range of local and national agencies which had prior contact with its perpetrator, AR. The later chapters of this report identify a number of opportunities to manage the risk that AR posed to the public which were either not recognised or not taken by individual agencies.

¶2. However, a proper understanding of how this attack was able to happen cannot be reached by simply looking at the involvement of the individual agencies, including the failures of those agencies.

¶3. This chapter addresses the five fundamental problems in how AR’s risk was understood and managed. These five problems were overlapping: each of them reinforced and exacerbated the others.

¶4. Everything that follows in this report should be read with these five fundamental and overlapping problems in mind. They affected and indeed infected all dealings with AR and the individual agencies. The examples cited in this chapter are more fully explained in Chapter 2: Chronology and in the chapters dealing with the relevant individual agencies.

A failure of any organisation or multi-agency arrangement to take ownership of the risk that AR posed

¶5. There was a fundamental failure by any organisation, or multi-agency arrangement, to take ownership of the risk that AR posed.

¶6. This manifested in a number of ways, including a disturbing lack of clarity as to who, if anyone, was the lead agency, which persisted through the Inquiry’s hearings. Witnesses in appropriate positions were asked who was responsible for AR’s risk. There was no consistent response. No agency was prepared to accept that it had the lead role in managing the risk that AR posed to others, with the sole and partial exception of the Child and Youth Justice Service (CYJS) which acknowledged it was responsible for assessing the risk posed by AR during the life of his referral order between February 2020 and January 2021.¹¹ T/S: 28/166/10-18, T/S: 28/218/7-219/14.

¶7. Examples of this included:

¶a. Lancashire Constabulary’s Community Safety team took the view in December 2019 that as soon as a referral had been made to Prevent, it was Prevent which was to be the lead agency;²² Chapter 7: Policing.

¶b. Prevent declined to refer AR’s case to a Channel panel on three occasions when, based on the information that should have been known to Counter Terrorism Policing North West (CTPNW), referrals ought to have been made;³³ Chapter 8: Prevent and Counter Terrorism Policing.

¶c. Forensic Child and Adolescent Mental Health Services (FCAMHS) closed AR’s case in March 2020 despite having carried out no structured assessment of the risks posed by AR to others;⁴⁴ Chapter 10: AR’s healthcare.

¶d. Lancashire Constabulary repeatedly took the view that its role was complete so long as a referral had been made to the Multi Agency Safeguarding Hub (MASH), even when officers repeatedly attended at the same address; this was compounded by the fact that the Constabulary did not routinely receive any feedback from the MASH or other agencies as to what action was being taken;⁵⁵ Chapter 7: Policing.

¶e. Lancashire County Council’s (LCC) Children’s Social Care (CSC) repeatedly ‘stepped down’ AR’s case to LCC’s non-statutory Early Help service (also known as the Child and Family Wellbeing Service (CFWS));⁶⁶ Chapter 9: Social care.

¶f. CFWS repeatedly closed AR’s case despite interventions having had no or no meaningful impact;⁷⁷ Chapter 9: Social care.

¶g. The lack of response to The Acorns School’s request for a multi-agency assessment of AR’s risk following the hockey stick attack at Range High School.⁸⁸ Chapter 11: Education.

¶8. The inability of any agency to identify clearly who held the lead responsibility, and the consequent regular shifting of AR’s case to others, reflects the structures that were in place at the time. A central theme of this Phase 1 report is, therefore, that throughout the relevant period leading up to 29 July 2024, no institution or agency took the overall responsibility for assessing and thereafter addressing the clear high degree of risk of violent harm to others that AR had demonstrated from early October 2019.

¶9. Whenever concerns were raised about risk of harm to others, they lacked an appropriate ‘destination’: put simply, there was no designated individual or agency with clear responsibility for ensuring that the risk to the public was assessed at speed and – to the extent possible – neutralised.

¶10. Conversely, there was an enduring focus on the part of many who were involved with AR, throughout the entire period leading up to 29 July 2024, on the potential risk of harm to AR as opposed to the risks that he posed to others. In very many cases involving children, it is clearly crucial and appropriate that the authorities should focus on the risk of harm to the young person in question. Frequently, the risk to the child themselves will be the central - if not the only - real safeguarding issue. However, in a case such as AR’s, when the available information demonstrates that a young person poses a significant threat to others, this should be treated with at least equal seriousness. The pervasive failure to act on AR’s dangerousness (with some notable exceptions) was a fundamental failure in this case.

¶11. For those convicted of serious criminal offences, the Multi Agency Public Protection Arrangements (MAPPA) are the means by which the dangerousness of the offender will be monitored upon release in the community. MAPPA is a statutory set of arrangements which provides a common framework for the identification, assessment and management of certain offenders in the community. There are four categories of MAPPA offenders: category 1 covers convicted sexual offenders who are subject to notification requirements; category 2 covers convicted violent offenders who have been sentenced to 12 months or more in custody; category 3 covers dangerous offenders who have been cautioned for or convicted of an offence which indicates that he or she is capable of causing serious harm and which requires multi-agency management; and category 4 covers terrorist or terrorist risk offenders.

¶AR self-evidently did not come within any of categories 1, 2 or 4. He could in theory have been considered for discretionary inclusion within category 3 following his convictions in February 2020, but the reality is that, as a child, he was never likely to have been referred to MAPPA absent an exceptionally robust identification of the risk he posed.⁹⁹ T/S: 31/117/1-6, T/S: 32/22/2-7.

¶12. My attention was also drawn to Multi-Agency Safeguarding Partnerships (MASPs), a non-statutory arrangement implemented in Lancashire in 2022 as part of its work under the Serious Violence Duty under the Police, Crime, Sentencing and Courts Act 2022. MASPs provide early intervention and support for children and young people (up to 18 years old) who are at risk of exploitation. Their introduction reflects an increased focus on ‘contextual safeguarding’ and the harm that can be caused to children by risks outside the home such as criminal exploitation. While those risks to the child may in some cases be found alongside an increased risk of harm to others from the child (for example, where involvement in criminal gangs means that the child is more likely to carry weapons), this is not part of the focus of the MASP. Accordingly, although this provides a potential model that is worth further exploration, the MASP structure does not adequately address the risks that a child or young person may pose to others.

¶13. Accordingly, both MAPPA and MASP, as they currently operate, fail to provide appropriate and comprehensive protection for the public in these circumstances.

¶14. Instead, at a multi-agency level, the three possible frameworks in place at the time for handling AR’s dangerousness were:

¶a. Prevent, which could bring multiple agencies together at Channel panel meetings aimed at reducing the risk of being drawn into terrorism;

¶b. Child Protection multi-agency working under Working Together to Safeguard Children, which was led by LCC Children’s Social Care and aimed at protecting children from harm as defined in the Children Act 1989; and

¶c. The multi-agency Early Help processes known as the Team Around the Family (TAF) led by LCC’s CFWS, which were focused on stopping cases escalating to Child Protection, often by a focus on improving parenting and family relationships.

¶15. While Prevent, by the nature of the cases which it routinely deals with, would have been the most likely framework to be able to address AR’s risk, none of these three frameworks was by any means a perfect fit. The risk of harm posed by AR fell between their respective remits.

¶16. At times, Prevent and Children’s Social Care (CSC) recognised the risk that AR posed to others, but were unwilling or unable (within their systems or policies) to flex to deal with it themselves. Examples of this include:

¶a. The First Referral to Prevent;¹⁰¹⁰ Chapter 8: Prevent and Counter Terrorism Policing.

¶b. The 2019 to 2020 multi-agency strategy meetings under Working Together to Safeguard Children.¹¹¹¹ Chapter 9: Social care and Chapter 10: AR’s healthcare.

¶17. At other times, all three multi-agency fora failed to recognise that such a risk existed:

¶a. The Second and Third Referrals to Prevent;¹²¹² Chapter 8: Prevent and Counter Terrorism Policing.

¶b. CSC’s response to the incident where AR carried a knife on a bus on 17 March 2022;¹³¹³ Chapter 9: Social care.

¶c. CFWS’s response to AR’s violent behaviour at home in January and November 2021.¹⁴¹⁴ Chapter 9: Social care.

¶18. In my assessment, the individual workers and managers within the agencies that dealt with AR displayed the variety of competencies, abilities and shortcomings that would likely be found in any detailed investigation of public sector multi-agency work. Some I found unimpressive. A few were clearly outstandingly good. Most fell in between with an inevitable mixture of strengths as well as weaknesses. I readily accept that all acted in good faith and with good intentions. However, the frankly depressing – and therefore urgent – matter requiring government attention is this failure – at an organisational and individual level – to stand up and accept responsibility for managing the risk that AR posed. Far too often, AR’s “case” was passed from one public sector agency to another in an inappropriate merry-go-round of referrals, assessments, case-closures and “hand-offs”.

¶19. Agencies repeatedly passing the risk to others and closing/downgrading their own involvement is not effective – or responsible – risk management. If, as a society, we are to avoid repetition of what happened in AR’s case, this culture has to end. This is the single most important conclusion of Phase 1 of this report. This failure lies at the heart of why AR was able to mount the attack, despite so many warning signs of his capacity for fatal violence.