The words “failure”, “failing” and “failed” appear more than 200 times in Monday’s Southport report.
Its findings leave almost no agency, organisation or individual involved in Axel Rudakubana’s life unscathed.
The police, council, mental health services, Prevent programme – none of them took ownership of the risks that he posed.
Only The Acorn School, which the attacker attended after being expelled from Range High School, is noted as having repeatedly intervened.
But the Chair of the inquiry, Sir Adrian Fulford, also clearly believes in parental responsibility.
The attacker’s father, in particular, is described as “obstructive” and “manipulative” in relation to the authorities.
It is rare to see a killer’s parents singled-out for not doing more to prevent their child’s crimes.
Together, the Southport attack was a failure of both parenting and policy – nobody, says the Chair, agreed who was responsible for the troubled teenager.
There was a “merry-go-round of referrals, assessments, case-closures and ‘hand-offs'”, he says.
There is even a specific moment when Sir Adrian believes the murders could have been prevented, after the attacker was caught with a knife on a bus in 2022.
But no arrest or search of his home took place, leaving the poison in his bedroom and the warped search history on his computer undetected.
The report’s recommendations include setting up an agency with overall responsibility for monitoring risk, to avoid repeat failings.
But there are searching questions too about access to online materials for children, the availability of weapons and the complexities of the attacker’s autism (the Chair is keen not to stigmatise others with condition).
Ultimately, only the attacker can account for his crimes. But for the families of the victims and survivors, today’s report contains the painful conclusion that he could – and should – have been stopped.
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