Dr Ciaran Murphy, a former social worker and member of the Association of Child Protection Professionals, believes services designed to protect children are now facing more cases where children are themselves the risk.
Yet there was nothing to stop him going to a dance class, murdering Alice da Silva Aguiar, nine, Bebe King, six, and Elsie Dot Stancombe, seven, and attempting to murder many more.
From the age of 13, Axel Rudakubana had been on the radar of police, safeguarding services, mental health teams and Prevent, the counterterrorism programme.
"You'd still be thinking about the child protection plan, you'd still be thinking about a strategy meeting," he said.
When the police arrived at the scene of horror in Southport last summer, the teenager holding the knife was someone they had been called about many times before.