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Axel Rudakubana has been removed from court after shouting and telling the judge: "I need to see a paramedic because I feel ill."

Rudakubana, 18, from Lancashire, was sentenced to life in prison, with a minimum term of 52 years, after he pleaded guilty to murdering three girls on Monday, on what was due to be the first day of his trial.

Warning: This article contains distressing details

Alice da Silva Aguiar, nine, Bebe King, six, and Elsie Dot Stancombe, seven, were murdered in the attack on a Taylor Swift-themed class at a small business park in the seaside town. Rudakubana also admitted 10 counts of attempted murder and possession of a kitchen knife over the attack in the Merseyside town on 29 July.

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But as the hearing got under way, Rudakubana told his lawyer he had chest pains, was too ill to continue and would like to see a paramedic. He continued shouting about his "chest hurting" with the judge, Mr Justice Goose, telling him: "Shouting from the dock is not going to make this any quicker."

Stanley Reiz KC defending said: "He has not eaten for a number of days. He has drunk very little over that period of time.

"There was concern about his ability to be in a high pressure situation."

Mr Justice Goose said he had been reassured Rudakubana was fit to attend and the court would continue until a break at 1pm.

Rudakubana shouted: "I can't remain quiet. I haven't eaten for ten days. I feel ill. I'm not going to remain quiet."

When the judge tried to carry on with the case, Rudakubana shouted: "Don't continue."

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He was then told to leave the dock. A family member shouted "coward", while other relatives shook their heads as he left.

Mr Justice Goose said he would be brought back in to be sentenced later in the day and the prosecution opening continued in his absence. An officer entered court a few minutes after he left, and said medical staff were "happy with his state of fitness" but wanted a second opinion from a doctor.

He returned to court for the afternoon, but began shouting again and was removed. The judge confirmed he had been deemed fit to attend by two paramedics.

'Run': Yoga instructor felt knife in her back

After Rudakubana left the dock, the prosecution continued to go through the events of 29 July. Relatives held their heads in their hands and wiped their eyes, while sobbing could be heard from the public gallery.

Eight other children, aged between seven and 13, were injured in the mass stabbing at The Hart Space, along with yoga instructor Leanne Lucas and businessman John Hayes.

At the time Rudakubana entered the building, all the children were gathered around tables making bracelets and singing along to Taylor Swift songs. Rudakubana entered and grabbed the nearest child, putting his arm around her. At first, Ms Lucas thought he was there to collect her.

"But he then moved on to a second child and then a third, Alice Da Silva Aguiar," the prosecution tells the court. He moved quickly through the room, towards Ms Lucas.

In her witness statement, Ms Lucas said she "felt a knife go into her back" and everyone ran towards the door of the dance class. She recalled Rudakubana chasing after them as the children ran down the stairs.

Once outside, Ms Lucas screamed at the children to "run away, run away".

CCTV footage showed a child trying to leave the building before being pulled back in by Rudakubana. She then re-emerged and collapsed on the floor outside. A woman in the public gallery put her hand over her face and sobbed as the video played.

A woman was waiting to collect her daughter heard the screaming and managed to grab her child, and three others - one of whom, Alice Da Silva Aguiar, was bleeding from her chest - and get them into the car. Alice collapsed inside of the vehicle. She died the following day from her injuries.

'Good thing those children are dead'

One of the girls inside the studio ran towards the toilet, followed by Heidi Liddle, an adult who had been helping supervise the children. Ms Liddle locked them inside the bathroom and braced her foot against the door, telling the child not to make a sound.

"Outside, they could hear children screaming, and then the door rattled," said the prosecution's Deena Heer.

"When she heard voices outside the door crying for the defendant to stop she realised that not all of the children had managed to escape."

When police arrived, the defendant was found at the top of the stairs, stood over the body of Bebe King, holding a large, kitchen knife.

The prosecution says Rudakubana told police "good thing those children are dead" and "I'm so glad, I'm so happy" after the attack.

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Some members of the families left the court as details of pathological evidence began to be read out. The court was told victims were stabbed dozens of times. Sky News is not publishing the most graphic details of the injuries sustained by the victims, at the request of the families.

Merseyside Police has urged social media users not to post details online either.

Killer was 'fascinated with violence'

Violent content was found on Rudakubana's devices, including images of dead bodies, victims of torture and cartoons depicting violence and rape.

Prosecutor Deanna Heer said this offered "a window into the defendant's mind at this time".

"It demonstrates that he was fascinated with violence of an extreme nature, that he had obtained information on killings and how to kill and he had obtained weapons capable of killing."

Toxin ricin pulp - a biological substance - was found in a plastic kitchen container in his bedroom. There is no antidote for ricin poisoning, and even a small amount can be deadly.

The court heard he had previous convictions for assault, possession of an offensive weapon and possession of a bladed article over an incident at his old school.

He was also found in possession of The al Qaeda Manual.

Rudakubana was 17 years old at the time of the attack, which has not been declared terror-related, according to Merseyside Police.

He further pleaded guilty to charges of producing ricin and possessing an al Qaeda training manual allegedly found in searches of his home in Banks, Lancashire, in the following days.

Because of his age at the time of the attack, Rudakubana cannot be given a whole life order - these are only reserved for criminals over the age of 21, but can be given to someone between the ages of 18 and 20 at the time of the offence if they have committed a serious crime.

Downing Street declined to comment on calls for whole-life sentences to be extended to cover offenders under the age of 18.

The Prime Minister's official spokesman said: "The thoughts of the prime minister and, obviously, the whole country will be with families and everyone impacted by this horrific tragedy today as they relive the trauma of what's happened, and the whole country stands with them and the people of Southport who have shown such strength and courage in the face of unimaginable horror.

"Given court proceedings are ongoing, I'm not going to provide further commentary, including on sentencing, which is a matter for judges."

Watch a special programme from Southport on the UK Tonight with Sarah-Jane Mee at 8pm.