Source · Prevention of Future Deaths

Bernadette Rosario

Ref: 2026-0341 Date: 3 Jul 2026 Coroner: Andrew Cox Area: Cornwall 56-day deadline: 11 Nov 2026 est. (estimated from the Judiciary.uk publication date) Responses identified: 1 of 2 1 response identified · 2 indexed addressees

Response deadline: 11 November 2026 (estimated from the Judiciary.uk publication date).

Coroner's concerns

Coroner’s Concerns (source excerpt)
The evidence revealed that the police, Carrick CMHT and the probation service were significantly under-resourced/under-staffed at the time of these events. The police had 50 CID vacancies with Officers carrying double a full workload.
View full coroner's concerns
The evidence revealed that the police, Carrick CMHT and the  probation service were significantly under-resourced/under-staffed  at the time of these events. The police had 50 CID vacancies with  Officers carrying double a full workload. Carrick had 2/3 agency  staff. Workloads within the probation service were at over 160%.  I found the lack of resource/excessive workloads contributed to  serious failures to work across agencies and manage [REDACTED]. As one witness put it, there was a collective failure properly to  understand risk and then take steps to reduce it. Put another way  by the same witness, everyone was in their lane but no one was  looking across lanes. I draw to your attention my findings from  paras 188 onwards of the attached judgment. I found this contributed to ineffective multidisciplinary team or  cross-agency working and it prevented effective integrated offender management. I felt there would be real value in senior  executives in the agencies concerned, and potentially other key  state agencies, sitting down to review the lessons to be learned  from this incident and taking steps to prevent similar deaths from  occurring in the future.

Responses 1 respondent

Devon Cornwall Police

Police / Law Enforcement PDF ↗
AI-generated response summary

Devon and Cornwall Police established an Investigation Academy three years ago, which has significantly improved investigator capacity, reduced workloads to no more than 15 live investigations in most areas, and strengthened training and support for detectives. They are willing to collaborate on multi-agency working but await the conclusion of a Domestic Homicide Review before participation.

View full response
Dear Mr Cox Bernadette Rosario – Prevention of Future Deaths Report I write further to your letter dated 6 July 2026 enclosing Prevention of Future Deaths Report. Please accept this letter as the formal response submitted on behalf of Devon and Cornwall Police under Rule 29 Coroners (Investigations) Regulations 2013. I have carefully considered your Judgement and specifically your findings of fact set out between paragraphs 140 - 153 and that CID were significantly under resourced and overworked leading up to and at the time of Bernadette Rosario’s passing. To address this there have been significant efforts made to boost our PIP 2 capacity and capabilities. The investigative landscape within Devon and Cornwall Police has changed significantly over the last three years. In response to growing organisational challenges around investigator capacity, capability, retention and performance, the Investigation Academy (IA) was established with four key priorities:
1. Recruitment Pathways: To reduce attrition, improve the student experience and strengthen pathways into investigation, particularly through internal Police Constable to Detective Constable progression routes.
2. Training: To develop a meaningful PIP 1 training offer for both investigators and supervisors, whilst enhancing the existing PIP 2 training provision.
3. CPD and Accreditation: To establish a robust and consistent continuing professional development (CPD) framework for both PIP 1 and PIP 2 staff, alongside clearer and more effective accreditation processes.
4. Business Improvement: To improve the systems, governance and performance frameworks that underpin investigative standards and support continuous organisational improvement.

[Page 2] These priorities closely align with the Investigation Academy's original aims and pillars set out in force governance papers (see attached – DCC GOV BOARD) What have we achieved? The Investigation Academy has delivered substantial progress across all four pillars, resulting in measurable improvements in investigative resilience and performance. Key achievements include:
• Reducing investigator workloads, with officers now carrying no more than 15 live investigations in most areas.
• Reducing pathway attrition to below 10%, placing the force amongst the strongest performers nationally.
• Improving workforce resilience, with Crime Command now operating close to its establishment design.
• Increasing the number of officers progressing through the PC to DC pathway, bringing greater operational experience into investigative roles.
• Establishing a more structured audit and governance framework through Investigation Quality Audits (IQ Audits) and senior officer review processes, providing consistent oversight of investigative quality, timeliness and performance.
• Strengthening support for new detectives through the development of Professional Development Units (PDUs), improving student experience, reducing workloads and contributing to improved accreditation and retention outcomes. Evidence from force reporting shows PDUs have increased accreditation rates and lowered the burden on trainee detectives. (As attached Sec 5a FMS). What has driven these improvements? Several key developments have underpinned this progress.
• A strengthened IA infrastructure - The Academy has introduced a consistent force-wide approach to investigative scrutiny, governance, performance oversight and professional standards, creating greater consistency across commands.
• Improved workforce and HR processes - Enhanced pathway management, clearer oversight of investigator development and more effective workforce planning have improved recruitment, retention and deployment of investigative resources.
• The introduction of PIP 2 Professional Development Units - The creation of PIP 2 PDUs has provided a structured and supported development pathway for new detectives. This has enhanced the student experience, reduced the operational impact on learners, improved accreditation outcomes and contributed significantly to reducing attrition during the first three years of service. Page | 2

[Page 3] Remaining Risks and Challenges Whilst progress has been significant, we continue to work to alleviate some remaining risks. These risks appear mainly within the staffing of the Public Protection Unit (PPU). Further work is required to improve workforce numbers, however, the strengthening of Crime Command staffing now provides greater flexibility to improve the movement of experienced investigators across commands and address resilience gaps over time. National policy has also driven the implementation of dedicated RASSO teams and wider national changes to investigative structures. This may have implications for investigator capability and resilience in the medium term, requiring ongoing workforce planning and monitoring. Conclusion on Investigative Capacity Three years on, the Investigation Academy has become a key driver of investigative improvement across the force. Through investment in pathways, training, accreditation and business improvement, the force has seen tangible gains in workforce resilience, student experience, accreditation and investigative performance. While challenges remain, particularly around PPU capacity and future national reforms, the foundations are now in place to continue building a sustainable and highly capable investigative workforce. Multi-agency Integrated Offender Management I have also considered the highlighted need for effective cross-agency working and integrated offender management. Devon and Cornwall Police are very willing to collaborate with both the interested persons in this matter and wider stakeholders to enable the learning to be implemented. At present, we await the conclusion of the Domestic Homicide Review before any participation. This is so Devon and Cornwall Police are able to engage in a group meeting when the available information supports a full and frank discussion, allowing us to collectively deliver the best and most appropriate outcomes for the family and our wider public.

Report sections

Investigation and inquest
On 3/7/26, I concluded the inquest into the death of Bernadette Rosario who was stabbed to death by her son, [REDACTED], on 28/3/23 at the age of 61.   

I recorded the cause of death as 1a) Stab wounds to face, head and upper limbs   

I recorded a conclusion that Bernadette was unlawfully killed. A number of serious failures on the part of various state agencies contributed to the outcome.
Circumstances of the death
On 28/3/23, Bernadette was stabbed to death at her home address of 2 Clayton Terrace, Carluddon, St. Austell in Cornwall. Her assailant had  broken into her property and stolen knives approximately 18 months  before her death and had made threats to kill her either himself or by  encouraging another to do so.    

When her assailant was discharged from hospital in December 2022,  there was a serious failure to discuss and reconcile conflicting clinical  judgments as to the underlying nature of his diagnosis. There was no  satisfactory assessment of risk or risk management planning that  reflected the differing clinical opinions.    

Those responsible for managing Bernadette’s assailant in the community failed properly to assess the risk of serious harm he posed to her. As a consequence, no or no adequate steps were taken to safeguard her or  reduce the risk she faced.    

On the evidence, it is more likely than not that the serious failures to  reconcile conflicting clinical judgments and to assess and decisively act  upon the risk of serious harm Bernadette’s assailant posed to her both  contributed to her death more than minimally.    

While there was a serious failure to prepare in timely manner a file for  potential prosecution following a break-in at Bernadette’s home in March 2022, the evidence is insufficient and likely to be of such a speculative  quality that it cannot be found it is either probable or possible this  contributed to her death more than minimally.   

A copy of my full judgment is attached.
Action should be taken
In my opinion action should be taken to prevent future deaths and I  believe you [AND/OR your organisation] have the power to take such action.

Similar PFD reports Shared signals

Responses identified

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Nov 2026 (estimated from the Judiciary.uk publication date).

Sent to

  • Chief Constable, Devon & Cornwall Police
  • Head of Operations south-

Source links

Data: judiciary.uk.