Devon Cornwall Police
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Source · Prevention of Future Deaths
Bernadetter Roasario
Ref: 2026-0341
Date: 3 Jul 2026
Coroner: Andrew Cox
Area: Cornwall
1 response identified · 2 indexed addressees
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Response deadline: 11 November 2026 (estimated from the Judiciary.uk publication date).
Date
3 Jul 2026
56-day deadline
11 Nov 2026 est.
estimated from the Judiciary.uk publication date
Responses identified
1 of 2
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.
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
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.
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.
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.
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Report details
- Reference
- 2026-0341
- Date of report
- 3 July 2026
- Coroner
- Andrew Cox
- Coroner area
- Cornwall
Responses identified
Responses identified
1 of 2
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-