Dear Mr Cox

INQUEST INTO THE DEATH OF TAMSIN ANN DOLAMORE

I am writing in relation to the above inquest and, specifically, the Regulation 28 report to prevent future deaths that you have directed to the Chief Constable following the conclusion of the inquest hearing.

I want to take this opportunity to both express my personal condolences and reiterate those previously offered at the inquest on behalf of Devon and Cornwall Police, to Tamsin's friends and family for their loss.

I am grateful to you generally for bringing the matters of concern raised in the Regulation 28 report to my attention. I welcome the opportunity to reassure you that we have very carefully considered what we can learn from Tamsin's death with a view to improve the service that we provide to the public. If you have any queries or concerns arising out of this response, then I would welcome discussing these with you.

Mr Andrew Cox HM Senior Coroner for Cornwall and the Isles of Scilly The New Lodge Penmount Truro TR4 9AA

SB / 009334 / 01693711 Page 2

Information Classification: CONTROLLED I will use the remainder of this correspondence to respond to the matters of concern set out in the fifth box of the Regulation 28 report.

Cornwall and The Isles of Scilly (‘CIOS’) Criminal Investigation Department (‘CID’) senior managers conducted a 5-day review in January 2023 of all open rape investigations being investigated by CIOS CID. Reviews of this size are not regularly conducted due to the resources they require, however it was a very useful exercise to understand the demands on our teams, areas we could seek improvement, to finalise any that needed an Inspector review as per policy and to reassure ourselves that the volume of crime being investigated was accurate. We identified 560 active rape investigations within CIOS, with 511 rapes under investigation by CIOS CID. Other rapes came under the Public Protection Unit. This is slightly under the 600 quoted but still significant numbers. This number does not include serious sexual assault.

This figure has improved slightly since CIOS CID have been allocated 76 Detective Constables (‘DC’) to deal with general CID crime types. Rape and other serious sexual offences are two types of the many other serious and complex crimes that we deal with. It has been suggested that RASSO offences account for around 35% to 40% of a Detectives workload. Clearly having vacancies impacts on the average amount of investigations that each investigator will have. Investigators workloads are at levels that have not be seen before and that is a combination of the rising demand from our communities and the vacancies. This high demand also reflects that our communities feel confident to report this type of crime. The vacancies are reducing, however and that is mainly by recruiting Police Officers at the early stages of their careers. To become a DC takes time and I would hope that within the next 12 – 18 months, as the new Detectives become experienced and qualified then it will reduce our vacancies and improve our staffing shortfalls. Attracting applications to become a DC has been a national issue for several years and Devon and Cornwall Police are not alone in this shortage.

Cornwall currently has 9 sexual offences liaison officers (SOLO) who perform the majority of the specialist video interview role (ABE). DC’s can also complete ABE interviews however they generally rely upon the SOLO for this support. It would be a fair assumption that if there were no DC vacancies then we may be able to use the additional capacity to assist with the ABE backlog. There are no SOLO vacancies, however we are currently preparing a business case to consider an uplift of SOLOs as we are aware of the good practice findings of the national Op Soteria Bluestone project which evidences the value of obtaining early victim accounts by correctly trained staff. The delay in obtaining an ABE account can be due to a number of factors, some of which are outside Police control. Whilst we are not as efficient in obtaining these accounts as we would want to be it is something we are aware off and seek to improve our timeliness in the year ahead.

I agree that staff numbers are a factor on our ability to process the work, but our staff provide the best service they can with many competing demands, and it was not a factor in this tragic death. Clearly, I would want us to be fully staffed as that would reduce average workloads and as explained there is ongoing recruitment but that will take time to see the improvement. We have many examples of good work within the teams, and we continue to prosecute RASSO offences in the courts with our CPS colleagues.

SB / 009334 / 01693711 Page 3

Information Classification: CONTROLLED The Chief Constable has also just agreed to launch Project Synergy which is an initiative to improve our investigative operating model, increase the resilience and wellbeing of our investigative teams and to improve investigative quality. We are currently in the process of recruiting a Detective Chief Superintendent to lead on this project across Devon and Cornwall. Its considerations include formation of investigative hubs whereby investigators will be brought together to increase resilience, enable more specialist officers to be established (including rape investigators) and to introduce investigation support officers to boost the available resource. We are hopeful that this new initiative will increase our capability to deal with the increasing investigative demand.

I hope that this provides you with some reassurance that, while there are staff shortages, we are working hard to do what we can to alleviate the associated demands.

Dear Andrew,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Thank you for your letter of 23 May, and annexed report of 22 May, containing recommendations on Preventing Future Deaths (PFD). I have read it personally and with care. I was deeply saddened to read about the circumstances relating to the tragic death of Tamsin Ann Dolamore. This is a particularly tragic loss, and my thoughts are very much with Tamsin’s family and friends. I will start by responding to your key recommendation on action to be taken, which is to provide statutory funding to support long-term therapy for the recovery of victims and survivors of rape, sexual violence, domestic abuse and child sexual abuse. I will then address your wider concerns in turn. The Government recognises that funding for victim support provision is crucial, and I agree that victims must have access to the support they need to build resilience to move forward with daily life. This is especially important for victims of the crime types you refer to, as they as they can be particularly traumatic. Your report noted the improvement and increases in funding for Sexual Assault Referral Centres (SARCs) across Devon & Cornwall. Indeed, to better support victims and meet demand for services we are more than quadrupling funding for victims’ services by 2024/25, up from £41 million in 2009/10. This includes up to £6.6 million for services supporting victims of sexual violence and domestic abuse, and funding to increase the number of Independent Sexual Violence Advisors (ISVAs) and Independent Domestic Violence Advisors (IDVAs) by 300, to over 1,000 by 2024/25. In addition, in September 2022, the Ministry of Justice and Home Office announced a joint fund for Violence Against Woman and Girls (VAWG) ‘by and for’ services. This will run over two years (2023/24 to 2024/25) and total up to £6 million. Ministry of Justice funding to Devon and Cornwall PCC for victim support services has increased from £2m in 2018/19 to £3.7m in 2022/23 - this equates to an 85% increase. This funding includes core funding for PCCs to allocate at their discretion, based on their assessment of local need; and funding that is ringfenced for Domestic Abuse and Sexual Violence support services and ISVAs and IDVAs. It is vitally important that this funding reaches those who need it most. and you make a very powerful point (if I may say so) about the need for a ‘joined-up approach’. We agree.

2 As you note, the Victims and Prisoners Bill is currently going through Parliament. To respond to your recommendation on introducing statutory funding, the Bill is not the right vehicle to set out how future funding may be directed. This is determined by HM Treasury as part of the Spending Review who decide departmental expenditure limits and set out a plan for how public money will be spent over a multi-year period, in line with government priorities. The Bill is a key opportunity to strengthen, through legislation, funding structures to make the best use of funding and resources – and to deliver that coordination you call for. The duty to collaborate is one measure within this designed to achieve this end. It will drive forward more effective, and targeted, strategic multi-agency collaboration on commissioning for victim support services. This places a joint statutory duty on Police and Crime Commissioners, Integrated Care Boards and local authorities to collaborate with each other when commissioning certain victim support services. The duty includes child and adult victims of domestic abuse, sexual abuse and other serious violence. The timing of the duty commencing is tied to the Parliamentary passage of the Bill, which is determined by the House Authorities, and following this we expect to consult on accompanying statutory guidance for local areas, as well as to plan for implementation as soon as practically possible. I’m pleased to learn about the steps being taken towards a more joined-up commissioning approach in Devon, Cornwall, Plymouth and Torbay. The duty will build on existing collaboration like this and create greater consistency, to help local areas within England map their local needs, and target provision of support more effectively. Lastly, you raise concerns about the serious matter of the number of open rape and serious assault causes and vacancies at Detective Constable level. As you have sent a separate PFD to the Chief Constable, I trust they will respond fully on the matter. I hope the information above provides the assurance that we have considered, and will continue to consider, your recommendations seriously, and that we are actively seeking to improve the services we provide to victims of crime, by implementing the actions I have outlined. Thank you for the effort and care you have given to this very sad case.

Dear Sir,

I refer to your report dated 16 May 2023 made under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

On behalf of all at Network Rail, I would like to take this opportunity to express my sincere condolences to the family of Ms Dolamore.

I detail below Network Rail’s considered response to the matters of concern raised in your report and offer our apologies for the delay in providing you with this.

The parapet at Menacuddle Hill/North Street Bridge

In response to your concern that the height of the parapet at Menacuddle/North Street Bridge was not compliant with legal requirements, Network Rail has extensively reviewed the possible measures that may be taken to rectify this and is committed to raising the height of the parapet to reduce the potential for further incidents.

Currently, the height of the parapet is partially compromised by several factors, including the road alignment, surface provision, the orientation of the structure and the age of construction. Progressive re-surfacing of the road over the years may have increased the height of the road surface, having the net effect of decreasing the parapet height, which has not changed since construction, which dates back to 1859.

To rectify this, on 6 September 2023, Network Rail issued an instruction to raise the height of the parapet to a minimum of 1250mm above adjacent surface level, with an additional course of stonework from an existing minimum height of 990mm. The current timescale for completion of the project is one year from instruction.

A site visit was undertaken at the end of September 2023 for the purposes of scoping and planning and appropriate measurements were taken. Following this, a proposal regarding the strategy and design of the project was submitted and feedback is currently being considered as of 10 October 2023. Once approved, the works will be issued to Network Rail’s appointed contractor for this project.

I hope that this response answers your concerns but if I can be of any further assistance, or if you would like further clarification, please do not hesitate to contact me.

Andrew J. Cox HM Senior Coroner for Cornwall & the Isles of Scilly HM Coroners Office

Network Rail Infrastructure Limited Registered Office: Network Rail, Waterloo General Office, London, SE1 8SW, Registered in England and Wales No. 2904587 www.networkrail.co.uk

OFFICIAL

Dear Andrew

Regulation 28 notification 306381

I am writing on behalf of , CEO, Cornwall Council in response to the regulation 28 notification .

It is our view that the findings of HM Coroner, in terms of the complexity of funding for sexual violence recovery services are correct. Currently, the only sexual violence recovery service that has a national requirement to be commissioned and delivered is the Sexual Assault Referral Centre (SARC) which is commissioned by NHS England (NHSE), under the Public Health Functions agreement.

There is no record of Ms Dolamore having any contact with the Council’s children’s social care services as a child. Professionals, parents, carers and young people are able to request support from children’s services through Cornwall’s Early Help Hub, which is the front door to Early Help services provided by the Council and Cornwall Foundation Trust (health). Early Help Hub staff are in place to help families consider whether a child is eligible for support and which service is most appropriate. The Early Help Hub has been successful in encouraging self-referrals from family members to empower young people and families to seek support when they need it; self-referrals are the second biggest source of requests for Early Help (after schools), with approximately 2,000 Early Help requests from family members over the last 6 months.

There is also no record of Ms Dolamore having contact with Adult Social Care. I understand that Ms Dolamore was briefly open to Cornwall Partnership Foundation Trust (NHS). I understand this was in relation to her clinical needs in 2017.

Mr Andrew Cox Senior Coroner for Cornwall & the Isles of Scilly

By email only: andrew.cox@cornwall.gov.uk

Date: 7th July 2023

Information Classification: CONFIDENTIAL The Police and Crime Commissioner (PCC) commissions the Independent Sexual Violence Advocate (ISVA) Service for those going through the criminal justice system and has involved Cornwall Council in developing the specification and assessing the bids for the current tender for this service.

In addition, Commissioners across Cornwall Council, NHSE and the Integrated Care Board (ICB) have pooled the limited resources available for longer term recovery services for those impacted by sexual violence and have commissioned the local Domestic Abuse and Sexual Violence service, Safer Futures, to provide therapy and group support for adults and children who have been impacted by sexual assault and violence.

Outside of this, recovery services such as counselling, group work, 1-1 support and therapeutic support rely on a mixture of national and local short term grant funding. Demand for all these services has always outstripped supply and has increased significantly over the last 3 years. Alongside increased demand the Domestic Abuse Services Cornwall Council commission are struggling to recruit enough qualified therapists, this is recognised as a national concern. Commissioners have managed to support some of this with Covid grant funding but there remain waiting lists for most services. Currently Safer Futures have a waiting list of approximately 4 months for therapy, with DASV services such, as CLEAR which is therapy for adults and children impacted by trauma, the Women Centres Cornwall providing therapeutic support and WAVES who provided counselling for Domestic Abuse have up to a 6 month wait for support.

There remains unmet need, as there does nationally. In part to address this, efforts to innovate and find more efficient and effective means of meeting demand for support continue to be actively explored. Across Cornwall, Devon, Plymouth and Torbay, commissioners and services are working together, pooling funds to pilot new approaches in providing support to those experiencing complex trauma following sexual violence, in an effort to bridge the gap between specialist mental health services (Community Mental Health Teams and Integrated Psychological Therapies) and sexual violence recovery services. This pilot is in its first year. In Cornwall, we are also piloting a sexual violence recovery toolkit to try and meet some of the increased demand by providing increased group and peer support which do not require qualified therapists, compared with traditional 1-1 therapy.

If professionals have concerns about a child’s safety and welfare, in accordance with statutory guidance (Working Together 2018) and with Cornwall Our Safeguarding Children Partnership policy and procedures, they are expected to contact Cornwall’s Multi-Agency Referral Unit (MARU). The MARU provides a multi-disciplinary response to concerns about the welfare or safety of a child or young person. The MARU helps by identifying the service that can best help meet the child’s needs, signposting if appropriate, or if appropriate

Information Classification: CONFIDENTIAL arranging for Children and Families Services to conduct an assessment to consider the most appropriate help.

The Council’s children’s services, and Cornwall’s Our Safeguarding Children Partnership, have made improving the identification and response to Child Sexual Abuse a priority focus over the last 5 years, building on the findings and learning from a Joint Targeted Area Inspection of sexual abuse in the family in Cornwall in October 2018. An Our Safeguarding Children Partnership Child Sexual Abuse strategy, developed by a dedicated OSCP sub- group, underpins a thorough understanding of the risks and support needs for both victims of sexual abuse and children who show harmful sexual behaviour so that multi-agency stakeholders are able make referrals that are prompt and proportionate. Resources are available from the OSCP to support this including a Child Sexual Abuse Referral and Assessment ‘What happens guide’. Partnership strategies address related issues such as violence to women and girls which incorporate a preventive approach. Cornwall’s OSCP remains integral to promoting understanding, appropriate responses and learning in regard to Child Sexual Abuse. There is a strong partnership commitment to continuous improvement, with work currently underway, for example, on a Child-on-Child toolkit for use in education settings to identify and respond at the earliest possible stage to emerging indications of harmful sexual behaviour and Child Sexual Abuse in schools.

All cases where a child is identified as being at risk of or having experienced Child Sexual Abuse are subject to a strategy meeting involving the Sexual Assault Referral Centre, Children and Family Services, Police, Health and Education to gain a holistic perspective of the needs of the victim, and to agree multi-agency enquiries and actions to investigate and reduce identified risks. A series of themed multi-agency audits on our response to Child Sexual Abuse has highlighted significant improvements in our response to the sexual health needs of children, multi-agency participation in child protection enquiries, and appropriate assessment and management of need and risks for other children. Strategy discussions are timely, well attended by partner agencies and result in swift actions and outcomes, with child protection enquiries of a consistently good standard.

Strategy meetings are also routinely held in respect of children where there are identified concerns about the risk of harmful sexual behaviour to consider their individual needs, avoid criminalisation of children and prevent further sexual harm/abuse. The Council has made a significant investment in developing Gweres Kernow, a specialist service to support children and young people who display concerning or harmful sexual behaviours. The approach is bespoke and looks to address the underlying issues relating to behaviours of concern promoting safety and wellbeing. This work is supported by a Clinical Psychologist. Gweres Kernow are integral to ongoing advice, guidance, and input into case referrals for harmful sexual behaviour. They provide a bespoke service and consultation on all matters relating to

Information Classification: CONFIDENTIAL HSB. Therapeutic, trauma informed child centred support is offered and promoted based on need rather than resource. Therapy is targeted, accessible and purposeful to the child and their carers.

Cornwall Joint Targeted Area Inspection in 2018 concluded that there is a wide range of appropriate commissioned services and a strong involvement of schools and of specialist psychological and therapeutic services, which provides individual psychological support to children and their carers, and we have continued to strengthen the range of support available to children and families since then.

The Council has made a significant investment in Jigsaw, a therapeutic programme for children, young people and families who have reported sexual abuse. Jigsaw is the primary in house therapeutic counselling service offering a psychology-based person-centred counselling to children and their carers, however support reflects the immediate needs of children and their carers and recognises and supports pre-existing therapeutic relationships. Support may therefore be sourced from either Jigsaw or a wide range of other therapeutic providers in Cornwall including Clear Therapy, targeted youth work from our locality Early Help teams, Dreadnought, CAMHS, and Independent Sexual Violence Advocates.

A strong working partnership with Safer Futures has led to commissioning of Non-Contact ISVA’s and Domestic Abuse Support Advisors through First Light, present now in all areas, effectively ensuring that a full 360-degree service is offered to families allowing a safe working relationship for support through disclosures and reports of abuse. This is essential given the relationship between victims of domestic abuse and sexual violence. In 2023 Children and Family Services have also made a further investment in two specialist non- contact Independent Sexual Violence Advisors (ISVAs), integrated with front line social work teams, to further widen the range of support options for children who have experienced sexual abuse.

There is ongoing scrutiny and quality assurance of the quality and effectiveness of multi- agency partnership working for children who have experienced sexual abuse through Cornwall’s innovative multi-agency Child Sexual Abuse dip sampling process. The dip sampling framework has found that up to 75% of reported child sexual assaults in Cornwall are child on child. Our specialist service for harmful sexual behaviour Gweres Kernow supports professionals on how to manage reports in a child first, trauma informed way as we are aware that children who present with these behaviours have often experienced their own adverse experiences as a child. This quality assurance framework has helped identify and reinforce best and better practice models, identify emerging area of concern and inform multi-agency stakeholder actions and service developments. Children and Family Services also attend the Sexual Assault Referral Centre peninsula wide sexual abuse dip sample audit

Information Classification: CONFIDENTIAL meetings to gain a broader perspective of Cornwall and Devon practice and support in both adults and children’s sexual abuse.

Staff are skilled and well trained in understanding signs of symptoms of Child Sexual Abuse. Both Children and Family Services and OSCP training offers a robust training offer in respect of Child Sexual Abuse and harmful sexual behaviour open to all professionals that work with children and the Brook Traffic Light system is widely used to identify harmful sexual behaviour and those at risk of child sexual abuse. Workforce development around identifying and responding to sexual abuse has improved. Partners can access a range of training and development opportunities to improve knowledge and understanding. These include and training such as ‘An introduction to sexual abuse’, ‘child on child sexual abuse’ and ‘Stopping me seeing the people I love’.