Mother killed by son 'failed' by state services

Serious failures by various state agencies contributed to the death of a woman who was stabbed "more than 100 times" by her son, an inquest has heard.

The inquest at Cornwall Coroners' Court in Truro heard Bernadette Rosario, 61, was found dead at her home in Penwithick near St Austell, Cornwall, on 28 March 2023.

Her son Michael Rowe, of no fixed abode, pleaded guilty to manslaughter of Bernadette on the grounds of diminished responsibly and was sentenced to a hospital order. He had made several threats to kill his mother ahead of her death.

Coroner Andrew Cox said a number of serious failures by the agencies involved had contributed to her death and ruled it had been an unlawful killing.

Her family said they had lost a bright light and someone who brought "light and laughter" wherever she went.

On behalf of the family, who all wore her favourite colour purple at the inquest, Francesca Rosario-Barrett said: "Bernadette is not only a partner, mother and granny, she was a younger sister who enjoyed life, loved her family and animals and was opinionated and kind.

"She didn't believe anyone should be left out or bullied.

"Bernie would still be alive today but instead, she was brutally murdered by her son because she was let down by a broken system that deemed multiple documented threats to her life to be unimportant."

Rosario-Barrett said the inquest was held to understand circumstances around Bernadette's death and identified areas for improvement, but feared any changes made would fail to make a significant impact.

She said: "We've come across numerous coroner reports that highlight the disjointed nature of social services.

"In Bernie's case, her murderer was incorrectly risk assessed and multiple agencies collaboration was lacking.

"Information sharing could have be improved."

Rosario-Barrett said the agency assessment of risk posed were "sometimes contradictory".

She said: "From what we've seen incidents like these occur regularly in cases involving murders with mental health issues.

"Until there is large injection of funding and a general overhaul of working practices, we feel more people will lose their lives all because of the failings of those entrusted with our safety.

"We, her loved ones, saw the pain and anguish Bernie went through for years trying to help her son.

"We will forever be broken and never stop missing her."

Coroner Andrew Cox said this had been a challenging inquest and concluded if any good was to come out of this "foreseeable and avoidable tragedy" something, or some things, significant and fundamental needed to change.

He said there would be "real value" in senior members of the core state agencies to sit down and talk through the issues of this case and discuss how they could improve.

Cox said his thoughts were with the family and he was extremely sorry to have met them under these circumstances.

"I hope you've felt listened to and this prevents similar tragedies from happening again."

He added the family had been dignified throughout the process.

Cox said all agencies needed to work together to deal with people like Rowe and he would be sending a prevention of future deaths report to the Cornwall Partnership Foundation Trust.

In a statement, trust chief medical officer Colm Owens expressed his "sincere condolences" to the Bernadette's family and loved ones.

"We have listened carefully throughout the inquest and accept the coroner's findings," he said.

"This was a tragic death, and we are deeply sorry for the suffering experienced by Bernadette's family."

Owens said since these events, the trust had "reflected extensively" on what happened and had started work to strengthen aspects of its practices.

He added: "We hope that by doing so we can reduce the likelihood of similar tragedies occurring in the future."

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