Tamsin Dolamore

Information Classification: CONTROLLED 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

, Chief Constable, Devon & Cornwall Police, with a 

copy for information only (ie no duty to respond) to 

2. 
1  CORONER 

, Police & Crime Commissioner 

I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall 
and the Isles of Scilly. 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 
On 12.5.23, I concluded an inquest into the death of Tamsin Ann 
Dolamore who died at the age of 24 on 9.1.18.     
 . 
The medical cause of death was recorded as: 
1a) Effects of multiple injuries 
1b) 
1c) 
II) 

I recorded an Open Conclusion. 

4  CIRCUMSTANCES OF THE DEATH 

Tamsin was raped as a schoolchild. In October 2017, she made a 
complaint to police that she had been raped again. (Of note, her adoptive 
parents, to whom a copy of this letter is being sent, were not aware of 
either incident until after her death.) Her GP reported her life having been 
turned upside down. It was intended that a SOLO would be appointed 
after the initial report but, in evidence, it was established that did not 
happen until the end of October, a delay of approximately a month. 

Tamsin was assessed by Outlook South West. It was felt she presented 
with too much risk and she was discharged from their service with a 
referral to the CMHT. After assessment by them (three months after the 
incident) it was felt she did not meet the statutory threshold and she was 
not taken on to caseload. At the time, there was a process for reviewing 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 

patient cases who fell between the two organisations but this had not 
been done by the time of her death. 

Tamsin was referred to the Women’s Centre who conducted a needs 
assessment. She was advised there was a five-month wait for support. 

On 8/1/18, Tamsin fell over 20’ from a railway bridge in St Austell on to 
the railway lines. The fall was unwitnessed and as there was no evidence 
of her intent in the form of a letter, email, text or similar, I concluded the 
evidence did not further or fully disclose the means whereby the cause of 
death arose and so returned an Open Conclusion. 

At inquest, I heard evidence from 
, general manager of 
Sexual Assault Referral Centre (SARC) of the importance of providing 
immediate care and support to rape survivors and the negative 
consequences that can occur where they feel their complaint is not being 
taken seriously, or there is a delay in the process. Tamsin’s parents were 
of the view that, at the time she most needed support and assistance, she 
was largely left to fend for herself. I agreed with that view. 

5  CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise 
to concern. In my opinion there is a risk that future deaths will occur 
unless action is taken. In the circumstances it is my statutory duty to 
report to you. 

The MATTERS OF CONCERN are as follows.  –  

I was informed by 
 that as of January this year, there were 600 
open cases of rape or serious sexual assault. I was told additionally that 
there are over 20 vacancies for DCs to progress these complaints. One 
consequence was that it was taking over a month to achieve best 
evidence through video interview or otherwise. 

 agreed that the lack of available DCs meant that both the 

quality and amount of work that could be done were affected. 

6  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.  

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 10 July. I, the coroner, may extend the period. 

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 Information Classification: CONTROLLED 

Your response must contain details of action taken or proposed to be 
taken, setting out the timetable for action. Otherwise, you must explain 
why no action is proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following 
Interested Persons: 

 – parents 

 – brother 

- 
- 
-  SWAST 
-  CPFT 
-  BTP 

I am also under a duty to send the Chief Coroner a copy of your 
response.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he believes may find it useful or of interest. You may make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response by the Chief Coroner. 

9 

[DATE]                                              [SIGNED BY CORONER] 

 12.5.23                                              

3

Information Classification: CONTROLLED 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  Network Rail 

1  CORONER 

I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall 
and the Isles of Scilly. 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 
On 12/5/23, I concluded an inquest into the death of Tamsin Dolamore  
who died on 9/1/18 at the age of 24.  
 . 
The medical cause of death was recorded as: 
1a) Effects of multiple injuries 
1b) 
1c) 
II) 

I recorded an Open Conclusion as the evidence of her intent was not 
sufficiently clear on a balance of probabilities. 

4  CIRCUMSTANCES OF THE DEATH 

Tamsin had reported a rape to police in October 2017. She had been 
referred to both Outlook South West and the Community Mental Health 
Team. She was not receiving active support from either at the time of her 
death. She had undergone a Needs Assessment at the Women’s Centre 
but there was a five month wait for support. 

5  CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise 
to concern. In my opinion there is a risk that future deaths will occur 
unless action is taken. In the circumstances it is my statutory duty to 
report to you. 

The MATTERS OF CONCERN are as follows.  –  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 

Tamsin fell approximately 21.5’ from Menacuddle Hill/North Street railway 
bridge in St Austell. During the course of the investigation, enquiries were 
made relating to the parapet at the bridge. Please find attached: 

-  Report of 

 at Strange, Strange & Gardner, Consultant 
Engineers, dated 30/8/18. You will note his view that the parapet 
does not meet the obligations of the Railway Clause Consolidation 
Act 1845; 
-  Email from 
-  Email from 
-  Email from 

 dated 24/5/19; 
, Cormac, dated 15/7/19. 

 dated 14/12/18; 

6  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.  

I consider the action that is necessary is to raise the height of the existing 
parapet so it complies with legal requirements. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 14/7/23. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be 
taken, setting out the timetable for action. Otherwise you must explain 
why no action is proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following 
Interested Persons: 

 – parents of Tamsin 

 – brother 

Cornwall Partnership Foundation Trust 
British Transport Police 

I am also under a duty to send the Chief Coroner a copy of your 
response.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he believes may find it useful or of interest. You may make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response by the Chief Coroner. 

9 

[DATE]    16.5.23                                          [SIGNED BY CORONER] 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 

3

Information Classification: CONFIDENTIAL  

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

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

Date: 

7th July 2023 

Dear Andrew  

Regulation 28 notification 306381 

I am writing on behalf of 
28 notification 

. 

, CEO, Cornwall Council in response to the regulation 

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.   

Cornwall Council  |  Konsel Kernow 
County Hall, Treyew Road, Truro, Cornwall   TR1 3AY 
E: alison.bulman@cornwall.gov.uk   |  T: 0300 1234 100 
www.cornwall.gov.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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’. 

Yours sincerely 
Dhywgh hwi yn hwir 

Strategic Director  
Care and Wellbeing 
Email: alison.bulman@cornwall.gov.uk

Information Classification: CONTROLLED 

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

Joint Legal Services 
Devon & Cornwall Police 
Middlemoor, Exeter 
Devon      EX2 7HQ 

27 June 2023 

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.  

NOTE: With effect from 1 January 2019, fax communication will not be possible.  Documents can either be sent via hard copy post or 
via email to legalservices@devonandcornwall.pnn.police.uk 
SB / 009334 / 01693711 

Joint Legal Services for Devon and Cornwall Police and Dorset Police gather and hold personal data.  This may be shared where 
necessary with third parties acting for and on behalf of the Chief Constable.  Personal data is processed securely at all times and is 
held no longer than is necessary.  The retention period is six years in accordance with the Limitation Act 1980.  Retention can be longer 
on a case by case basis where this is necessary and in accordance with the Management of Police Information (MoPI).  If you wish to 
know more about how we process personal data please do visit our respective websites at: 
https://www.devon-cornwall.police.uk/your-right-to-information/data-protection-requests/privacy-noticefair-processing/ 
http://www.dorset.police.uk/default.aspx?page=3882 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 2 

 
 
 
 
 
 
 
 
 
 
 
 
 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. 

Yours sincerely 

Assistant Chief Constable 

SB / 009334 / 01693711 

Page 3

The Right Honourable 

Alex Chalk KC MP 
Lord Chancellor & Secretary 
of State for Justice 

Mr Andrew J. Cox 

H.M. Senior Coroner Cornwall & the Isles of Scilly 
H.M. Coroner’s Office Pyder House, Pydar Street 

Truro, Cornwall 

TR1 1XU 11 

Dear Andrew,  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

6 July 2023 

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. 

T 020 3334 3555 
F 0870 761 7753 

E https://contact-moj.service.justice.gov.uk/ 

www.gov.uk/moj 

102 Petty France 
London 
SW1H 9AJ 

 
 
 
 
 
 
  
 
 
 
 
 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. 

Yours sincerely, 

RT HON ALEX CHALK KC MP 

LORD CHANCELLOR AND SECRETARY OF STATE FOR JUSTICE 

2

OFFICIAL 

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

20 October 2023 

Re: Regulation 28 Notice – Tamsin Ann Dolamore 

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. 

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 

Yours sincerely,  

Route Director, Western Route 

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