Family Condemns Systemic Failures After Pensioner's Brutal Killing
The grieving family of a pensioner who was fatally stabbed in what was described as a "ritual sacrifice" has delivered a powerful condemnation of multiple public agencies, stating that police forces and an NHS trust "failed on every level". The criticism follows a coroner's conclusion that proper procedures were not followed before the tragic incident.
Coroner Identifies Critical Lapses in Care and Procedures
Special needs bus driver Roger Leadbeater, a 74-year-old from Sheffield, was walking his dog Max in a local park in August 2023 when he was attacked by Emma Borowy, a 32-year-old woman who had absconded from an acute mental health unit in Bolton. The coroner's investigation revealed that Borowy, who died in prison four months after the attack, had a documented history of absconding from her ward nine times, attempting to escape fifteen times, and failing to return from leave on three occasions.
Sheffield coroner Tanyka Rawden outlined how, just two days before the fatal attack, staff at the Greater Manchester Mental Health NHS Foundation Trust granted Borowy escorted leave despite failing to follow their own established policies. The coroner determined that an accurate risk assessment was not conducted, and she concluded that "it is likely the risk factors would have been too high and leave would not have been granted" if proper procedures had been implemented.
Family's Heartbreaking Statement Outside Court
Outside Sheffield Coroner's Court, Mr Leadbeater's niece Angela Hector spoke emotionally about her uncle's death, directly addressing the organisations involved in Borowy's care. "I ask those who were in positions of trust – Greater Manchester Mental Health, Greater Manchester Police and South Yorkshire Police – Emma Borowy put her trust in you to keep her safe and well," she stated. "The public put their trust in you to protect us. You all failed on every level."
Surrounded by family members, Ms Hector described the ongoing trauma of losing her uncle in such violent circumstances. "This is like a horror film you cannot switch off, except this is real," she revealed, noting that her uncle sustained 124 separate injuries during the attack. She urged healthcare and policing professionals to "walk in our shoes for just one day – feel what it's like to live with the consequences of your decisions."
Disturbing Details Emerge During Inquest Proceedings
The inquest heard disturbing evidence about Borowy's mental state and previous behaviour. Diagnosed with paranoid schizophrenia, she told police and psychiatrists that she had been "tricked by the devil" into killing Mr Leadbeater in what she described as a "ritual sacrifice." Prior to the attack, she had spoken to officers about "murdering people" and causing a "bloodbath."
Borowy was first sectioned in October 2022 after being arrested for killing two goats with a knife. The coroner detailed other violent incidents and occasions when police found her with knives after she had left the ward at Royal Bolton Hospital. Significantly, Mrs Rawden noted that some of these concerning incidents were not known to the medical professionals treating her at the hospital.
Coroner Criticises Multiple Agency Failures
In her comprehensive conclusion, the coroner identified specific failures in Borowy's care management. She highlighted how a risk assessment completed after Borowy absconded on August 4th 2023 was "lacking in detail, inaccurate, and missing important and relevant information." Furthermore, when Borowy's care was transferred to a new consultant on August 7th – just two days before the fatal attack – that consultant authorised further leave without proper documentation or consideration of a detailed risk assessment.
Mrs Rawden stated this decision was "not reasonable or proportionate" and occurred outside established policies requiring face-to-face review at multidisciplinary team meetings following leave suspension. The coroner also criticised procedures at both Greater Manchester and South Yorkshire Police forces regarding the handover of vulnerable missing persons.
Organisational Responses and Planned Changes
The coroner announced she will be sending Prevention of Future Death reports to both police forces, the Home Office, the College of Policing, and the National Police Chiefs' Council concerning the handover of missing vulnerable individuals. She will decide in August whether to issue a similar report to the Greater Manchester Mental Health NHS Foundation Trust after hearing about proposed procedural improvements.
Julian Hendy from the Hundred Families charity, which supports relatives affected by mental health-related killings, commented: "We've heard that serious failings by many agencies all played a part in what happened to Roger. Without them, it's highly likely that Roger would still be alive today." He expressed concern about whether the trust was genuinely learning from such tragedies.
Greater Manchester Assistant Chief Constable Steph Parker offered an apology on behalf of her force: "On behalf of GMP I want to apologise to Roger's family for our failure to properly pass key information to other partners before and after he was killed." She confirmed the force is introducing a new mental health monitoring and handover form.
Detective Chief Superintendent Laura Koscikiewicz from South Yorkshire Police stated: "We fully accept the learning opportunities highlighted during the inquest and that changes should have been made sooner around the handover of missing people to other agencies. We are sorry that these processes were not in place at the time."
