Coroner Condemns Systemic Failures After Pensioner's Fatal Stabbing
A devastating inquest has concluded that a 74-year-old pensioner would likely still be alive today if mental health and police services had followed their own procedures. Roger Leadbeater, a retired bus driver from Sheffield, was brutally stabbed to death while walking his dog in a local park in August 2023.
"Ritual Sacrifice" Killing by Woman with Schizophrenia
The attacker, 32-year-old Emma Borowy, suffered from paranoid schizophrenia and had absconded from an acute mental health unit in Bolton. She later told authorities she had been "tricked by the devil" into carrying out what she described as a "ritual sacrifice" of Mr Leadbeater. The court heard how Borowy had previously spoken to police officers about "murdering people" and causing a "bloodbath".
Sheffield Senior Coroner Tanyka Rawden delivered a damning verdict, stating that Borowy's leave request would "probably have been rejected" if proper protocols had been followed. The inquest revealed that staff at Greater Manchester Mental Health NHS Foundation Trust failed to adhere to their own policies and did not possess an accurate risk assessment when they granted Borowy escorted leave just two days before the fatal attack.
Multiple Absconding Incidents Ignored
Shockingly, the hearing disclosed that Borowy had previously absconded from her ward nine times, attempted to escape fifteen times, and failed to return from leave on three separate occasions. Despite this alarming pattern, permission was still granted for her to leave the hospital under supervision.
Coroner Rawden highlighted how Borowy had been first sectioned in October 2022 after being arrested for killing two goats with a knife. She outlined other violent incidents where Borowy was found with knives by police after leaving the Royal Bolton Hospital ward, noting that some of these episodes were unknown to her treating clinicians.
Family's Heartbreaking Testimony
Outside Sheffield Coroner's Court, Mr Leadbeater's niece Angela Hector delivered an emotional statement surrounded by family members. She directly addressed the agencies involved, stating: "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. The public put their trust in you to protect us. You all failed on every level."
Ms Hector described how her uncle sustained 124 injuries during the attack, which she characterised as "barbaric beyond comprehension". She poignantly added: "This is like a horror film you cannot switch off, except this is real."
Coroner's Detailed Findings and Future Actions
In her conclusion, Coroner Rawden identified specific procedural failures. She noted that a risk assessment completed after Borowy absconded on August 4, 2023, was "lacking in detail, inaccurate, and missing important and relevant information". Furthermore, she revealed that Borowy's care was transferred to a new consultant on August 7 who authorised further leave "without clear documentation of the reasons for the decision, without consideration of a detailed risk assessment, and outside of the policies".
The coroner deemed this decision "not reasonable or proportionate" and announced she would be sending prevention of future death reports to both police forces, the Home Office, the College of Policing, and the National Police Chief's Council regarding the handover of missing vulnerable people. She will decide in August whether to issue a similar report to the mental health trust after reviewing planned improvements.
Charity and Police Responses
Julian Hendy from the Hundred Families charity, which supports relatives after mental health-related killings, stated: "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 a formal apology on behalf of the police 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. It is to our great regret that this tragic incident could ever have happened." She confirmed the force would introduce a new mental health monitoring and handover form immediately.
The case has raised serious questions about communication between mental health services and police forces, particularly regarding the transfer of information about vulnerable individuals who go missing from care. The coroner's findings suggest systemic failures that allowed a known high-risk patient to be in a position to commit this horrific crime.
