Family Condemns Catastrophic Failures After Pensioner's Brutal Murder
The grieving family of a pensioner brutally murdered by a woman who absconded from a mental health unit has delivered a devastating verdict on the authorities involved, declaring that two police forces and an NHS trust "failed on every level". The condemnation follows a coroner's conclusion that proper procedures would likely have prevented the tragedy.
A Life Cut Short in Sheffield Park
Roger Leadbeater, a 74-year-old special needs bus driver described by his family as a kind and gentle man, was walking his dog Max in a Sheffield park in August 2023 when his life was violently ended. Emma Borowy, 32, who had absconded from an acute mental health unit in Bolton, Greater Manchester, stabbed him multiple times in what she later described to authorities as a "ritual sacrifice".
Sheffield coroner Tanyka Rawden concluded a thorough inquest this week, revealing a shocking catalogue of systemic failures that allowed Borowy – who had paranoid schizophrenia and died in prison four months after the attack – to be at liberty despite presenting extreme danger.
Coroner Uncovers Repeated Procedural Failures
The inquest heard that Borowy had absconded from her ward nine times, attempted to escape fifteen times, and failed to return from leave on three separate occasions prior to the fatal attack. Despite this pattern, staff at the Greater Manchester Mental Health NHS Foundation Trust granted her escorted leave just two days before she killed Mr Leadbeater.
Coroner Rawden stated unequivocally that staff failed to follow their own policies and did not possess an accurate risk assessment. "It is likely the risk factors would have been too high and leave would not have been granted" if proper procedures had been observed, she concluded.
The coroner further criticised both Greater Manchester Police and South Yorkshire Police for their handling of vulnerable missing person handovers, noting critical information was not properly shared between agencies.
Family's Heartbreaking Testimony
Outside Sheffield Coroner's Court, Mr Leadbeater's niece, Angela Hector, surrounded by family members, delivered an emotional statement directly addressing the responsible organisations. "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," she said.
Ms Hector described her uncle's death as barbaric beyond comprehension, revealing he sustained 124 separate injuries. "This is like a horror film you cannot switch off, except this is real," she told reporters, urging those involved in Borowy's care to "walk in our shoes for just one day" and understand the devastating consequences of their decisions.
History of Violence and Missed Warnings
The inquest heard disturbing details about Borowy's psychiatric history and prior violent behaviour. She had been first sectioned in October 2022 after being arrested for killing two goats with a knife. She had previously spoken to police officers about "murdering people" and causing a "bloodbath", telling psychiatrists she was "tricked by the devil" into the killing.
Coroner Rawden outlined several other violent incidents and occasions where Borowy was found with knives by police after leaving the ward at Royal Bolton Hospital. Shockingly, some of these critical incidents were not known to the medical team treating her.
Inadequate Risk Assessment and Unreasonable Decisions
A specific risk assessment completed after Borowy absconded on August 4, 2023 – where she threatened to kill a friend – was described by the coroner as "lacking in detail, inaccurate, and missing important and relevant information".
Most damningly, on August 7, just two days before the murder, Borowy's care was transferred to a new consultant who authorised further leave during a meeting. The coroner found this decision was made "without clear documentation of the reasons, without consideration of a detailed risk assessment, and outside of trust policies". She deemed the authorisation "not reasonable or proportionate".
Official Responses and Promised Reforms
Coroner Rawden 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 regarding missing vulnerable person handovers. She will decide in August whether to issue a similar report to the mental health trust after hearing about proposed improvements.
All involved organisations have issued apologies. Greater Manchester Assistant Chief Constable Steph Parker apologised for the force's failure to properly share key information, announcing the immediate introduction of a new mental health monitoring form. South Yorkshire Police also accepted the findings and apologised for processes not being in place.
Karen Howell, chief executive of Greater Manchester Mental Health NHS Foundation Trust, offered "sincere apologies and regret", acknowledging the trust "should have done more" and that the killing "could have been prevented". She stated significant changes have been implemented since the tragedy.
Charity Warns of Repeat Tragedies
Julian Hendy from the Hundred Families charity, which supports relatives affected by mental health-related killings, said serious failings by multiple agencies contributed to Mr Leadbeater's death. "Without them, it's highly likely that Roger would still be alive today," he stated, expressing concern about whether lessons are truly being learned to prevent future avoidable tragedies.
The case has exposed profound weaknesses in the interface between mental health services and policing, raising urgent questions about patient risk management, inter-agency communication, and accountability when vulnerable individuals fall through gaping cracks in the system.
