Coroner Condemns NHS Trust Over 'Barbaric' Park Killing
A coroner has delivered a damning verdict on the decision to grant escorted leave to a schizophrenic patient who later stabbed a dog walker to death in what the victim's family described as a 'barbaric beyond comprehension' attack. Roger Leadbeater, 74, was walking his springer spaniel Max in a Sheffield park on August 9, 2024, when he was attacked by Emma Borowy, 32, who inflicted more than 50 stab wounds.
Systemic Failures Exposed
Sheffield coroner Tanyka Rawden concluded that Mr Leadbeater was unlawfully killed and stated that the risk Borowy posed to the public was not properly considered by staff at Greater Manchester Mental Health NHS Trust when approving her leave. The coroner emphasised that the doctor's decision was 'not reasonable or proportionate' and that had an up-to-date assessment been available, leave would likely not have been granted.
Borowy had been sectioned under the Mental Health Act after stealing and slaughtering two goats in what was described as a witchcraft ceremony in October 2022. Despite a documented history of violent outbursts, escape attempts, and warnings that she had 'discussed murdering people', doctors at Royal Bolton Hospital repeatedly granted her escorted leave.
A Pattern of Missed Warnings
The inquest heard disturbing details about Borowy's behaviour in the months leading to the attack:
- She absconded from mental health wards nine times in ten months
- She assaulted staff and smashed windows during escape attempts
- She was caught trying to smuggle a knife from the dining area
- A worried friend reported to police that Borowy had spoken of creating a 'bloodbath'
Just over two weeks before the killing, an assessment highlighted Borowy's aggression and that she had placed others at risk during previous escape bids. Yet on August 7, 2023, she was granted escorted leave to visit a shop, from which she ran off and travelled to Sheffield where she attacked Mr Leadbeater.
Family's Devastating Statement
Mr Leadbeater's niece, Angela Hector, delivered an emotional statement after the inquest, accusing the NHS trust and two police forces of having 'failed on every level'. She described how her uncle sustained 124 injuries in the attack and fought desperately to survive.
'Defensive wounds covered his hands, arms, and legs but Emma Borowy kept going, even as Roger lay dying, trying desperately to crawl away,' Ms Hector said. 'This is like a horror film you cannot switch off. Except this is real.'
The family implored health and policing authorities to ensure lessons are learned, stating: 'Roger will never come home. That outcome cannot change. But you must make sure no other family suffers this devastation.'
Broader Context of Failures
The tragic case follows other killings involving patients under the supervision of Greater Manchester Mental Health NHS Trust. In March 2020, seven-year-old Emily Jones was fatally attacked in Bolton by Eltiona Skana, who had paranoid schizophrenia. An independent review later said the trust's understanding of risks posed by Skana was 'poor'.
Similarly, in February 2020, Ryan Lowry was killed by his paranoid schizophrenic cousin in Trafford, with an inquest jury finding that police and medical staff failed to share concerns about escalating violence.
Accountability and Reform Demands
Julian Hendy, director of charity Hundred Families which supports relatives after mental health-related homicides, said: 'Without these failings, it's highly likely that Roger would still be alive today.' He expressed concern that despite the trust insisting it had 'learned lessons', other tragic avoidable deaths had exposed 'almost exactly the same problems'.
The coroner revealed she would be writing a report to prevent future deaths in relation to the police forces involved, though she awaits details of changes from the mental health trust before taking similar action. Greater Manchester Assistant Chief Constable Steph Parker apologised to Mr Leadbeater's family for failures in information sharing and promised new stringent handover procedures.
The case has raised serious questions about risk assessment procedures, inter-agency communication, and accountability within mental health services, with the victim's family demanding concrete action to prevent similar tragedies.
