Pensioner killed by woman who left unit was failed on every level, says family

The family of a pensioner who was killed in a “ritual sacrifice” by a woman who went missing from an acute mental health unit has said two police forces and a NHS trust “failed on every level”, after a coroner concluded the patient’s leave request would probably have been rejected if procedures had been followed.

Special needs bus driver Roger Leadbeater, 74, was stabbed multiple times by Emma Borowy, 32, as he walked his dog Max in a Sheffield park in August 2023 after Ms Borowy absconded from leave from a unit in Bolton, Greater Manchester.

On Thursday, Sheffield coroner Tanyka Rawden concluded an inquest which heard how Ms Borowy, who died in prison four months after the attack, had absconded from her ward nine times, attempted to abscond 15 times and failed to return from leave three times.

Ms Rawden outlined how permission was still given for escorted leave two days before Mr Leadbeater was attacked, when staff at Greater Manchester Mental Health NHS Foundation Trust failed to follow their own policies and did not have an accurate risk assessment.

The coroner concluded “it is likely the risk factors would have been too high and leave would not have been granted” if the procedures had been properly followed.

Ms Rawden also criticised the procedures of both Greater Manchester and South Yorkshire police forces when dealing with handovers of vulnerable missing people.

Outside Sheffield coroner’s court, Mr Leadbeater’s niece Angela Hector said: “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.”

Surrounded by members of her family, Ms Hector said: “To everyone involved in Emma’s care, whether from a health or policing perspective, I ask you to walk in our shoes for just one day – feel what it’s like to live with the consequences of your decisions.

“I am certain you would think twice before granting leave, before withholding vital information, before ignoring clear warnings.

“Roger will never come home. That outcome cannot change.

“But you must make sure no other family suffers this devastation.”

She recounted how her uncle suffered 124 injuries in the attack which was “was not just violence, it was barbaric beyond comprehension”.

She said: “This is like a horror film you cannot switch off, except this is real.”

The inquest heard how Ms Borowy, who had paranoid schizophrenia, told police and psychiatrists she was “tricked by the devil” into killing Mr Leadbeater in a “ritual sacrifice”, and had previously spoke to officers about “murdering people” and causing a “bloodbath”.

She was first sectioned in October 2022 after being arrested for killing two goats with a knife.

The coroner outlined other violent incidents and times when she was found with knives by police after she had left the ward at Royal Bolton Hospital.

Mrs Rawden said some of these incidents were not known to those treating her at the hospital.

In her conclusion, the coroner said a risk assessment was completed after Ms Borowy absconded on August 4 2023 and threatened to kill her friend, but this was “lacking in detail, inaccurate, and missing important and relevant information”.

Mrs Rawden said Ms Borowy’s care was transferred to a new consultant on August 7 – two days before the attack – who authorised further leave during a meeting “without clear documentation of the reasons for the decision, without consideration of a detailed risk assessment, and outside of the policies which stated that leave after a suspension should be reviewed face-to-face at the next multi-disciplinary team meeting”.

The coroner said this decision was “not reasonable or proportionate”.

She said she will be sending prevention of future death (PFD) reports to both police force as well as the Home Office, the College of Policing and the National Police Chief’s Council, relating to the handover of missing vulnerable people.

But she said she would wait until August to decide whether to issue a PFD report to Greater Manchester Mental Health NHS Foundation Trust, after she heard about a range of measures the trust was intending to implement to improve procedures.

Julian Hendy, from the Hundred Families charity, which supports families after mental health-related killings, said: “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.”

Mr Hendy said Greater Manchester Mental Health Trust has said it has “learned lessons” at previous inquests, adding: “We need better evidence the trust is learning from these terrible cases because if they aren’t, there will surely be more avoidable tragedies.”

Greater Manchester Assistant Chief Constable Steph Parker said: “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, and that our processes at this time were not more thorough to effectively work with partners.”

Ms Parker said the force accepted the coroner’s findings and is immediately introducing a new mental health monitoring and handover form which it will look to share nationally.

Detective Chief Superintendent Laura Koscikiewicz, head of crime at South Yorkshire Police, said: “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, to ensure key information is passed on.

“We are sorry that these processes were not in place at the time and we are committed to delivering continuous improvement around missing people investigations to ensure this does not happen again.”

Karen Howell, chief executive of Greater Manchester Mental Health NHS Foundation Trust (GMMH) said: “On behalf of GMMH, I want to say how very sorry we are to Mr Leadbeater’s family, friends and everyone affected by his.

“I can only begin to comprehend the pain of losing a loved one under such terrible circumstances, let alone of learning that it could have been prevented.

“GMMH should have done more, and I want to reiterate our sincere apologies and regret.”

Ms Howell said the trust has “undergone significant changes to improve the safety and effectiveness of the care provided” since Mr Leadbeater’s death but accepted there is more to be done.