Pensioner killed in ‘ritual sacrifice’ was failed on every level, says family
The family of a pensioner killed during a “sacrifice” by a woman missing from an acute mental health unit said two police forces and the NHS trust had “failed at every level” after a coroner concluded the patient’s leave request was likely to have been refused if procedures had been followed.
Special needs bus driver Roger Leadbeater, 74, was stabbed multiple times by Emma Borowy, 32, while walking her dog Max in a Sheffield park in August 2023 after Ms Borowy escaped from a unit in Bolton, Greater Manchester.
On Thursday, Sheffield coroner Tanyka Rawden concluded an inquest into how Miss Borowy, who died in prison four months after the attack, escaped from her cell nine times, attempted to escape 15 times and failed to return on leave three times.
Ms Rawden told how Mr Leadbeater was still granted companion leave two days before he was attacked because 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 that if procedures had been followed properly “the risk factors would probably have been so high that they would not have been permitted”.
Ms Rawden also criticized the procedures of both Greater Manchester and South Yorkshire police forces when dealing with the surrender of vulnerable missing persons.
Outside Sheffield coroner’s court, Mr Leadbeater’s niece Angela Hector said: “I would ask those in positions of trust (Greater Manchester Mental Health, Greater Manchester Police and South Yorkshire Police) to trust that Emma Borowy will keep her safe and well.
“The people are counting on you to protect us.
“You have all failed on every level.”
Surrounded by family members, Mrs Hector said: “To everyone involved in Emma’s care, whether from a health or policing perspective, I would ask you to step into our shoes for just one day and feel what it is like to live with the consequences of your decisions.
“I am sure you will think twice before giving consent, before withholding vital information, before ignoring clear warnings.
“Roger will never return home. This outcome cannot be changed.”
But you must ensure that no other family suffers this devastation.”
He explained that his uncle’s attack, in which 124 people were injured, was “not just violence, but incredible barbarity.”
He said: “It’s like a horror movie you can’t turn off except it’s real.”
The inquest heard Ms Borowy, who suffers from paranoid schizophrenia, told police and psychiatrists she had been “tricked by the devil” into killing Mr Leadbeater in a “ritual sacrifice” and had previously spoken to officers about “killing people” and causing a “bloodbath”.
He was first slaughtered in October 2022 after he was arrested for killing two goats with a knife.
The coroner outlined other violent incidents and times he was found with knives by police after leaving the ward at the Royal Bolton Hospital.
Ms Rawden said some of these incidents were unknown to those treating her in hospital.
As a result, the coroner said the risk assessment was completed after Ms Borowy ran away and threatened to kill her friend on August 4, 2023, but it was “lacking detail, inaccurate and missing important and relevant information”.
Ms Rawden said Ms Borowy’s care was transferred to a new consultant on August 7 – two days before the attack – who granted further leave during a meeting “without clear documentation of the reasons for the decision, without consideration of a detailed risk assessment and outside policies stating that post-suspension leave should be reviewed face to face at the next multi-disciplinary team meeting”.
The coroner said the decision was “not reasonable or proportionate”.
He said he would send future prevention of deaths (PFD) reports to both the force and the Home Office, the Constabulary College and the National Police Chief Council on the handover of missing vulnerable persons.
But he said he would wait until August to decide whether to publish a PFD report to Greater Manchester Mental Health NHS Foundation Trust after hearing about a range of measures the trust planned to implement to improve procedures.
Julian Hendy, of the Hundred Families charity, which supports families following mental health-related murders, said: “We have heard that serious failures by many organizations played a part in what happened to Roger.
“If it weren’t for them, it’s very possible Roger would still be alive today.”
Mr Hendy said Greater Manchester Mental Health Trust had said it had “learned lessons” from previous investigations, adding: “We need better evidence that the trust has learned from these terrible cases because if it hasn’t there will surely be more avoidable tragedies.”
Greater Manchester Deputy Chief Constable Steph Parker said: “On behalf of GMP, I would like to apologize to Roger’s family for our failure to accurately pass on important information to other partners before and after he was killed.
“It is with great regret that this tragic event has occurred and that our current processes are not more comprehensive to work effectively with partners.”
Ms Parker said police accepted the coroner’s findings and immediately implemented a new mental health monitoring and transfer form and would seek to share it nationally.
Detective Superintendent Laura Koscikiewicz, crime chief at South Yorkshire Police, said: “We fully accept that changes should have been made to the handing over of missing persons to other agencies sooner to ensure the learning opportunities and important information highlighted during the investigation were passed on.
“We regret that these processes were not in place at the time and are committed to continuous improvement in missing persons 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 would like to say how sorry we are to Mr Leadbeater’s family, friends and everyone affected by him.
“I am only beginning to understand that the pain of losing a loved one under such terrible circumstances could have been avoided, let alone learned.
“GMMH should have done more and I want to reiterate our sincere apologies and regret.”
Ms Howell said since Mr Leadbeater’s death the trust had “made significant changes to improve the safety and effectiveness of the care provided” but acknowledged there was more to be done.
