Killer's victim 'failed on every level' - family

The family of a pensioner killed by a woman who went missing from an acute mental health unit has said two police forces and an NHS trust "failed on every level".

Emma Borowy, 32, fatally stabbed Roger Leadbeater, 74, as he walked his dog in a park in Sheffield on 9 August 2023 after Borowy absconded from leave from a unit in Bolton.

At the end of an inquest on Thursday, Sheffield coroner Tanyka Rawden concluded that Leadbeater was unlawfully killed.

Following the inquest, Angela Hector, Leadbeater's niece, called on Greater Manchester Mental Health NHS Foundation Trust, Greater Manchester Police and South Yorkshire Police to ensure "no other family suffers this devastation".

Outside Sheffield Coroner's Court, 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."

The inquest heard how Borowy, who had paranoid schizophrenia, told police and psychiatrists she was "tricked by the devil" into killing Leadbeater in a "ritual sacrifice".

She had previously spoken to officers about "murdering people" and causing a "bloodbath".

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

The inquest was told she had previously absconded from her ward nine times, attempted to abscond 15 times and failed to return from leave three times.

The coroner said permission was still given for escorted leave two days before 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.

Rawden said Borowy's request would probably have been rejected if procedures had been followed.

Borowy died in prison four months after the fatal attack on Leadbeater.

Concluding the inquest, Rawden said it was "likely the risk factors would have been too high and leave would not have been granted" if the procedures had been properly followed.

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

Rawden said she would be issuing prevention of future death reports to South Yorkshire Police and Greater Manchester Police.

Speaking to Leadbeater's family, Rawden said: "There aren't any words that come close to being adequate. I'm so sorry that Roger is not with you any more.

"He clearly meant the world to you and I can't imagine what you're going through.

"I'm sorry I can't give you what you want, Roger back."

Surrounded by members of her family outside the court, Hector said in a statement: "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."

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

"This is like a horror film you cannot switch off, except this is real," she said.

Greater Manchester Police Assistant Chief Constable Steph Parker said: "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.

"We accept the coroner's findings and know that it is vital that we move to get things right to prevent anything like this happening again.

"We are immediately introducing a new mental health monitoring and handover form to ensure our processes are as stringent and risk informed as possible, which we will look to share with policing nationally.

"We are already delivering refreshed training to all local teams around the management of missing people across Greater Manchester.

"Nothing can bring back Roger to his loved ones, but we owe it to them and the public that all necessary learning is baked into our operational procedures to keep people safe."

Karen Howell, chief executive of Greater Manchester Mental Health NHS Foundation Trust (GMMH), said: "GMMH should have done more, and I want to reiterate our sincere apologies and regret.

"Since Mr Leadbeater's death in 2023, the trust has undergone significant changes to improve the safety and effectiveness of the care provided, including the appointment of a new executive leadership team who are reengineering and rebuilding our organisation.

"We are encouraged that the coroner has recognised our progress, and fully accept there is more to be done. We will carefully consider the coroner's findings and will take the actions that we are committed to delivering.

"We understand that this does not change what happened, and our thoughts and sympathies remain with Mr Leadbeater's loved ones now and always."

Det Ch Supt Laura Koscikiewicz, head of crime at South Yorkshire Police, said: "First and foremost, I would like to extend my deepest sympathies to Roger's family. The inquest into the circumstances surrounding Roger's death has been difficult for those who knew and loved him, and our thoughts remain with them at this time.

"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 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."

She added that a new handover process had been introduced which would "ensure key relevant information is passed onto partner agencies when a missing person is passed over to them".

"This will help to ensure we are collectively able to better understand risks and safeguard vulnerable people, as well as staff working across all agencies," Koscikiewicz said.

"We will now ensure the further points of learning raised within the coroner's findings and the prevention of future deaths report are fully implemented in order to deliver further organisational learning."

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