Roger Leadbeater, 74, was walking his dog when he was stabbed multiple times by Emma Borowy, 32, in August 2023. Borowy had escaped from a mental health unit while on authorised leave just days before the attack.
An inquest into Mr Leadbeater’s death heard that Borowy, who suffered from paranoid schizophrenia, later told police and psychiatrists she believed she had been “tricked by the devil” into killing him as part of a “ritual sacrifice”. She died in prison four months after the attack.
On Thursday, Sheffield coroner Tanyka Rawden concluded that Borowy’s leave would probably not have been granted if proper procedures had been followed by Greater Manchester Mental Health NHS Foundation Trust.
The inquest heard that Borowy had absconded from her ward nine times, attempted to abscond on 15 occasions and previously failed to return from leave three times. Despite this history, she was granted escorted leave two days before the fatal attack.
The coroner said Borowy’s care had recently been transferred to a new consultant, who approved further leave without clear documentation, without a detailed risk assessment and outside established policies that required face-to-face reviews following previous suspensions of leave.
Ms Rawden concluded that had procedures been properly followed, the risks would have been deemed too high and leave would not have been authorised.
Borowy had first been sectioned in October 2022 after being arrested for killing two goats with a knife. The coroner also criticised both Greater Manchester Police and South Yorkshire Police for failures in the handover of information relating to vulnerable missing people.
Outside the coroner’s court, Mr Leadbeater’s niece, Angela Hector, described the attack as “barbaric” and criticised the mental health trust and both police forces.
“Emma Borowy put her trust in you to keep her safe and well,” she said. “The public put their trust in you to protect us. You all failed on every level.”
Ms Hector said her uncle suffered 124 injuries during the attack, adding: “This was not just violence. It was barbaric beyond comprehension. It’s like a horror film you cannot switch off, except this is real.”
The coroner confirmed she will issue prevention of future death reports to both police forces, the Home Office, the College of Policing and the National Police Chiefs’ Council, focusing on the handling of vulnerable missing people. A decision on whether to issue a similar report to the mental health trust will be made later this year.
Greater Manchester Police apologised to the family, admitting failures in sharing critical information, while South Yorkshire Police said it accepted the lessons highlighted by the inquest and acknowledged that changes should have been made sooner.
