A dog walker stabbed to death by a schizophrenic artist in a ‘barbaric’ attack was ‘failed on every level’ by the NHS, his family said today.
Roger Leadbeater’s relatives spoke out after a coroner slammed a doctor’s decision to let Emma Borowy leave the unit where she was being treated.
The 32-year-old was allowed out for 30 minutes despite a warning that she had ‘discussed murdering people’ plus a string of violent outbursts and escape attempts.
Tragically the regular cannabis user instead travelled 40 miles away and launched a frenzied attack against Mr Leadbeater two days later.
The 74-year-old – who was walking his springer spaniel Max in a Sheffield park – was stabbed more than 50 times on August 9, 2024.
Borowy later told police she had killed the pensioner – who drove a minibus taking children with special needs to school – as a ‘ritual sacrifice’.
The devil had ‘tricked’ her into believing she needed to kill him, the mother-of-one added.
Borowy was charged with murder, but four months later she was herself found dead in prison after a ‘suspected suicide’.
Roger Leadbeater, 74, (pictured) was walking his springer spaniel Max in a Sheffield park on August 9, 2024 when he was stabbed more than 50 times
Artist Emma Borowy (pictured) was sectioned under the Mental Health Act after being diagnosed with schizophrenia, but was granted escorted leave despite repeated violent outbursts and escape attempts, an inquest heard
Angela Hector, niece of Mr Leadbeater, accused an NHS trust and two police forces of having ‘failed on every level’ following the conclusion of his inquest
A doctor who reviewed the decision to give her escorted leave later concluded it was ‘difficult to justify the manner and circumstances of the decision making’.
Today a coroner said the risk Borowy could pose to members of the public was not properly considered by staff at Greater Manchester Mental Health NHS Trust when her escorted leave was approved.
The doctor’s decision was ‘not reasonable or proportionate’, Sheffield coroner Tanyka Rawden added.
Had an ‘up to date’ assessment been available and considered, ‘it is likely the risk factors would have been too high and leave would not have been granted’, the coroner said.
Recording a conclusion that Mr Leadbeater was unlawfully killed, she concluded that Borowy knew what she was doing was wrong when she stabbed Mr Leadbeater and that the defence of insanity would therefore not have been available to her had she lived to stand trial.
Afterwards in an emotional statement, Mr Leadbeater’s family – who attended every day of the proceedings – slammed the NHS trust which treated Borowy, as well as two police forces who picked her up following earlier escapes, accusing them of having ‘failed on every level’.
And they spelt out in grim detail how the pensioner sustained 124 injuries in an attack that was ‘barbaric beyond comprehension’.
‘He fought with everything he had,’ his niece Angela Hector said.
Artist Emma Borowy, 32, was sectioned after stealing and slaughtering two goats in a ‘witchcraft’ ceremony
Emma Borowy was in the care of the Greater Manchester Mental Health NHS Trust
Pictured is the family of Roger Leadbeater when the inquest in Sheffield started in December 2024
‘Defensive wounds covered his hands, arms, and legs but Emma Borowy kept going, even as Roger lay dying, trying desperately to crawl away.
‘This is like a horror film you cannot switch off. Except this is real.’
Demanding changes so no family has to endure what hers has, she added: ‘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.
‘You must make sure lessons are learned.
‘You must make sure that for once accountability leads to effective action.
‘That is the only justice left for Roger and the only way to honour his memory.’
Borowy had been sectioned under the Mental Health Act after stealing and slaughtering two goats in a ‘witchcraft’ ceremony in October 2022.
She became convinced she was ‘an alien’ and that extra-terrestrials could contact her through a special crystal.
Mr Leadbeater, 74, (pictured) was described by his family as a ‘good, hard-working and decent man’ whose job was to drive children with special needs to school
Roger Leadbeater was walking his springer spaniel Max in a Sheffield park on August 9, 2024 when he was stabbed more than 50 times
Ahead of the inquest, Mr Leadbeater’s family (pictured) said their concern was that doctors ‘just didn’t follow’ procedures for protecting mental patients
Mr Leadbeater’s family wore these blue ribbons to the inquest in Sheffield
The regular cannabis user wouldn’t take anti-psychotic medication due to the side-effects.
But despite absconding from mental health wards nine times in ten months, plus a string of violent outbursts, doctors at Royal Bolton Hospital repeatedly granted Borowy escorted leave.
Just over two weeks before she killed Mr Leadbeater, an assessment highlighted Borowy’s ‘aggression’ and that she had placed ‘others at risk’ during previous escape bids.
These included smashing windows, assaulting staff and scaling walls.
Borowy had been caught trying to smuggle a knife out of the dining area, while a week later she ‘repeatedly punched’ a nurse.
In January 2023 she had gone missing for 12 days after being allowed into the hospital grounds, with a worried friend later reporting she had spoken of creating a ‘bloodbath’.
The friend – who lived in Sheffield – contacted South Yorkshire Police to say she was ‘scared’ of what Borowy might do.
‘She is concerned about Emma as she has assaulted people previously and discussed murdering people,’ a police report read to the hearing stated.
The friend also told officers: ‘Emma gets angry easily and wants to murder people.’
However the inquest was told there was no record of the threat in her medical notes.
After being allowed out of the unit again on August 4, 2023, Borowy was found in a bush in Sheffield, over 40 miles away.
Flanked by emotional relatives, Mr Leadbeater’s niece Angela Hector today implored NHS bosses and police chiefs to ensure ‘lessons are learned’ from his ‘barbaric’ and avoidable killing
Relatives of Mr Leadbeater have demanded to know why doctors kept granting Borowy (pictured) spells of leave despite her repeatedly going missing for days at a time
Three days later she was yet again given escorted leave, this time to visit a shop.
But she ran off and again travelled to Sheffield where she attacked and killed Mr Leadbeater.
Borowy later said she had been ‘receiving messages from Lucifer’ and hadn’t slept or taken her anti-psychotic medication for three days.
Giving evidence at the inquest, consultant psychiatrist Dr Dilraj Sohi said hadn’t met Borowy before granting her leave on August 7, having just taken over as her doctor.
He said she had been ‘settled’ in the run-up to his decision, saying he would probably have taken the same step even if he had assessed her face-to-face first.
The inquest has heard that because Borowy’s symptoms were stabilising, doctors had no choice but to prepare her to be discharged.
The hearing was adjourned for over 12 months so the coroner could obtain an expert report into the decision.
After reviewing the case, Dr Amlan Basu said it was ‘difficult to justify the manner and circumstances of the decision making’.
Today the coroner said the decision to allow Borowy escorted leave should have been referred to a meeting of senior doctors due to her history of threats and failing to take her medication.
Earlier this month officers from the Greater Manchester and South Yorkshire forces admitted handover procedures involving vulnerable adults had not been updated since Mr Leadbeater’s death – a situation the coroner branded ‘disappointing’.
Today she said she would be writing a report to prevent future deaths in relation to the police forces.
However she will not do so in relation to the mental health trust at this stage while she awaited details of changes it was making, she added.
The tragic case comes after another shocking killing carried out by a patient who was also under the supervision of Greater Manchester Mental Health NHS Trust.
Emily Jones, seven, was fatally attacked as she rode her scooter in her local park in Bolton on Mother’s Day in March 2020.
Emily Jones, seven, was stabbed to death by Albania-born Eltiona Skana, 33, as she rode her scooter in her local park in Bolton on Mother’s Day in March 2020
Ryan Lowry (pictured) was axed to death in the street by his paranoid schizophrenic cousin on February 27, 2020
Skana admitted manslaughter by diminished responsibility and is serving a life sentence.
NHS bosses ordered an independent review which later said the trust’s understanding of the risks posed by Skana was ‘poor’.
The same trust was criticised over the death of Ryan Lowry, who was struck 13 times with an axe by his paranoid schizophrenic cousin.
Police and medical staff failed to share concerns about Ashley Glennon’s escalating violence in the run-up to the fatal attack in Trafford in February 2020, an inquest jury later found.
Glennon later pleaded guilty to manslaughter by reason of diminished responsibility and was sentenced to an indefinite hospital order.
All three bereaved families were supported by charity Hundred Families which supports relatives after mental health-related homicides.
Today its director Julian Hendy said: ‘This is such a terrible case.
‘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.’
There was clear evidence before the killing that Emma Borowy posed ‘a serious risk of violence to herself, her family, and others,’ he said.
Mr Hendy said that despite Greater Manchester Mental Health NHS Trust (GMMH) insisting it had ‘learned lessons’, other ‘tragic avoidable deaths’ had exposed ‘almost exactly the same problems’.
‘We need better evidence the trust is learning from these terrible cases, because if they aren’t, there will surely be more avoidable tragedies.
‘This has to stop.’
Afterwards Karen Howell, chief executive of GMMH, acknowledged that Mr Leadbeater’s death could have been prevented, expressed ‘sincere apologies and regret’ to his family and said the trust should have ‘done more’.
She said that since his death the trust had ‘undergone significant changes to improve the safety and effectiveness of the care provided’ and was ‘rebuilding’ its organisation.
‘We will carefully consider the Coroner’s findings and will take the actions that we are committed to delivering,’ she added.
Also apologising to Mr Leadbeater’s family afterwards, 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.’
A new ‘handover process’ would ensure police ‘better understand risks and safeguard vulnerable people’, she added.
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.
‘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.’
She added that new ‘stringent’ handover procedures were being shared with other police forces in order to ‘keep people safe’.
For confidential support, call Samaritans on 116 123, visit samaritans.org or visit www.thecalmzone.net/get-support
