The family of a pensioner killed in a “ritual sacrifice” by a woman who escaped from a mental health unit said authorities “failed on every level” to protect him.
Roger Leadbeater, 74, was stabbed multiple times by Emma Borowy, 32, while walking his dog in a Sheffield park in August 2023.
The attack occurred after Borowy absconded while on leave from her unit, an inquest into Mr Leaderbeater’s death heard.
On Thursday, Sheffield coroner Tanyka Rawden concluded that Borowy’s leave request would probably have been rejected if procedures had been followed.
Borowy, who had paranoid schizophrenia, told police and psychiatrists she was “tricked by the devil” into killing Mr Leadbeater in a “ritual sacrifice”. She died in prison four months after the attack.
She had absconded from her ward nine times, attempted to abscond 15 times and failed to return from leave three times, the inquest heard.
The coroner outlined how Borowy was still granted permission for escorted leave two days before she attacked Mr Leadbeater.
Borowy’s care was transferred to a new consultant who approved more leave “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”.
Ms Rawden concluded “it is likely the risk factors would have been too high and leave would not have been granted” if the procedures at Greater Manchester Mental Health NHS Foundation Trust had been followed.
Borowy was first sectioned in October 2022 after being arrested for killing two goats with a knife.
Ms Rawden also criticised both Greater Manchester and South Yorkshire police forces for how they dealt with handovers of vulnerable missing people.
Outside the coroner’s court, Mr Leadbeater’s niece Angela Hector criticised Greater Manchester Mental Health, Greater Manchester Police and South Yorkshire Police.
“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.”
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Ms Hector urged the responsible authorities to “feel what it’s like to live with the consequences of your decisions”, adding: “I am certain you would think twice before granting leave, before withholding vital information, before ignoring clear warnings.”
She described how her uncle had suffered 124 injuries, in an attack that “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.
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The coroner will now send prevention of future death (PFD) reports to both police forces, the Home Office, the College of Policing and the National Police Chief’s Council, in relation to the handover of missing vulnerable people.
Ms Rawden said she would wait until August before deciding to issue one for the hospital trust – which said it “learned lessons” and intended to implement a range of measures to improve procedures.
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.”
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South Yorkshire Police’s Detective Chief Superintendent Laura Koscikiewicz 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.”
