Coroner expresses concern over decision to grant leave to patient who killed man

Relatives of a man fatally attacked by a woman who had escaped from a secure medical facility informed an inquest that his demise could have been avoided. Emma Borowy, aged 32, murdered Roger Leadbeater, 74, on 9 August 2023, while he was walking his dog, Max, in a Sheffield park. During testimony at the inquest on Thursday, Mr. Leadbeater’s family stated that numerous “missed opportunities” had occurred. Angela Hector, Mr. Leadbeater’s niece, commented: “My only hope would be that no other family goes through what we have been put through.” The inquest heard that Ms. Borowy, diagnosed with schizophrenia and psychosis, had absconded from the Royal Bolton Hospital on eight occasions since being sectioned under the Mental Health Act in October 2022. The Bolton resident, a mother of one, had additionally attempted to escape at least eight other times and had spoken of “hurting people” mere days prior to taking Mr. Leadbeater’s life. Senior coroner Tanyka Rawden reported that Mr. Leadbeater, a former bus driver who was employed as a minibus driver for children with special needs when he died, sustained a total of 75 “sharp-force injuries,” which included an injury to his right eye. Ms. Hector, acting as the family’s representative at the inquest, stated that her uncle “died in the most horrendous and undignified circumstances.” She characterized him as “kind, loyal, caring” and “a true gentleman.” “He was more than just an uncle. He took on the role of dad, brother, grandad and friend.” “He played a massive part in our family and now there is a huge black hole which we will never be able to fill.” Ms. Hector mentioned that her uncle, who perished in what appeared to be an unprovoked assault, had “walked his dogs on that field around that time for 27 years.” She added: “For him, he was in the right place at the right time.” His dog stayed beside him but had to be euthanized due to the “trauma” it experienced, she further noted. A prison officer at HMP New Hall, where Ms. Borowy was detained on remand following a murder charge before she died by suicide, reported that she “often spoke about how awful she was and couldn’t believe what she had done.” “Emma stated she didn’t think anyone could help her, wished it hadn’t happened, and said it was unforgivable.” The hearing on Thursday at the Medico-Legal Centre also revealed that a serious incident review conducted after Mr. Leadbeater’s death determined that the doctor responsible for Ms. Borowy’s care acted contrary to policy by granting her leave from the hospital on 7 August, prior to her absconding. Ms. Rawden expressed being “very concerned” by the choice made by Dr. Dilraj Sohi, a consultant psychiatrist, to approve additional leave for Ms. Borowy following a 30-minute meeting where 40 patients were reviewed. Furthermore, Dr. Sohi had never personally encountered Ms. Borowy, who had been absent without leave three days earlier. Emma McDaid, who authored the report, stated that the doctor “should have seen her” face-to-face before deciding on her release. She further noted that a determination to grant Ms. Borowy additional leave ought to have been made by a “multi-disciplinary team.” “There is always some clinical variance, that needs to be considered. However, I would expect [guidelines] to be followed and if there was a variance from policy I certainly would expect a clinical rationale for that reason.” Dr. Sohi had previously informed the inquest that a vulnerable adult form, generated by South Yorkshire Police on 4 August after officers found Ms. Borowy during her AWOL period, had not been communicated to the hospital. The document characterized her as “delusional, suicidal and talking about hurting people.” Dr. Sohi indicated that the “likelihood” was he would have still approved leave for Ms. Borowy on 7 August, even with knowledge of that information. He remarked: “We do live in hope that people can and will improve.” Ms. Rawden stated she might require the assistance of an independent psychiatry expert to help her determine if the actions of the Greater Manchester Mental Health NHS Foundation Trust, specifically, were “reasonable based on the evidence of what was known at the time.” She further commented that the Trust’s decision-making process regarding granting leave was “difficult to understand.” She emphasized: “It’s so important that lessons are learned from this.” Ms. Rawden postponed the inquest and scheduled a review date for 7 March.