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Investigation and inquest
On 11 August 2023 I commenced an investigation into the death of Roger Gary Leadbeater aged 74. The investigation concluded at the end of the inquest on 22 January 2026. The conclusion of the inquest was unlawful killing.
Circumstances of the death
Roger died on 9 August 2023 due to multiple stab wounds inflicted by a patient who was detained in hospital under the Mental Health Act and who had absconded from escorted leave.
The patient had been known to Mental Health Services since 2008 and had experienced psychosis and command hallucinations telling her to hurt others.
She had previously killed animals and assaulted people, and she presented a risk to animals and people.
During her last admission to hospital between October 2022 and August 2023, the patient was violent to staff. She absconded nine times, attempted to abscond fifteen times, and failed to return from leave three times.
Despite handovers between police forces and between the police and the Trust not being clearly recorded, there was evidence of the patient using drugs, carrying weapons and making threats to harm people during her periods of absence.
On 7 August 2023 the patient’s care was transferred to a new inpatient Consultant Psychiatrist and Responsible Clinician.
During a thirty-minute board meeting that morning a period of escorted leave was authorised. This decision was made 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 at the next Multi-Disciplinary Team Meeting.
The patient absconded whilst on escorted leave and two days later her actions brought about Roger’s death.
Coroner’s concerns
During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation.
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave.
Information checked against the published report and official responses