David Illingworth represents bereaved family at inquest finding unlawful killing by mental health inpatient

January 23, 2026

David Illingworth, instructed by Kayley Giddings of Brunskill Solicitors, represented the bereaved family at the inquest into the death of Roger Leadbeater. At Sheffield Coroner’s Court on 22 January 2026, the Coroner concluded that Roger was unlawfully killed by a mental health in-patient (“the patient”) during a period of absence without leave (“AWOL”).

On 9 August 2023, Roger died in Shortbrook Park, Sheffield as a result of multiple stab wounds inflicted by the patient in an unprovoked attack. The court heard that the patient had been diagnosed with paranoid schizophrenia and had been subject to detention under the Mental Health Act. Prior to the episode of AWOL in which she stabbed Roger, the patient had previously absconded from periods of leave 9 times, attempted to abscond 15 times, and failed to return from leave 3 times.

At the time of Roger’s killing, the patient had been suffering from command hallucinations. These included voices in her head telling the patient to kill her friend. The patient told the police in an interview that Lucifer had told her that killing was OK, and that she felt she had no choice but to kill a member of the public in order to appease Lucifer, so as to avoid having to kill her friend.

David made submissions on the law on legal insanity as it applies in the coronial jurisdiction – the test being whether, on the balance of probabilities, the Coroner could be satisfied that the patient was not legally insane at the time of Roger’s killing: R (O’Connor) v HM Coroner for District of Avon [2009] EWHC 854 (Admin). The key element of the test for legal insanity in this case was whether the patient knew what she was doing was both legally and morally wrong.

Relying on the case of Keal [2022] EWCA Crim 341, David submitted that any delusional sense the patient may have had that killing was a ‘necessary evil’, in order to avoid having to kill her friend, did not mean she was unaware that killing was legally wrong. Keal established, in particular, that including within the insanity defence cases in which a defendant committed an act under an impulse which by mental disease they were in substance deprived of the power to resist would be contrary to the law as it stands, which does not recognise a defence of irresistible impulse.

Ultimately, the Coroner concluded that she could be satisfied on the balance of probabilities that the patient was not legally insane at the time of Roger’s killing, and therefore a short-form conclusion of unlawful killing was reached. The Coroner also issued regulation 28 reports on the prevention of future deaths to Greater Manchester Police and to South Yorkshire Police, regarding the handover of a missing person who has absconded from Mental Health Act detention.

David regularly appears at inquests representing both bereaved families and for public authorities, including in Article 2 cases such as this which pose complex factual and legal issues.