New NHS probe into killings of pensioners finds deaths were 'avoidable'
A battle by a family seeking the truth from the health service about the brutal killing of their elderly parents by a mentally ill man is almost at an end. They tell health correspondent Seanín Graham about the traumatic impact...
TWO years after Wendy Little Cawdery discovered the lifeless bodies of her parents wrapped in rugs following a frenzied knife attack, she still has been unable to grieve.
The reason, she says, is a "horrible process" involving a fight with a health trust to get answers about the events that led to the barbaric slaughter of 83-year-old pensioners Michael and Marjorie Cawdery in their Portadown home.
'Mike', a retired scientist and his wife were devoted to each other and had been married 55 years. They had just returned from their weekly shop in Tesco when they were attacked by Thomas McEntee in the 'random' incident.
It emerged that McEntee (41) a paranoid schizophrenic who was given a life sentence after admitting to manslaughter last year, had attempted to seek medical help in hospitals on four separate occasions in the days leading up to the attack on May 26, 2017.
Given the complexities of the case, the highest level health service investigation was ordered by the Southern health trust and finally given to the family last summer - a report they rejected as "offensive" and "botched".
The trust's 'independent' SAI concluded there were "no factors" in the health service's handling of McEntee that "caused or influenced" the killings.
The Cawdery family demanded a second independent probe - and in an unprecedented development, got it.
Known as Level 3 Serious Adverse Incident (SAI) reports, the fresh investigation is 95 pages long - the original was just 16 - and contains interviews with 66 individuals.
Crucially, the final report, which was given to the family a fortnight ago, concludes that the horrific killings were "avoidable", stating: "The tragic adverse event occurred in the context of a significant deterioration in Mr A's (McEntee) mental health and as a result of Mr A entering the home of Mr and Mrs Cawdery, culminating in the fatal outcome. This could not have been predicted but could have been avoided".
In addition, a separate review into whether the original SAI followed the strict procedures set in place for such confidential investigations - which are a key mechanism in the health system for "learning" from mistakes - has concluded that the reporting system should be reviewed as a "matter of urgency".
For Ms Little Cawdery, and her husband, Charles Little, who lived next door to her elderly parents in the quiet Co Armagh suburb and were the first to discover their bodies, the rigour of the fresh probe should be the benchmark for future homicide investigations linked to the health service.
"To actually see that their deaths were 'avoidable' in black and white... on the one hand it was victory for us but on the other it made your blood run cold," Mr Little said.
"The original SAI was basically a timeline. We insisted they should do the review again and investigate what had gone wrong because it was offensive, it was the most awful document and didn't tie up with some of the evidence.
"But the worry is, if they rubberstamped the last one - and even sent a 'draft' to the coroner - how many more have they rubberstamped? It calls into question the whole process."
Mr Little, who was almost run down by McEntee as he fled the scene, said the family were "broadly content" with the outcome of the second report.
"We're satisfied that the truth appears to have come out...the new SAI concurs with our view there were opportunities missed that could have averted the deaths," he said.
The couple say they have a "high regard" for the independent panel who have given them fortnightly briefings over the past nine months during the course of their investigation.
By contrast, they didn't even know the first SAI had been ordered and weren't interviewed as part of it. They had to continually lobby the Southern health trust to access details.
Ms Little Cawdery said this experience had severely compounded her distress.
"We didn't expect to be treated as if we were inconsequential - as if we shouldn’t be here at all. My parents died. We were part of the incident and weren't even interviewed by the health service, they didn't want to know us.
"It's been horrible, the whole process. A lot of our attention has been given over to this - we haven't dealt with the bereavement yet, it's still to come. We haven't had time to grieve because of this. It will be interesting when we get to the end of this, we don't know what’s going to happen, it's taken over our lives.
"You shouldn’t have to go through all this to get to the answers, if it wasn't for Charles and the rest of the family being able decipher the nonsense..we would never had got to this point with the truth."
With the final report due to be approved by the north's Health and Social Care Board (HSCB) in coming weeks and then sent to a Coroner, the family say they are preparing themselves for the trauma of an inquest.
They accept that McEntee, who was seen naked walking in Newry on the day of the killings and presented himself to Daisy Hill hospital but was not admitted, was in the midst of a "mental health crisis".
While he was taken from Newry to Craigavon Area hospital in an ambulance with a police escort he was not detained under mental health legislation - and got up and left while waiting to be assessed in the A&E Department.
McEntee, who had a given an address in Kilkeel but was in a Belfast mental health facility when he was sentenced last year, stole a bottle of wine from an off-licence before making his way to the nearby Cawdery family home on Upper Ramone Park and carried out the savage killings.
The family believe there were multiple lost opportunities by the health service to intervene and want the full, final version of the new SAI to made public.
Such reports have never been published in Northern Ireland, unlike other parts of the NHS.
Mr Little pointed to the findings of a public inquiry into the hospital deaths of five children published last year, which stated there had been a "transformation" in the health service compared to 20 years ago, with "greatly improved mechanisms" to learn from serious failings - a view he rejects.
"When the Hyponatraemia report was published in January 2018, we hadn't even met the SAI panel heading up the first review - and a meeting would only take place because we forced them," he said.
Ms Little Cawdery added: "I don't think there was any change, as they tried to avoid giving us the whole story. There were clear omissions in first SAI. That's very worrying.
"But we hope this fresh investigation will make a change. We have aspirations to get things changed. We want this new report to become part of a training package that should be given to people investigating SAIs. We are going to call for it to be published."
In a detailed statement released last night, the Health and Social Board said they recognise the "enormous distress" caused to the family and "unreservedly apologise".
"The thoughts of Health and Social Care system (HSC) are with the Cawdery family following the tragic events of 26th May 2017, and we continue to offer our sincere condolences at their loss.
"An independent panel was appointed to conduct a Level 3 Serious Adverse Incident (SAI) review. This work is complete and has been shared with the families affected by this tragic event.
"The HSC will now take time to carefully consider the report and its recommendations and will involve the families in this process.
"We fully recognise the enormous distress that the families affected by this tragedy have suffered and we would unreservedly apologise for this. It is essential we learn from this tragic incident and put steps in place to reduce the risk of the possibility of something similar happening in the future.
"There is also a commitment to ensuring that we enhance how we engage with all impacted families affected in these difficult circumstances. The HSC would also like to express its gratitude to the panel for the diligent and professional manner in which they conducted this review."
The Southern health trust said it "wouldn't be providing any additional comment" to the Board's statement "at this stage".