Analysis: Pledge to overhaul the SAI system must now be heeded
A QUEST for truth into NHS failings following the brutal killings of an elderly Co Armagh couple led to an apology from the top figure in the health service to relatives earlier this month.
The Cawdery family's relentless drive for answers confirmed "missed opportunities" that led to the pensioners’ "avoidable" deaths - and also exposed major shortcomings in the investigative process that is used in our health system when things go seriously wrong.
Crucially, it revealed problems in six other cases in which a suspicious death or 'homicide' occurred - and which were subject to what is known as level 3 independent 'Serious Adverse Incidents' (SAIs).
It has now transpired that the Hughes family from west Belfast are included within these botched SAI reviews.
As part of the investigation, their involvement was supposed to be key, as set down by health service in 2016 when they re-wrote the procedures for conducting such probes following a string of blunders and accusations of 'secrecy' and cover-ups by relatives kept in the dark.
However, not only were the Hughes family excluded from taking part in this review, they didn't even know of its existence.
Their brother, 62-year-old James Hughes, a "gentle giant" who practised Buddhism and tried to befriend his mentally ill killer, suffered a violent death by a parnanoid schizophrenic who had sought help from the health service three days before the tragedy.
Since the passing of the former psychiatric nurse, his family has criticised the system but say they believe their brother and his killer were both “victims”.
They have repeatedly said they want lessons to learned in the mental health sector to ensure another family do not have to suffer the "hell" they have experienced.
The central remit of the SAI is to identify learning. The Belfast health trust has now accepted that it failed to carry the review properly and also failed to include the family, resulting in a second independent SAI being ordered.
Permanent Secretary Richard Pengelly, who made the apology to the Cawdery family - which they sought - on August 7, pledged "improvements to SAI processes including better engagement with families".
While it is accepted that reviews into such tragic crimes are complex, the failure of two separate health trusts to, it would appear, deliberately exclude affected families is profoundly disturbing.
In the absence of a health minister, Mr Pengelly is the top official in the service with health trusts answerable to him.
His pledge to overhaul the SAI system must now be heeded.