Family of Michael and Marjorie Cawdery killed by mentally ill patient welcome new NHS probe
Seventeen months after an elderly couple were stabbed to death by a mentally ill man, their loved ones continue to seek answers from the health service as to what went wrong. They have discovered that a second review is to take place into the catastrophic chain of events. Health correspondent Seanín Graham reports
"They hadn't just been killed, they'd been slaughtered - how do you recover from that? And then to find that day this guy had been down to Daisy Hill Hospital naked and somehow had ended up at Craigavon Area Hospital and had been allowed to walk out."
Charles Little, son-in-law of Mike and Marjorie Cawdery, who was the first person to discover their bodies in their Portadown home on May 26, 2017.
RELATIVES of an elderly couple stabbed to death by a mentally ill patient have accused the health service of “retraumatising” them following a botched investigation.
Such is the level of concern about the serious adverse incident (SAI) report into the killings of 83-year-old pensioners Michael and Marjorie Cawdery that Northern Ireland’s most senior NHS officials have taken the unprecedented step of ordering a second high-level probe – a year on from the first.
A separate review is to take place into whether the original SAI, carried out by the Southern Health and Social Care Trust, followed the strict procedures for such confidential investigations – which are a key mechanism in the health system for “learning” from mistakes.
The Irish News can also reveal that the Health and Social Care Board has for the first time issued a public apology to the Cawdery family for the “distress” they experienced.
In a statement following a query from this newpaper in light of concerns raised by relatives about the health service’s handling of the case, a board spokeswoman said: “We want to acknowledge and are sorry for the loss and distress which the Cawdery family has experienced. An independent team has been established to conduct a review into this case and the terms of reference are being finalised.”
Correspondence seen by The Irish News shows draft terms of reference for the health service’s own review of itself. These include a proposal to examine why the Southern trust team failed to speak to the Cawdery family in its review. Trust investigators instead only consulted the killer’s family.
The SAI team began their report three months after the killings. It was not published until May this year and was never made public. A copy was sent to the coroner.
Michael, a retired scientist, and his wife Marjorie were devoted to each other and had been married 55 years. They had just returned home from their weekly shop in Tesco on May 25 last year when Thomas McEntee killed them in a ‘random’ frenzied attack in their Portadown home.
McEntee, a paranoid schizophrenic, stayed in the couple’s home for two hours afterwards, during which time he showered and changed into Mr Cawdery’s clothes.
McEntee, who was given a life sentence after admitting manslaughter, had sought medical help on four occasions in the days leading up to the attack.
The first SAI concluded that “no factors” in the health and social services’ handling of McEntee “caused or influenced” the deaths.
The Cawdery family fought to get a copy of the report. When they received it in June they branded it “shambolic” and demanded a fresh investigation with their input.
Charles Little, the couple’s son-in-law who discovered their lifeless bodies wrapped in rugs, said “lessons had not been learned”.
However, he said he accepts the board’s apology.
“It has taken 17 months but the family is pleased that the board has at last publicly apologised for the distress caused to them,” he said.
Face-to-face with killer
Mr Little, who lives in the house next door to his in-laws and is married to their daughter Wendy, came face to face with McEntee after the killings. He said he has been “living off anger” for the past year.
“We lived literally next door within the same garden. One of the reasons we were there was to keep an eye on Mike and Marjorie,” he said.
“They were 83. They were still sharp but frail and I feel very, very guilty that I wasn’t there. Wendy and I were out shopping. I wasn’t there to do something.
“When we got back it was a lovely, sunny day and I was just about to start painting the shed. I was sitting outside on our step having a glass of orange squash, throwing a ball to the dogs and McEntee walked around the corner of the house carrying Mike’s car keys. He was very calm. The dogs ran up to him and he stood absolutely stock still.
“He looked odd and I asked if he was OK. I assumed he was a mechanic because Mike was having trouble with the car and he had the keys. Mike always had the keys clipped to his belt.”
Mr Little said police showed “more compassion” than any member of the health service in their handling of the case.
“The PSNI were brilliant right from the word go. You would have been forgiven for thinking they were the health and social care people. They were compassionate, considerate, caring and went out of their way to help us,” he said.
'No contact' from health trust
“The Southern health trust used the SAI review as a reason not to talk to us.
“We thought we would be central to the SAI. That’s what their procedure actually says. Instead we had no proactive contact from the Southern trust for nearly a year despite repeated advice from the police to engage with us.”
The couple’s son Graham said the family are seeking counselling but that they will “never recover”.
Mr Little added: “It is traumatic enough going through the actual incident but then to find that the one organisation that is supposed to give you care is going out of its way to drive you away – when we had in fact become their patients as a result of the incident – is traumatic. It’s like we’ve been retraumatised."
Deaths 'could have been prevented'
The Irish News has seen a copy of the original SAI report which concludes there was “nothing in Thomas McEntee’s behaviour or in the most recent examination of his mental state (approximately four days before the event) to indicate that staff could reasonably have predicted that he was at risk of carrying out such an act”.
The trust acknowledges some “identified learning” in relation to referrals of psychiatric patients between trusts and updating home treatment ‘crisis responses’. The sharing of information with the police is also highlighted.
However, the family say they believe their parents’ deaths could have been prevented.
“Had the health authorities acted correctly the whole thing could have been avoided,” Mr Little said.
“If McEntee had been assessed properly in Daisy Hill Hospital in Newry he would have been transferred directly into a psychiatric bed in Craigavon.”
The family “feel sorry” for McEntee and describe him as a “victim”.
“He was failed and we were failed... but we cannot forgive him,” Mr Little said.
Asked if it is willing to publicly apologise to the Cawdery family for the distress caused to them by its original SAI process, the Southern trust responded with a statement which did not apologise.
It read: “The Public Health Agency and Health and Social Care Board are working with the Cawdery family to establish a new independent review.
“The trust is fully committed to this process and we will be working closely with all of those involved.”
High level 'SAI' probes most serious in health service
LEVEL-THREE serious adverse incident (SAI) investigations are extremely rare in the Northern Ireland health service and relate to its most serious failings, including murder and abuse.
Other than the Cawdery case, the most recent high-profile probe relates to the Muckamore Abbey hospital abuse scandal, in which learning disabled patients were allegedly physically assaulted by nursing staff.
There have been fewer than a dozen of these confidential reviews over the past two years.
Strict criteria and guidance have been established in relation to the membership of the review teams, deadlines for reporting and – crucially – the involvement of families.
Official guidance states: “It is the role of the chair to ensure engagement with families, that their views are sought, that support has been offered to them at an early stage and they have the opportunity to comment on the final draft of the report.”
In relation to Muckamore, an independent safeguarding expert from England was commissioned to head its detailed report and families of vulnerable patients were questioned.
However, a medical professional from another health trust in Northern Ireland chaired the Cawdery SAI case – something about which the family raised concerns.
Relatives of Michael and Marjorie Cawdery also had no input and say they were “excluded” from it.
The new SAI team appointed to investigate the Cawdery case for a second time will include an expert from a mental health team in London and a highly regarded psychiatrist from Dublin. The family will also be consulted.