Case Studies: Healthcare

Killings by a Man with Severe Mental Illness were “Entirely Preventable”

Patrick Mullarkey of O’Reilly Stewart Solicitors acted on behalf of the family and next of kin of Marjorie and Michael Cawdery, both aged 83, who were killed in their home in Portadown, Co Armagh, by an absconding mental health patient, Mr Thomas Scott McEntee, on 26th May 2017.

During the course of an Inquest, which proceeded before Coroner Maria Dougan in Banbridge Courthouse between 12th and 26th June 2023, the Court heard how Mr McEntee, a man suffering with a severe mental health illness, had come repeatedly to the attention of healthcare authorities and the Police in the 5 days leading up to the killings.

Delivering her Inquest Verdict and Findings on Wednesday 13th December 2023, Coroner Dougan found that the deaths of Mr and Mrs Cawdery in their home were “entirely preventable”.  Identifying a litany of omissions and failures on the part of healthcare authorities and the Police, the Coroner noted that had the Police Service of Northern Ireland detained Mr McEntee under Article 130 of the Mental Health Act (Northern Ireland) Order 1986, on two separate occasions on 22nd May 2017 and 26th May 2017, and had mental health practitioners in the Belfast and Southern Trusts assessed Mr McEntee comprehensively and extensively on two separate occasions on 22nd May 2017 and 24th May 2017, then Mr McEntee would not have been in the location of the Deceased’s home on 26th May 2017, thereby preventing their deaths.

The Coroner noted, “On all the evidence before me, there was a succession of omissions and missed opportunities, emanating from poor communication, a lack of informed and effective decision making on the part of Police Officers in PSNI, and staff in BHSCT and SHSCT, in their contact, care and treatment of Mr McEntee.  These omissions and missed opportunities, whilst, analysed individually, may not be considered grave, the combination had devastating consequences.  I find that, had these opportunities not been missed, the course of events would have been different and would have changed the outcome”.

In coming to her conclusions, the Coroner identified and analysed four incidents leading up to the killings when Mr McEntee, displaying signs of mental health illness, had come in contact with PSNI and with healthcare authorities.  The first such incident occurred in Belfast city centre and then at the Mater Hospital on 22nd May 2017, the next at Daisy Hill Hospital in Newry on 24th May, the third interaction occurred the following day, on 25th May 2017, in Warrenpoint, and finally on 26th May at Daisy Hill Hospital in Newry and at Craigavon Area Hospital.

Analysing the reasons for the omissions and the failures on the part of the public agencies, the Coroner identified repeated failures on the part of the Police to understand the nature and extent of the powers that they had to deal with a patient presenting in Mr McEntee’s condition.  Similarly, there was a failure by the treating medical and nursing personnel, when Mr McEntee presented to them, to obtain an appropriate handover from attending Police Officers, to obtain collateral information which might affect decision making and outcome.  There was a failure to appreciate the nature of the patient’s presentation, and there was a failure to enquire further into his treatment and his compliance.  Had such measures been taken, then all personnel would have been better informed about the patient’s paranoid thinking at the time and, on balance, there was sufficient evidence to have considered Mr McEntee suitable for Hospital admission.

Making a series of recommendations relating to the training of PSNI and healthcare personnel, and noting the current inadequacy of the guidance, protocols, and codes of practice which underpin practice in the management of mental health presentations such as Mr McEntee’s, the Coroner worryingly concluded, “…Sitting here today, on the written and oral evidence before me, I cannot be satisfied, and as acknowledged by some witnesses to the Inquest, that, some of the failings, which have been identified, would not occur again.  More needs to be done.  My hope is that the tragic loss of Michael and Marjorie Cawdery continues to serve as a catalyst for collective and sustained change, in the recognition and treatment of people in mental health crisis, thus ensuring that no family endures the pain that the Cawdery family carries”.

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