The killings of Mr Michael and Mrs Marjorie Cawdery were “entirely preventable”, according to His Majesty’s Coroner for Northern Ireland. In a narrative verdict which took over four hours to fully outline, Maria Dougan summarised the detailed evidence heard earlier this year which indicated a lack of legal understanding amongst both police officers and mental health professionals as well as a lack of clear communication across a number of incidents relating to their handling of Mr Thomas McEntee in 2017.
Perhaps most devastatingly of all, when covering evidence about the lessons learned, the Coroner stated —
“Sitting here today, I cannot be satisfied – as acknowledged by some witnesses – that some of the failings would not occur again. More needs to be done.”
— Maria Dougan, HM Coroner for Northern Ireland.
I wrote earlier in the year about the inquest in to the deaths of Mr and Mrs Cawdery. They were killed when Mr McEntee entered their home whilst seriously unwell and attacked them after they returned from shopping and he was subsequently convicted of manslaughter on the grounds of diminished responsibility – was detained in a secure mental health unit where he remains for treatment. There is a summary timeline of key events on my original post if you’re not yet familiar with the narrative but it involved five different contacts on four different dates in May 2017 which have been analysed by the coroner after taking evidence.
If I may say so, it was an extremely thorough and impressive piece of work on her part and the Coroner leaned heavily on the report of expert witness Inspector Jon Owen QPM from Avon and Somerset Police. He was quoted at length and his insights were highly impressive, also. I have followed detail in a number of inquest proceedings and this is amongst the most thorough I have known and its conclusions are fairly devastating and very precise. My thoughts and condolences go to the family and friends of Mr and Mrs Cawdery who must have found today especially difficult and their ongoing dignity in the face of this disaster was praised by the Coroner who was determined to give them answers.
ARTICLE 130 MHO
NB: for the purposes of the points I need to make here, article 130 of the Mental Health Order (Northern Ireland) 1986 (the MHO) is identical to the provisions in section 136 Mental Health Act 1983 (the MHA) and for that matter, to s297 of the Mental Health (Treatment & Care) (Scotland) Act 2003. Those distinctions which do exist are not relevant to the points being raised here – it’s for this reason, this inquest should have resonance across the United Kingdom.
On 22nd May 2017, police officers encountered Mr McEntee in Belfast and on 26th May they encountered him in Newry, to the south. In both encounters, the coroner found the grounds for using article article 130 of the Mental Health Order 1986 (MHO) were met and officers decided instead to proceed on a voluntary basis. The coroner found on 22nd May, having assisted Mr McEntee to an Emergency Department in Belfast on a voluntary basis, that officers found it necessary to threaten him with detention under a130 to ‘persuade’ him to remain there, thus placing him in to a state of de facto detention which means he should have been properly detained.
When officers encountered Mr McEntee again on the 26th May in Newry, he had been walking naked in the town and then gone to the Emergency Department where police found him. They detained and restrained him, including use of handcuffs but again did not detain him under a130 MHO because he calmed significantly after they had done so. It was then decided, between police, mental health staff and paramedics he should be conveyed ‘voluntarily’ to Craigavon ED, some twenty miles away, rather than the Newry ED, 100-yards away. The coroner found the officers should have detained him under a130 MHO and removed him without delay to the Newry ED.
There was considerable discussion about officers’ knowledge, training and awareness of local protocols, which stated for example, where the grounds for use of a130 were satisfied, the power should be formally invoked – a position the coroner adopted in her findings. She highlighted that police failures to use a130 in Belfast and Newry contributed, along with poor communication of both risk and background, to inadequate health responses. But she also specifically criticised Newry ED for their failure to ensure adequate assessment on 24th May, stating that had this happened Mr McEntee would have been admitted to hospital (ie, ‘sectioned’).
DETENTION OR VOLUNTARY?
I’ve written before about the dilemma of whether officers should detain or proceed on a voluntary basis. In short, I’ve always encouraged officers to think about how voluntary things really are becuase when police officers ask anybody to do anything, there is always an element of “or else” in the request. For example one of the ‘voluntary’ incidents here involved officers restraining and handcuffing someone who was also thought by many to lack decision-making capacity because of the various unusual things they were saying. How voluntary is it, if the police are handcuffing you amidst resistance?!
“Voluntary” in mental health terms really means that someone is exercising a genuinely free, capacitous choice to do something. Mental illness can obviously affect someone’s capacity, but so can the officers’ presence. How free is the person to make a choice, for example, to completely decline the police or NHS offer of assistance and walk away? If you’re not free to just walk, then in reality, you’re detained – whether or not a130 / s136 has been used – it’s a form of de facto detention and it happened again on 26th May in Newry, having happened on 22nd in Belfast.
When determining whether something is voluntary or whether powers have been or are being used, the key question is whether the person is not only agreeing to go to ED on a supposedly voluntary basis, but whether they will remain at ED until assessment is concluded. Where we are talking about someone who has already left (or if you like, absconded) from a voluntary arrangement which is attempting to secure care arrangements, where they are obviously paranoid and potentially lacking most decision-making capacity and found naked in the town, you might think this would be a risk consideration when thinking about whether to apply a power of detention to someone who seems willing, at least for now, to attend hospital.
It is vital officers consider not only whether someone will agree to attend hospital, but whether they can be relied upon to remain there until the process is complete and if you’re not happy to let someone walk, then the decision is not truly voluntary.
INQUEST FINDINGS
The Coroner’s summary of findings was quite incredible, in my view. She went through details of decision-making about which I cannot do justice in a post without it stretching your attention span. It took her four hours to summarise evidence, then a further hour to cover the findings.
- The deaths were “Entirely preventable” – these were the coroners words.
- Mr McEntee should have been detained a130 in three of the circumstances which were described and could have been detained in one more.
- He should have been admitted to hospital after assessment (ie, sectioned).
- Several of these interventions would have prevented the appalling outcomes seen.
- There was poor communication across the agencies.
- There was delay in reporting him absconded from ED on 26th May, a delay driven by a joint protocol on absconding.
- Policies, protocols and training were inadequate.
- She found the Code of Practice (NI) is out of date and requires revision.
The Coroner said she would be exercising her right under Rule 23(2) of the Coroner’s Rules (Northern Ireland) to write to the Chief Constable of PSNI and the Permanent Secretary of the Department of Health to highlight the issues on guidelines, training. She has specifically called for an extensive package of training for ALL officers in PSNI but went on to add there should be multi-agency training within that and legal training for healthcare staff, some of whom admitted they had no working knowledge of article 130 MHO.
PAIN AND ANGUISH
Mr Charles Little, son-in-law to the Cawderys commented after the conclusion —
“What is really, really shocking is the utter chaos that appears to have existed in both the health service and the police, and their inability to appreciate how ill this man was. It was just really breathtaking how bad it was.” He stated the deaths on his in-laws should never have happened, “I still believe there is no justice when only the ill man is held accountable.”
Mr Little went on to point out: prior to the inquest there had been a serious incident review by the NHS and a similar review from the police – and neither found any shortcoming, of any kind. He has stated his family’s intention to seek a review of the events to re-consider accountability, including potential criminal offences of corporate manslaughter, gross negligence manslaughter and misconduct in public office.
…… and remember, the Coroner stated her belief this could happen again.
I have followed this one very closely — I not only agree with her and everything Inspector Owen said but I’m not only concerned about Northern Ireland. Officers ‘voluntarily’ assisting people to hospital instead of using s136 powers is daily business and we already know people have subsequently absconded and come to harm. We also know the police are asserting an initiative which seeks to withdraw from managing mental health demands and this inquest helps us understand how carefully such things must be considered. There’s nothing about the issues in this case that were not knowable in 2017 and it’s yet another Coronial reminder of the need for properly produced, agreed multi-agency protocols which are kept up to date and under review.
It’s all there to be known and understood — and it has been for years, including the stuff about ‘voluntary’ assistance. Every hyperlink in this post which contains the word ‘voluntary’ is a different post on the topic, because I’ve done a number of them going back to 2014.
It’s all there to be known and understood.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 