Inquests touching upon the deaths of Lillian Majorie Cawdery and Michael Julien Hope Cawdery
| Jurisdiction | Northern Ireland |
| Judge | Miss Dougan |
| Judgment Date | 13 December 2023 |
| Neutral Citation | [2023] NICoroner 22 |
| Date | 13 December 2023 |
| Court | Coroners Court (NI) |
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Neutral Citation No: [2023] NICoroner 22
Judgment: approved by the court for handing down
(subject to editorial corrections and proofing prior to publication)*
Ref: [2023] NICoroner 22
Delivered: 13/12/2023
IN THE CORONERS COURT FOR NORTHERN IRELAND
__________
CORONER MARIA DOUGAN
INQUESTS TOUCHING UPON THE DEATHS OF
LILLIAN MAJORIE CAWDERY
AND
MICHAEL JULIEN HOPE CAWDERY
__________
Mr Steven McQuitty BL (instructed by Ms Sophie Laverty, Coroners Service for
Northern Ireland); on behalf of the Coroner
Mr Thomas Fitzpatrick BL (instructed by Mr Patrick Mullarkey, O’Reilly Stewart
Solicitors) for the Next of Kin
Mr Sean Smyth BL (instructed by Ms Sarah Loughran, Directorate of Legal Services) on
behalf of the Belfast Health and Social Care Trust (BHSCT) and the Southern Health and
Social Care Trust (SHSCT)
Ms Rachel Best BL (instructed by Mr Andrew Jackson, PSNI Legal Services) on behalf of
the Police Service of Northern Ireland (PSNI)
Ms Ciara Ennis BL (instructed by Mr Patrick McMahon, Patrick McMahon Solicitors) on
behalf of Mr Thomas Scott McEntee
__________
I want to thank, first and foremost, my own legal team for their support and
dedication, throughout this inquest process, together with the staff from the
Coroners Service for Northern Ireland. I also wish to thank the legal representatives
acting on behalf of the Properly Interested Persons (PIPs) for their assistance and for
the collaborative approach that has been adopted throughout.
I want to formally recognise the engagement and resilience of the extended Cawdery
family. I admire their tenacity and determination in seeking answers about the loss
of their loved ones. Michael and Majorie Cawdery, both aged 83 years old, were
kind-hearted people, whose lives tragically ended, in the most unimaginable way. I
am grateful for the respect that the Cawdery family have shown this inquest process
and I offer my sincere condolences on the loss of Michael and Marjorie.
Introduction
[1] The inquests proceeded in Banbridge Courthouse from 12 June 2023 until
26 June 2023. During the 10-day inquests, I heard oral evidence from 40 witnesses,
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and I considered a further 28 statements, together with voluminous reports, notes,
and records, which were admitted pursuant to Rule 17 of the Coroners (Practice and
Procedure) Rules (Northern Ireland) 1963 (‘1963 Rules’). It has not been possible to
recite all the evidence in these findings, although all the evidence received by me has
been considered in its totality, before arriving at these findings.
Summary of events
[2] Shortly after 12 noon on Friday 26 May 2017, Michael, and Majorie Cawdery
(hereinafter referred to as ‘the deceased’) left their home at 42 Upper Ramone Park,
Portadown, to do their grocery shopping in the local Tesco store. At approximately
12:25 hours, Mr Thomas Scott McEntee broke into the deceased’s home. At 13:35
hours, the deceased returned home and entered their property. At approximately
15:15 hours, the son-in-law of the deceased, Mr Charles Little, observed Mr McEntee
leave the deceased’s home and drive off in their car. Mr Little and his wife
Mrs Wendy Cawdery, daughter of the deceased, entered the home. They found the
deceased lying on the floor, with extensive wounds, wrapped up in rugs. They both
died from their injuries. Later that afternoon, Mr McEntee was arrested by PSNI in a
field in Portadown. There is no dispute that the deceased died from the injuries
inflicted by Mr McEntee. Mr McEntee was found guilty of their manslaughter, by
reason of his diminished responsibility, upon his guilty pleas at Craigavon Crown
Court on 23 May 2018. A High Court Judge sentenced Mr McEntee on 28 June 2018,
to life imprisonment in respect of the manslaughter convictions, with a minimum
tariff of ten years. The detailed sentencing judgment can be found at R v McEntee
Scope of the Inquest
[3] It was agreed by the Properly Interested Persons prior to the inquest
commencing that proceedings would:
(1) consider the four basic factual questions, as required by Rule 15 of the 1963
Rules, concerning:
o Who the deceased was;
o When the deceased died;
o Where the deceased died;
o How the deceased died;
And to determine the cause of death in relation to each deceased.
(2) To examine whether any of the following caused or contributed to their
deaths:
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(i) The events of 22 May 2017
(a) The police interaction with Mr McEntee on that date;
the decision making in terms of the use of powers
available to police at that time; what powers were used
and what powers were available; what protocols were
applied; what training the officers had received in use
of such powers and policies;
(b) The BHSCT staff decision making; care path
determined for Mr McEntee; the continuity of care after
he left the Mater Hospital and transferred to the
SHSCT;
(c) What information was conveyed to Trust staff by police
about Mr McEntee;
(d) Whether alternative decisions that might have been taken at
that time would likely have altered the outcome.
(ii) The events of 24 May 2017
(a) The SHSCT staff decision making; care path determined for
Mr McEntee; whether it was capable of implementation;
(b) Whether alternative decisions that might have been taken at
that time would likely have altered the outcome.
(iii) The events of 26 May 2017
(a) The decision to refer Mr McEntee to Craigavon Area
Hospital for admission, as opposed to Daisy Hill Hospital;
(b) The communication of information about Mr McEntee to
staff at Craigavon Area Hospital;
(c) The police interaction with Mr McEntee on that date; the
decision making in terms of the use of powers available to
police at that time; what powers were used and what
powers were available; the decision to refer Mr McEntee to
Craigavon Area Hospital for admission as opposed to Daisy
Hill Hospital; what training the officers had received in use
of such powers and policies;
(d) The SHSCT staff decision making, care path determined for
Mr McEntee; the care path options available to Trust staff;
the policies or guidance relied upon;
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