The deaths of a retired couple who were killed by a man with a severe mental health illness were “entirely preventable”, a coroner has found.

Pensioners Marjorie and Michael Cawdery, both 83, were stabbed to death at their home in Portadown, Co Armagh, on May 26, 2017.

Paranoid schizophrenic Thomas Scott McEntee, who is now aged in his mid-40s, pleaded guilty to manslaughter on the grounds of diminished responsibility and was given a life sentence in June the following year.

Delivering inquest findings at Banbridge courthouse on Wednesday, coroner Maria Dougan said that on the balance of probabilities the deaths could have been avoided if police and health care workers had dealt differently with McEntee in several interactions in the days leading up to the fatal incident.

She identified a series of “omission and missed opportunities” that, if acted on, would have meant McEntee would not have been in the location of the Cawderys’ home on the day he killed them.

The coroner raised particular concern about a police failure to use powers available to them under mental health legislation to take McEntee to a place of safety when they encountered him in the days prior to the killings.

Ms Dougan also said she was not satisfied that all the lessons from the incident had been learned by the Police Service of Northern Ireland (PSNI) and the Belfast and Southern health and social care trusts.

The coroner identified four incidents prior to the killings when McEntee had been displaying signs of mental illness and was involved in interactions with either police or health care staff.

The first was in Belfast city centre and then the Mater Hospital in the city on May 22; the second was at Daisy Hill Hospital in Newry on May 24; the third was the following day in Warrenpoint, Co Down; and fourthly on May 26 at both Daisy Hill Hospital and Craigavon Area Hospital.

McEntee, who was from Kilkeel, Co Down, ultimately absconded from Craigavon Area Hospital and broke into the Cawderys’ home on nearby Upper Ramone Park when they were out shopping.

When they returned to their house, he was still in the property and he killed them.

Mr Cawdery was a retired veterinary surgeon and research pharmacologist.

During his career he had worked for the colonial government of Kenya and Uganda.

Mr Cawdery was a civil servant in the colonial government of Uganda and latterly a company director and housewife.

Sitting here today, on the written and oral evidence before me, I cannot be satisfied, as acknowledged by some witnesses to the inquest, that some of the failings which have been identified would not occur again.

Concluding her lengthy findings, the coroner said: “I find on the balance of probabilities that the deaths of Michael and Marjorie Cowdery on May 26 2017 in their own home were entirely preventable.”

She added: “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 the Police Service of Northern Ireland and staff in the Belfast trust and Southern trust in their contact, care and treatment of Mr McEntee.

“These omissions and missed opportunities, while 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.”

Ms Dougan said the inquest was the most “complex and difficult”, both emotionally and evidentially, she had presided over. She praised the dignity and resilience of the couple’s family throughout the process.

The coroner expressed concerns that lessons had not been sufficiently learned and said she would be sending her findings and recommendations to the PSNI and Stormont’s Department of Health for consideration.

“I commend the large body of work that has been taken forward by the PSNI and the health and social care trusts to date,” she said.

“The litmus test for lessons learned is what would PSNI officers and trust staff do now when faced with the same situation?

“Sitting here today, on the written and oral evidence before me, I cannot be satisfied, 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 continues to endure the pain that the Cawdery family carries.”

I still believe there is no justice when only the ill man is held accountable

The son-in-law of Mr and Mrs Cawdery has said hearing the evidence about their deaths was “brutal and shocking”.

Speaking outside court, Charles Little, who discovered their bodies inside their home, said: “Although we have heard the evidence, going through it again it is still brutal and shocking.

“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.”

Mr Little said the deaths should never have happened.

“I still believe there is no justice when only the ill man is held accountable,” he said.

“As you heard, there was a raft of areas and things which went wrong.

“I am asking the victims of crime commissioner to push for a review of corporate manslaughter, gross negligence manslaughter, misconduct in a public office, all the relevant legislation to take forward and see if there can be reviews of that legislation which can accommodate situations like this and hold people and hold organisations to account.

“The coroner found it to be entirely preventable, it should not have happened, it should never have happened.”

In response to the ruling, PSNI Assistant Chief Constable for Local Policing Bobby Singleton said: “The Police Service of Northern Ireland acknowledges the stark comments of the coroner today, Wednesday 13 December. I am acutely aware that today will have been another very upsetting and difficult day for the Cawdery family and all those affected by this incident.

“The Police Service has, following our own internal review and a Serious Adverse Incident Review conducted by the Health Trust, already taken steps to address identified shortcomings in our handling of incidents linked to the murders of Michael and Marjorie.

“When we receive the full written verdict, which was delivered over four hours today, we will immediately consider the findings and will work with our partners to ensure that any further recommended actions are addressed.”

In statements to the BBC, the Southern health trust said it accepted and will review the coroner’s findings while the Belfast trust said it was committed to learning from them.