A man who fatally stabbed an elderly couple sought treatment for his mental health problems at the hospital twice in the days before the attack, according to evidence presented at the inquest.
On May 24, 2017, Thomas Scott McEntee visited Daisy Hill Hospital twice. Two days later, he attacked 83-year-olds Michael and Marjorie Cawdery.
At their Portadown, County Armagh, residence, McEntee stabbed the couple.
Schizophrenia with paranoid symptoms affected him.
He has received a minimum 10-year prison term.
The Southern Trust's Daisy Hill mental health clinic was visited by McEntee, of Kilkeel, County Down, without an appointment on Wednesday, the court was informed. He requested medication.
The Home Treatment Crisis Response Team was contacted because McEntee's medical history was not listed in the Southern Trust database.
The team's six hospital-based members were all on client calls at the time.
The court was informed that some were unreachable as a result of the area's poor mobile phone coverage.
A receptionist testified at the inquest that it had taken 45 minutes to reach any team members.
At first, McEntee consented to delay his arrival until a team member could make it back to Newry to meet him.
But at 16:30 BST, having waited roughly an hour and a half, he left. No medical experts had ever examined him.
Four hours later, he visited the hospital once more. This time, he visited the emergency room.
There, a junior doctor testified in court that the man had claimed to have self-harmed and that his mental health had suddenly deteriorated in the previous few days.
He claimed he had previously lived in Londonderry and that the Mental Health Team there would be aware of his past. He claimed that he had missed three days' worth of medication before visiting the emergency room.
McEntee told the doctor that he would be unable to keep himself safe if released because of his "life not worth living thoughts," which the doctor claimed he had. .
The doctor called Craigavon Hospital's senior mental health nurse and spoke with someone on the Mental Health Team.
Due to a lack of medical records at the Southern Trust, he promised to get in touch with the Western Trust, where McEntee had been receiving care, and get back to her.
The doctor testified before the court that she thought McEntee needed a mental health evaluation because she had self-harmed that day and had expressed suicidal thoughts.
When the mental health team at Craigavon returned her call, she was informed that the patient did not require an assessment because his "life not worth living thoughts" were persistent and related to his disorder and that he could be released; the team would get in touch with him the following morning.
The physician answered "yes" when asked if she believed an evaluation was necessary.
She responded that she believed the mental health senior nurse had used "experience and expertise to make that judgment" in response to the coroner's question about whether she had resisted or debated the choice.
She claimed that she was the one who made the referral and that she thought the mental health nurse's choice had been made with the help of information from the Western Trust and more professional experience.
Thomas McEntee was released from the hospital with the instruction that the next day, the crisis team would contact him if he called the emergency room and left a phone number.
After a social worker secured overnight housing for the homeless at a nearby hotel, he left. He lacked a phone.
A section of the Mental Health Risk Assessment form that required a doctor to fill out was not known to the ED doctor on call, it was also revealed in court.
McEntee would have been classified as a medium risk patient and could not have been released without an assessment, according to the Cawdery family's legal representative, if the form had been correctly completed.
According to the Home Treatment Crisis Response Team's lead mental health nurse, the system "did not work as well as it should have.".
According to him, new procedures allow for the contact of a shift coordinator in the event that all team members are on calls. Clients will be seen more quickly as a result.
In order to address the problem of weak mobile signal reception in south Armagh and Mourne, a new paging system is also being implemented.
The investigation is ongoing.
