The grandson of an elderly couple killed by a man with severe mental health issues has said he has been angered to learn their deaths could have been avoided.
Michael and Marjorie Cawdery were attacked in their Portadown home by Thomas McEntee in May 2017.
McEntee, who has paranoid schizophrenia - admitted killing the couple in their Upper Ramore Park home in May last year on the grounds of diminished responsibility and was jailed for a minimum of 10 years last year.
Major concerns were raised over missed opportunities to address his mental health.
Now a new independent investigation by the health board - ordered after the first one was branded a whitewash by the family - has found the death of this couple could have been avoided.
On the morning of the attack on the Cawderys, police received reports that McEntee had been walking naked along the road outside Newry.
He was taken to Craigavon Area hospital in an ambulance, with a police escort, but while waiting to be assessed he got up and left.
A short time later he broke into the Cawdery's home and killed them.
The report published on Wednesday found that McEntee's actions that day occurred in the context of a significant deterioration in his mental health.
It concluded that the deaths could not have been predicted - but could have been avoided.
The couple's teenage grandson Alexander Cawdery, who was one of the first on the scene, has spoken for the first time about the day that changed his life forever.
“At the time it happened I was just going into my GCSEs and ever since then it’s been tough,” he told UTV.
“Angry, very angry indeed. There’s nothing more infuriating than knowing that someone you loved died for an avoidable reason. It’s unacceptable.”
The family has waited for more than two years for the report’s findings.
The family believes that the way the health system deals with mental health patients needs to be completely overhauled.
“It was just absolutely shattering to read it,” Charles Little, the Cawdery’s son-in-law said.
“To know that two people you loved have been slaughtered for no reason, the whole process took two years and two months. Two years and two months to find out what they did wrong.
“They need to start taking mental health care seriously. They are not looking after their patients. That’s why it was avoidable - had they looked after Thomas McEntee as they should have done, our parents would still be alive.”
In a statement the Health and Social Care Board said: “We fully recognise the enormous distress that the families affected by this tragedy have suffered and we would unreservedly apologise for this.
"It is essential we learn from this tragic incident and put steps in place to reduce the risk of the possibility of something similar happening in the future.”
This commitment from the HSC is too late for the Cawdery family, but they hope another family will never have to suffer like them.