character lines

Ellie is a clinician with years of experience in hospitals, hospices and the community. Everything she does comes from a simple love of humanity, in all its mess and interest. And like all people skilled in their art, she practises it with a glorious kind of flow, intuitively adapting her stance to events, almost like a dance, making it look effortless and free. I’ve never seen her lose her temper. I’ve never seen her fail.

Which is why I’m glad we’re visiting Mr Coulsdon together.

There are so many exclamations, warning triangles and block caps on Mr Coulsdon’s record, it would be tidier if they simply replaced them all with a picture of a snarling beast and the words Here be dragons. Mr Coulsdon is notoriously, emphatically, tirelessly bad-tempered – a situation exacerbated by ill health, both mental and physical, of course, and his social situation. But it has to be said the starting point was maybe never that propitious.

Mr Coulsdon’s lounge window is just to the right of the entrance to the block. He has a tatty sheet permanently taped across it, bowed down in the middle. The TV is on full volume – Formula One, by the sound of it. We ring the bell a couple of times, but nothing happens.

‘He’s definitely at risk, so we’d better go in and see he’s okay,’ says Ellie. ‘A quick in and out. I’ll do the obs, you do the typing. How’s that?’
‘Fine by me.’
We let ourselves in using the ‘tradesmen’ button. His flat door is always open – taped up, dented, the scars of many forced entries in the past.

‘Hellooo? Mr Coulsdon? It’s Ellie and Jim – from the hospital. Come to see how you are…’

Other than a plain leather sofa in the far corner, the room is surprisingly, resonantly bare. No carpet, shelves or decorations, no pictures or home comforts. Mr Coulsdon is sitting in the middle of the room in an office chair, his bandaged, ulcerated right leg up on a stool. Just beyond it is the TV, cars screaming round a track. His foot is right in the middle of the screen, and you’d think Mr Coulsdon would angle things – the telly or the foot – so he could get a better view. But it’s hard to shake the idea that like a dodgy off-peak boiler, Mr Coulsdon will find a way of keeping the needle in the red.

‘Mind that!’ he snaps. I’m not sure what he means, because there’s really nothing to mind. ‘These people!’ he says, and links his fingers across his belly.

‘We won’t keep you long’ says Ellie, standing where he can see her, tilting her head on one side as if he’s the most fascinating thing she’s seen so far this morning. ‘How’re you feeling?’
‘How d’ya think I’m feeling?’ he says. Then he flicks me a sly glance and waggles his fingers in the air. ‘With my hands!’
‘Oh – that old chestnut’ says Ellie, putting her bag down. ‘Now then Mr Coulsdon. First things first. Can we turn the TV down a touch, please? Only I can’t hear myself think’
‘Who’s taken the bloody remote?’ he says, scratching his enormous beard as if he thinks it might feasibly be in there. He catches me watching him.
‘What’ve you done with it?’ he snaps.
‘Found it!’ says Ellie, picking it off the floor beside him and flourishing it in the air. The furious yowling of the racing cars eases up.
‘There! That’s better!’
‘For you!’ says Mr Coulsdon. ‘How long’s this nonsense going to take?’
‘Oh not long. Of course – you don’t have to have it at all if you don’t want.’
‘Well I don’t want it! All these people coming round here, messing me about. And nothing ever gets done!’
‘About what?’
‘This!’
‘What – the foot or your flat?’
‘The flat! The flat!’
‘What’s the matter with the flat?’
‘It’s a dump. A trash heap. I wouldn’t keep a dog here.’
‘It looks pretty tidy to me. Do you have people come round to help?’
‘If you can call them people.’
‘Well – look. That’s another matter. I can have a word with one of our social workers about it if you’d like?’
‘Social workers? Scum of the earth.’
‘I’m sorry you feel like that. I think they do a great job under difficult circumstances, Mr Coulsdon.’
‘Do you?’
‘Yes. Absolutely. But look – I’m not here for that. I’m here to do your obs and make sure your leg is okay. That’s it. I won’t if you don’t want me to, but I have to know you understand the consequences of saying no before we leave. Do you follow me?’
‘Jesus Christ! Just get on with it, will you? I haven’t got all day.’
‘All right, then. Thank you. Jim’s here to write the facts and figures down.’
‘Hi’ I say, perching on the edge of the sofa and opening the laptop.
‘I did wonder,’ he sniffs, his chair creaking dangerously as he shifts position. ‘I can see it wasn’t for his looks.’
‘No – you see? That’s what they call character lines,’ I tell him.
‘Oh is that right?’ says Mr Coulsdon. ‘I thought it just meant you were old.’

rosemary & june

Rosemary sits at her kitchen table sipping a cup of coffee.
It was quite a business making it.

‘The pots there! The pots!’ she said, jabbing a bony finger in the general direction of the cluttered work surface.
‘What pots?’
I thought she meant a coffee jar. There was one with tea bags in it, one with sugar and another with receipts and coupons, but no coffee jar.
‘There! Where I’m pointing! Oh for goodness sake! What’s the matter with you?’
And finally I understood. She meant the foil wrapper of plastic coffee containers, the kind that fits over a cup and you fill with hot water. Like mini-percolators. It had been right in front of me all the time, but because it wasn’t what I was expecting, I hadn’t paid it any attention. So anyway – I made her a cup and set it in front of her.
‘That’s absolutely marvellous. Thank you,’ she said.
‘You’re welcome.’

The kitchen isn’t cold, but even so, Rosemary is sitting in a huge puffa jacket that completely swamps her. She’s not wearing anything else, though, other than a pair of Christmas socks with grippy soles and about a hundredweight of rings and bracelets. She has the kind of sharp features and Bloomsbury haughtiness that makes you think of Edith Sitwell or Virginia Woolf. Every time she goes to raise the coffee cup, she gives her right hand a peremptory little shake in the air – like the Queen waving from a carriage – and all the bangles slide down her arm, disappearing under the sleeve of the puffa.

Apart from some meals on wheels she has no carers or domestic help, which is worrying, given her reduced situation. It would have been a beautiful town house half a century ago. Now it’s sadly reduced, with the slumped and rickety feel of a place poised on the edge of serious disrepair. I can imagine it in a few years time, stripped to the bricks, airing out, radio on and a skip in the flattened garden, the snapping of tarpaulin on the stripped roof, whistles, shouts, nail-guns, boots. For now, though, it’s perfectly, eerily quiet, just me, Rosemary and the clicking of the kettle as it cools.
‘Do you have family nearby?’ I ask her.
‘Family? Good God, no!’ she says. ‘I’m ninety-five! No – it’s just me.’
She takes a sip of coffee.
‘And my sister, June, of course,’ she adds, shakily setting the cup down again.
‘Oh! You have a sister? That’s nice!’
‘It isn’t,’ she sniffs. ‘We don’t get on. Now – if you’d kindly finish your examination. And don’t try to kid me. I know all the terminology.’

boomerang

Brenda’s daughter Emma shows me in. She’s polite but thin-lipped, pale and precise, like someone with a hundred other things to do and none of them as stressful.

‘Mum has dementia and doesn’t know it,’ she whispers in the kitchen after letting me in the back door. ‘It’s been getting worse this last year. She’s been found wandering in the street a few times, brought back by neighbours and police. She lives with my brother, Tom, but they don’t get on. Tom had a Jack Russell, Billy. Mum used to look after him when Tom was at work, but she kept tripping over it so we…erm… we made other arrangements.’

It sounds ominous, but I don’t get a chance to ask what she means, because Emma turns and walks through into the lounge.
‘The nurse is here, mum.’
‘Nurse? What nurse?’

Brenda is still sitting in the chair she was helped into by the ambulance when they brought her back from hospital. She’s resolutely straight-backed, like someone who got delivered to the wrong house by mistake and doesn’t feel able to tell anyone.

The way the seats are arranged means that Emma is on the right and I’m on the left, with Brenda the focus of our attention. It’s an unfortunate set-up, the community health version of good cop / bad cop, with me smiling and nodding and making encouraging noises, tapping away on the laptop, and Emma perched quietly on the opposite side, picking her mother off every time she glosses over the facts, which is all the time, of course. Even though I’ve got every sympathy for Emma, still I’d rather she was in another room. I can’t help glancing at the empty dog crate with a photo pillow of a Jack Russell at one end, Billy transmuted from pet to soft furnishing.
‘Where’s Billy?’ says Brenda. ‘I’ll take him for a walk later.’
‘Billy’s gone,’ says Emma.
‘Gone? Wha’d’ya mean, gone? Gone where?’
‘We talked about this, mum He kept pulling you over.’
‘Don’t be so soft.’
‘Don’t worry about Billy, mum. He’s out of the picture. Okay? When you went into hospital. He’s been taken care of. We’re talking about you now.’
‘I don’t care about me.’
Emma sighs. Zips her fleece higher up her neck. Pushes her hands deep into the belly pockets of it.
‘No,’ she says. ‘And that’s the problem.’
‘I’m sure there’s some way you can get to walk…erm… the dog, Brenda. With someone else, maybe? You know? To hang on to?’
I glance at Emma. She closes her eyes and twitches her head from side to side.
I smile and look back at Brenda.

If she heard any of this she doesn’t let on. She’s switched her attention to an old, dented, dark-wood boomerang that’s hanging from a nail on the opposite wall.
‘D’you know what that is?’ she says.
‘A boomerang! Looks like a proper working one. Not the souvenir type.’
‘My father brought that back for me. He was in the merchant marine.’
‘Was he!’
‘Yes. The merchant marine. And he brought that back for me. A lovely boomerang.’
‘Did you ever take it over the fields and throw it?’
Brenda laughs.
‘What? It’ll take the top of your head orf! Like a boiled egg!’
‘I think you’re supposed to catch it.’
‘Are you? Well I’m sure I don’t know’
Emma sighs. When I look at her she raises her eyebrows.
‘Anyway. Let’s get back to seeing how we can help,’ I say.
Brenda looks sad again.
Stares at the dog crate.
‘I think I’ll take Billy out later,’ she says.

mr carrington’s cosy

Talking to Mr Carrington on the phone, I imagine him to be something like Mr Banks from Mary Poppins, sitting in a wing back armchair by an open fire, glass of brandy in one hand, phone in the other, hospital discharge summary on his tartan-rugged lap.
‘It’s the most extraordinary thing’ he says. ‘And to cap it all I have to wear this blasted boot.’
‘I’ll be over in about half an hour.’
‘Splendid! D’you know where I am?’
‘Roughly. How far down is number seventy?’
‘Stand in front of the old pub, turn to your right, stride up the hill three lampposts, turn and fire. Can’t miss.’
‘Great. See you shortly.’
‘Righto. Let yourself in. You’ll find me upstairs. Downstairs is rather out of bounds at the moment.’

* * *

I’m sorry to say that even Mary Poppins, with all her grit and sparkle and domestic magic, would take one look at number seventy, blush and pretend to have an appointment the other side of town.

It’s a deeply unprepossessing row, one house leaning against its neighbour up the hill like drunks on a tipping bench. Number seventy is probably the worst, with its gappy tiles, hanging gutterings, cracked windows, rotten fascias, peeling paint, and a particularly malign-looking buddleia standing like a giant spider by the broken gate, arching its branches over the steps.

I don’t open the door so much as lift it delicately to one side. In front of me is a damp and gloomy hallway, a precipitous flight of stairs.
‘Up here!’ shouts Mr Carrington.
‘Okay…’
The stairs creak and give alarmingly. When I put out a hand to grab the rail, it wobbles with such a wormy shudder I decide to take my chances and pick my way spot to spot with my hands free.

Onto the landing, and another vista of neglect. Whole sections of wallpaper rolling off the walls. A scattering of junk. Skeins of old web. A spotted smell so rich you can hear it muttering.
‘First door on your left,’ says Mr Carrington. ‘If there was a door.’
Astonishingly, someone’s managed to cram a hospital bed into the room, squeezing it in at the only possible angle that could work. Behind it is a bookshelf filled with dusty books and crowned with a leather briefcase that looks like it’s just been fished out of a pond.
‘Good to see you!’ says Mr Carrington.
We shake hands.

If this is Mr Banks, he’s been marooned on an island for a good many years – which I suppose, in a way, he has. His mane of ash gray hair flows into an equally vast beard, so wild I only see he has a mouth when he laughs.

After my examination – which he passes easily, with nothing concerning in any of his observations – I try to talk to him as tactfully as I can about his circumstances, the trip hazards, the damp and so on. Each point he bats away with the practised ease of someone who’s had the same conversation many times before.
‘Don’t worry. I’m quite used to it,’ he says. ‘Honestly. I’m quite happy as things are. Once my foot is better I’ll be able to tootle down the shops as before. So long as someone can fetch me a few essentials in the meantime, I’ll be absolutely fine.’
The room is freezing, though. When I tell him how worried I am about that he laughs.
‘Oh for goodness sake!’ he says, swatting the air between us. ‘I like it cold. Always have. It keeps me sharp! And if I get a bit chilly – well! I’ve got my cosy.’
He roots around under his pillow, produces a filthy hat and pulls it over his head, squashing his hair out to the side.
‘See?’ he says. ‘What d’you think?’
‘Well. It certainly looks – warm.’
‘Exactly!’ says Mr Carrington, snatching it off again, his hair springing back. ‘So there we are, then. Now. Let’s talk about something else. Let’s talk about you.’

the bastard biscuit tin

Henry is remarkably chipper given everything that’s happened over the past month. First there was the high-fall, fractured vertebrae, ribs, haemothorax, concussion; then there was the long-lie before he was discovered by his wife. Unfortunately, it was a busy night and an ambulance couldn’t get to him for an hour. When it did, there was a further delay waiting for backup (Henry’s a large patient; it was a difficult extrication). The hospital was overcrowded (which probably accounted for the delayed ambulance responses), and Henry’s long stay there was complicated by an infection he picked up.
‘By rights I shouldn’t be here,’ he says, wincing as he changes position in the armchair. ‘I’m lucky to be alive.’
‘So how did you fall?’ I ask him.
‘Y’know what? I think I’ll have a leaflet printed so I can hand it out,’ he says. ‘With diagrams and a number you can ring.’
‘Sorry, Henry. I know you must be sick of it all.’
‘It’s okay. I don’t really mind. I’ve been through it so many times now it helps iron out the bad feeling.’
He shifts his weight again.
I move a cushion; adjust the footstool.
When he’s ready he sighs and says: ‘It was that bastard biscuit tin.’
‘What biscuit tin?’
‘The fancy one. Although it’s not so fancy now. It’s got a big, foot-shaped dent in it.’
‘You tripped on a biscuit tin?’
‘Worse than that,’ he says. ‘Did you notice the stairs when you come in?’
‘Kind of.’
‘Did you notice they haven’t got bannisters on the hall side?’
‘No.’
Henry shrugs.
‘It’s funny what you see and what you don’t. They’ve been like that since we moved in twenty year ago. The people we bought the house off took them out to shift some furniture upstairs and never got round to putting them back. I meant to when we moved in, but… y’know.’
‘Absolutely.’
‘We got into the habit of putting stuff on the bottom step to go up or the top to go down. The biscuit tin needed going down, so I put it on the second step from the top – for safety sake, because I didn’t want Agnes tripping over it. And then I forgot all about it. Just lately I’ve been coming down backwards so I can hold onto the rail on the wall-side. Well – my hips a bit dodgy and it was easier that way. So of course I didn’t see the tin. I stepped on it, it flew straight back, and pitched me head first through the gap where the bannisters should’ve been. I landed in the hall just missing the back of my neck, and the rest is history.’
He rubs his neck.
‘As was I, very nearly.’

stepping on a crack

We’ve been told to double-up for this one, so Sasha is sitting in her car outside the hostel, waiting.
‘S’up’ she says, winding down the window.
‘Any sign?’
‘Nope’
‘They said he left the ward by taxi an hour ago.’
Sasha shrugs and puts her phone in her pocket.
‘Well I don’t know what route the taxi took because no-one’s been in or out since I’ve been here,’ she says. ‘and I’ve been here like forever. A proper stakeout. Wha’d’you suppose is in that pan?’
She nods and I turn to look: an orange saucepan on a window ledge outside the building.
‘Dunno. Maybe it caught fire. Why? You can’t be hungry.’
‘Hungry? I’ve been gnawing the steering wheel.’
‘That’s the Christmas effect. Stretches everything.’
‘Tell me about it. I’ve just been googling gastric bands.’
I yawn, look up and down the street.
‘Maybe he got dropped off just before you came, Sash.’
‘All right. I suppose we oughta knock, then.’
She squeezes out of the car, hauls her bags from the boot, and we both go up the stoop to the front door. There’s a carrier bag of empty jam jars on the top step with a note tied to the top.
For Janice.
‘I think they mean Jamice’ says Sasha, pushing the intercom. A dialling tone – then a crackly voice from some remote location.
Scheme manager mouths Sasha, then leans in to the intercom.
‘Hello. It’s the nurses from the hospital. Come to see Frankie.’
The voice says something we can’t understand. A pause, then the door buzzes and I shoulder it open. There’s another, inner security door – and just as I realise we need  buzzing through that, too, the intercom rings off.
Sasha frowns.
‘You’re gonna have to be quicker than that, Jimmy boy’ she says, then goes back out onto the stoop to push the button again. Another wait. The intercom crackles again, but this time the inner door clicks without any words being said.
‘You’ve done this before,’ says Sasha.
What? says the voice.
‘I said we’re in now, thanks very much.’

The lobby has the beaten, low-lit and musty atmosphere of homeless shelters the world over. Some of the doors have numbers, some of them just the ghosts of numbers. Many of them have been kicked-in and repaired, painted and repainted so many times the panels and joints of the wood have a gloopy, approximate look.
Sasha knocks on Frankie’s door. There’s no reply.
‘Did you ring his mobile?’
‘It went to voicemail.’
‘Try again.’
We both hear it ringing from inside the room.
‘So he’s either ignoring us, gone out again and left his phone, or he’s lying on the floor. Either way we’re going to have to do something.’
‘Let’s see if the scheme manager has a key.’
Sasha goes back to the intercom to explain the situation; I put a bag down to stop the inner door closing again, then go back to the steps beside Frankie’s room and knock a few more times, putting my ear to the door to see if I can hear anyone moving.
‘He’ll be over in five minutes,’ says Sasha, coming back. ‘Anything?’
‘Nah. I don’t think he’s in.’

We wait for the scheme manager.
There’s a door marked Private just behind Sasha.
‘What d’you think’s through there?’
‘I dunno. Wonderland.’
Sasha checks her phone again.
‘What are you looking up now?’
‘Places to eat.’

Even though he sounded miles away on the intercom, the scheme manager is with us in five minutes, exactly as he said. Graham completely fills the hallway, so tall and powerfully built I wouldn’t be surprised to hear that his DNA was ten percent viking and fifteen oak.
‘He’ll be in the hospital,’ he says, pulling an enormous fob of keys from his parka pocket and squeezing between us to get to the door.
‘But he’s only just come out!’
Graham looks at me and smiles.
‘I’m guessing you haven’t met Frankie before?’
‘No.’
Graham presses his lips and shakes his head.
‘It’s always the same. They say medically ready for discharge, Frankie hears it as medically ready for drinking. He’ll have got the taxi driver to drop him at the nearest off-licence.’
Graham knocks on the door, calls out, then puts one of his keys in the lock and lets us in.
‘See?’ he says. ‘Empty.’

The room is as squalid as you’d expect. A scattering of filthy clothes, food cartons, random stuff. The bed is rucked up, seamy – bloody, even, the pillows.
‘He fell over and whacked his head,’ says Graham. ‘That’s why he went in this time.’
Frankie’s phone is on the table. Graham picks it up and balances it in his hand like an urban tracker able to tell where the owner was, what they were thinking, where they were heading, simply by the weight.
‘He must’ve come by to pick up some money and left his phone,’ he says, then carefully puts it down again.
‘We’ll follow it up, reschedule and let you know,’ says Sasha.
‘Thanks,’ says Graham. ‘You know – Frankie’s the sweetest guy. Everyone’s done their best, but it’s hopeless, really. He had everything. Great job. Pillar of the community. But something happened somewhere along the line and he drifted off track. Who knows? Whatever it was it’s turned him into the world’s slowest suicide. Anyway! There you are! Thanks for dropping by! And a Happy New Year…!’

He shows us out and waves when we turn to look.

At the bottom of the stoop we pause to let a young family go by: a bearded guy in a red check shirt and Timberland boots, having an earnest discussion on the phone whilst he pushes a baby in a pram, and a tiny boy carefully skips along the pavement beside him.

‘Poor Frankie,’ says Sasha as we watch them. ‘Maybe that was it. Maybe he stepped on a crack.’

the plan

Stress is like bad weather. You could draw isobars on a map. Arrows indicating direction of flow. Cloud banks. Lightning.

The Out of Hours team had taken a stormy call from Graham first thing that morning. He said his mum Sara had effectively been fly-tipped back home, and the promised follow-up from our community health team scheduled for the next day was completely unacceptable.

I didn’t know anything about it, so before I picked up the phone to call Graham back I scrolled through the extensive notes on the system. They described how Sara had been admitted to hospital by ambulance with an infection, then subsequently found to have suffered an ischemic stroke. Unfortunately she still had marked problems with balance and coordination even after thrombolysis, and her speech, memory and mood were also affected. Various treatments and therapies had been started, but Sara had become distressed and unhappy on the ward. Graham attended a multi-disciplinary meeting to weigh-up the benefits of keeping Sara in hospital with the risks of sending her home. Everyone had been in agreement: the plan was to discharge on the understanding it would be bed care only for 48 hours until the community health team could assess and organise the necessary moving and handling equipment. Carers had been arranged to come in four times a day to help with all of this.

A substantial set of notes, but one that demonstrated the lengths the hospital was prepared to go to get Sara back home as safely as possible.

When finally I manage to speak to him, Graham is as cross as the Out of Hours operator had described.

‘I’m not stupid’ he snaps. ‘I know what they’re really worried about. They just want the bed. They couldn’t care less. But what they don’t seem to understand is how much my mum used to do for herself. She was an independent lady. She couldn’t bear to lie around all day. I can’t just leave her there, soiling herself in those pads. I mean – there’s nothing here for her. If I can help her to the commode I will…’

He races on barely pausing to breathe, mixing in the horrors of his mum’s current situation with anecdotes about the bridge club she went to twice a week, the dog, the twins’ birthday coming up, the state of the garden and so on. If I didn’t have the MDT summary in front of me I would never have guessed that Graham had been there at all.

As gently as I can I try to go over the plan as described in the notes. Bed care only, until the community health team can go in the next day to assess all transfers and order up the necessary equipment.
‘It’ll go in as urgent,’ I tell him. ‘We’ll work as quickly as we can.’
‘She’s an active person!’ says Graham.
‘Yes, but then – of course – she’s had this stroke…’
‘All this lying around isn’t good for anybody. She’ll get bed sores. She’ll go mad.’
‘I think the plan is to go steady and build your mum’s strength up gradually. The last thing you want is for her to fall, break something, and go straight back to hospital. It didn’t sound as if she was very happy there.’
‘She wasn’t happy.’
‘No. So look. We’ve got to take things steady and give them time to work. The carers will be coming in through the day and evening. We can organise someone in the middle of the night if that would help, too. We’ll get a therapist in to assess all the manual handling angles, see about a hospital bed and take it from there. How does that sound?’
‘I think if my mum wants to get out of bed I’m not going to sit there and do nothing. I know you don’t like it, but there you are. I’m just being honest. I know what I can and can’t do. And what I can’t do is simply sit there and put my fingers in my ears when she cries out.’

As sympathetically but as clearly as I can I go over the plan again. Graham is too stressed to take it in, though. After I put the phone down I talk it over with my colleagues. We look at the schedule but there’s nothing we can do to bring the manual handling assessment forward. The best we can do is send a nurse in to do a quick review of obs, pressure areas and a welfare check.

I give the nurse a heads-up on the situation; she thanks me with an ironic smile.
‘Why d’you always give me the difficult ones?’ she says.

*

When I see the nurse at the end of the shift I ask her how the review went.
‘Easy,’ she says.
‘Oh? Really? Wow! I’m amazed. Graham was so incredibly stressed on the phone.’
‘Well I wouldn’t know about that,’ says the nurse. ‘There was no-one in. Turns out his mum fell. She’s back in the hospital.’