a ghost called alf

I’m looking through Judy’s notes, the last time someone listened to her chest. I can’t help laughing.
‘What’s so funny?’ she says.
‘Well – I think the nurse who wrote this must’ve been hungry. She’s written bilateral crepes.’
I show her the little drawing in the notes. The rough sketch of her lungs, a line of little crosses at the bottom of both, an arrow pointing to them.
Judy’s expression doesn’t change.
‘What does that mean?’ she says.
‘It should say creps.’
‘Craps?’
‘Creps. Short for crepitations. I think that’s what it stands for. Anyway, it’s that crackly sound you get sometimes when there’s gunk in the lungs.’
Judy shrugs.
‘I know all about that,’ she says. ‘I’ve had enough of that.’
‘You’re sounding better today, though.’
‘I’m not dead yet, then?’
‘No! Alive and kicking.’
‘I’ll kick you in a minute.’
‘I wouldn’t mind.’
She stares at me.
‘Where are you from?’ she says. ‘Or-stralia?’
‘Australia? No! I was born in London but brought up in the Fens.’
‘Oh,’ she says. ‘That explains it.’
I shut the folder and carry on with the examination.

Judy is ninety-eight but looks older. In fact, with her quilted housecoat, netted, silvery hair, enormous slippers, stiffly jointed movements – the way she wobbles along clinging to a kitchen trolley loaded with toast, Tommy Tippee beaker and emergency button – it feels like I’m in a marionette update of the Red Riding Hood story, where the Big Bad Wolf works for a Community Health Team, and lets himself in with the keysafe.

‘Are you going to be much longer?’ she says.
‘No. Almost done.’
She takes a toot of tea from the beaker.
‘Would you like me to freshen that up for you?’
‘No – thank you,’ she says. ‘I shall need the lavatory.’
There’s a pause whilst I add my notes to the folder.
‘What did you do – before you retired?’ I say.
‘Shorthand typist,’ she says.
‘How lovely!’ I say. ‘I like typing. It’s one of the most useful skills I ever learned. That and driving.’
‘I worked in a brewery,’ she says, moving on. ‘That’s where I met Alf.’
‘Did he work in the office, too?’
‘Nah. He was in and out. But we’d throw things at each other and we sort of went on from there.’
‘Sounds brilliant.’
‘It was hard during the war, though. Terrible hard. There were these Ack Ack guns on the roof. You should’ve heard ‘em when they went off. Boom! Boom! Boom! The whole place shook like it was gonna fall in. They were having a pop at all them German bombers comin’ over. It was a terrible business. Terrible.’
‘How long were you married, Judy?’
‘A long time. So long I couldn’t tell ya. But Alf’s been gone for years now and – well – that’s that.’
‘I’m sorry.’
‘What for? It’s not your fault. Is it?’
‘No. I suppose not.’
‘Well then.’

I put the finishing touches to the notes.

‘Why don’t you go upstairs and have a lie-down if you’re tired?’ she says.
I look up from the folder.
‘Sorry, Judy – what?’
‘Not you,’ she says. ‘Him.’
She narrows her eyes and nods at the empty chair behind me. I turn to look.
‘My old man,’ she says, sighing and leaning back again. ‘If I don’t keep talking to him he might go orf’ with someone else.’

almost done

Eric used to work at Battersea Power Station.
‘I was so tall they used me as a crane, off-loading the trucks,’ he says. ‘Only kidding. I was an electrician.’
‘That’s a cool place to work’ I say, immediately thinking how hot it must’ve been. ‘Iconic. I think it’s luxury flats now.’
‘Well…’ he says, unlacing his huge fingers and holding his hands apart, illustrating with that one, broad gesture the way things go in the world.
Eric’s wife, Georgie, carefully pushes a wheelchair into the room. Even though she’s a few years younger than Eric she’s still in her nineties.
‘Old bones run in the family,’ she says, getting the wheelchair ready. ‘If you can call it running. C’mon, Eric. Chop chop. He wants you on the bed.’
I’ve come to redress Eric’s pressure sore and generally give him the once over. He’s so stiff and frail now it’s like manoeuvring an old longcase clock. It doesn’t help that we’re surrounded by tables of photo frames and ornaments, souvenirs and trophies, the random accumulation of a long and busy life.
‘There!’ says Georgie. ‘Nothing to it!’
Georgie’s tells me as brightly as she can about the nursing homes they’ve been looking at. Eric rolls onto his side and puts the flat of his right hand over his forehead. I can see how painful this is for him, the indignity of strangers coming into the house to perform such intimate functions, the prospect of moving to a nursing home where he’ll be even more dependent.
Suddenly, the light seems to dim in the room, as if there’s been a momentary interruption to the power supply.
‘Oops,’ says Georgie, and then, when it comes back up again: ‘There we are!’
I try to distract him from the task at hand.
‘Were you born here, Eric?’
‘America,’ he says.
‘America? Wow! What happened?’
‘My father was a soldier in the Great War. He fought with the Americans and ended up going over there. To see what it was like. My mother went too of course and that’s where I was born. They did alright I think, but she missed home too much and we all came back. I was only little. And now here we are.’
I’m conscious of the jump he’s just made, and how maybe I should say something about it, about the sudden and dizzying vistas that can open up between the past and the present sometimes. But I can’t think how to put it into words, and anyway, I’ve got to concentrate on the dressing. So all I end up saying is: ‘Almost done.’
Georgie squeezes me on the shoulder.
‘I’ll be out back if you need me,’ she says. ‘I like it when the nurses come. It means I get five minutes to myself.’
And she hurries out of the room.

fifi the owl

Jeremy is busy marching through the house. He has such a neutral style of movement, and his face is so slack and empty, it’s hard not to think of him as some kind of ultra-realistic, domesticated robot. Except, if he was a robot, it would be one that had a serious neural problem, maintaining the impulse to go from A to B, but utterly lacking the ability to make sense of anything when he got there. He marches up to my chair and stands looking down at me. Then without any change of expression he marches back across the room again, opens the door to the kitchen, goes through, and then shuts the door quietly behind him.
‘He’s like this the whole time,’ says Sheila, smiling the kind of resilient smile I imagine her beating from a metal she mined from her soul.
‘It’s really quite exhausting,’ she says, perching on the arm of the sofa, ready to go if needed. ‘It’s alright for Jeremy. He can switch off at three and have a good sleep. I try to get some time in, too, but it’s not the same as proper bedrest. Then you see he’s on the go again through the night. And I must admit I’m starting to feel the strain.’

Jeremy had a fall the other day. The ambulance came and found it was only a minor injury, so he didn’t need to go to hospital.
‘Thank goodness,’ says Sheila. ‘Jeremy in a hospital! Imagine the chaos!’
But the fall seems to have precipitated a realisation that things can’t go on as they have been.
‘I’ve done my best,’ she says. ‘I have two sons, and they’ve both been telling me I’ve got to put him in a home. And – well, I don’t know – it just hasn’t felt right for me. The son in Australia can’t do much to help, of course, but the other one comes down regularly and does what he can to give me a break. We haven’t had carers because – as you can see – he’s perfectly mobile and there’s not much for them to do. I shower him once a week and the rest of the time I’m just chasing him round the house with a sponge. He wears pads, because he’s doubly incontinent, and that’s a terrible problem. But carers? Up until recently I couldn’t see what they could do for us. I don’t want to waste anybody’s time…’

The kitchen door opens and Jeremy walks back through, straight up to the coffee table, where he picks up a magazine, flicks through it urgently, puts it down again, turns, heads back to the kitchen and slowly shuts the door.
‘But now I know I have to put Jeremy in a home,’ she carries on. ‘He’s not safe here, and I’m completely exhausted. I can feel my health beginning to go.’
‘I’m not surprised. I think you’ve done amazingly well to cope this long.’
‘Do you?’ she says. ‘I don’t know. You see – I feel so wretchedly guilty all the time. And the funny thing is, I know that if the situation was reversed, he wouldn’t hesitate. If it was me marching around the place like this, Jeremy would be outside waiting for the ambulance.’
‘Oh. Sorry to hear that.’
She shrugs.
‘You can only ever do what feels right for you,’ she says.

On the other side of the room is a large, red brick fireplace and black slate hearth. All along the mantelpiece, and standing around the hearth, are dozens of stone and ceramic owls. The largest is to the right of the fireplace – a cat-sized modern sculpture, where the owl has been reduced to the minimum details you need to identify it: plump body, pointy ears, engraved lines for the wings, and two deep-drilled and perfectly round holes for the eyes.
‘Do you like my owls?’ says Sheila.
‘I do,’ I tell her. ‘Especially that one.’
‘Fifi?’ says Sheila. ‘Yes. She’s my favourite, too. She keeps an eye on us. She doesn’t miss a trick.’
‘No,’ I say. ‘I can see that.’

the man with all the goals

Melvin answers the door in his pants. He’s quite a sight. Wild white hair sweeping back from his head, a long, ginger-white goatee to match; perfectly round gray-blue eyes, and the kind of ravaged and rangy body you might see trotting alongside your jeep on the Serengeti.
He doesn’t speak. He just stands there, staring at me, one hand on the door, one hand adjusting himself.
‘Hello!’ I say. ‘My name’s Jim. From the Rapid Response Team. I’ve come to see Helen.’
He smiles suddenly, a wide, gummy affair, but makes no other sign that he’s understood what I’ve just said.
‘Here’s my badge’ I say, holding it up.
He glances at it, then carries on staring at me.
‘Is it okay if I come in and see her, d’you think? Helen?’ I pause. ‘Is she in?’
He opens the door wider, still holding on to it, which I take as an invitation to come in. It’s a squeeze to get past him, though, especially with all my bags. The hallway is so tiny there’s barely room for the two of us. I’m expecting Melvin to make some room, but he doesn’t.
‘I’ll take my shoes off,’ I say, struggling in the cramped space. ‘It’s a bit wet outside.’
‘If you don’t mind,’ he says, suddenly animated, as if the last minute or so was just a technical glitch. ‘We’ve had so many people in and out.’
‘No worries,’ I say. ‘I bought these shoes ‘cos they’re easy to slip on and off. There! Good! Okay! So – shall we go through…?’

The sitting room is swelteringly hot. The gas fire’s on all-bars, and the air ripples above a free-standing radiator (all of which explains the pants). Melvin hops over to his chair and goes through an athletic, sitting down routine, involving him taking his weight on his arms, raising his legs, lowering himself slowly, then folding his bony arms and legs and smiling with a self-satisfied leer.
Helen waves me over.
‘Ignore him,’ she says.

The examination is straightforward. Everything’s fine. Helen’s recovering well and she’s happy to be home. I tell her we’ll be discharging her from our service, but that it’s easy for us to come back if anything changes.
Melvin watches the whole procedure with intense interest. Whilst I’m writing up the notes, he starts talking again.
‘I played a lot of football,’ he says, as if I’d asked. ‘A lot of football. But it did my head in. Have you heard that before?’
‘D’you mean sport and head injuries? I think I heard something.’
‘It’s the big leather balls. Laces down the middle. I played centre forward. I was heading it all the time.’
‘I suppose it wouldn’t do your brain much good. All that shaking. Like boxers.’
‘I did boxing, too. And rugby. You bang your head a lot in rugby.’
‘You certainly do.’
‘But football was the main thing. I did all the trials. I played semi-professionally for years. One game I scored eleven goals. This guy comes up to me after, and he says How’d you do it, Melvin? How’d you score all them goals? And I says to him What goals? I don’t know what you mean, mate. The ball comes to me, something happens, it’s in the net. That’s it. It’s a natural thing, like breathing. They sent me to Germany.’
‘Did they?’
‘This German coach, he runs over to me. He leans in … like this … and he wags his finger in my face… like this … and he says You! You’re the man with all the goals. You’re a professional. You shouldn’t be here. So I says to him Mate! What goals? I don’t know what you’re talking about. The ball comes over – it’s on my head – it’s in the net. That’s it. It’s got nothing to do with me.
‘How’d he take it?’
‘How’d who take what?’
‘The German manager. How’d he take hearing about all the goals?’
Melvin shrugs.
‘He could see,’ he says. ‘He knew what he had there.’
‘So then what happened?’
‘I came back, didn’t I? Got a job in a laundry. And here we all are!’
‘Just ignore him,’ says Helen.

at the very top of the street

You wouldn’t think people actually lived on this street. It’s one of the main thoroughfares, an artery of urban bustle, crowds spilling over the pavements day and night, drinking in the pubs and cafes, streaming in or out of the concert venue, staring in the windows of the chi-chi boutiques, taking selfies outside the old theatre, or crowding round the buskers who work the passing trade on the pedestrian cut-throughs. The street heads up at a shallow incline, diverging endlessly left and right, then gradually thins, and quietens, until it runs out of energy at the top, where a main road cuts across it at right angles, running from the station to the sea. Here the shops are more down-at-heel. There’s a second hand camera shop, an antique clothes shop, a tailoring and alteration shop, a shop for rent, all of them weathered and worn, their wooden facades peeling. The person who did the display in the window of the antique clothes shop – how long ago? – has opted for a nightmarishly whimsical look: a stuffed fox head tied into a hacking jacket; some tackle lying around, a few vacant toys, as if they’d given up trying and taken to lure customers in with appalled terror instead. I wonder if there’s anyone in the shop at all. Maybe they’re just behind the netting, holding their breath, staring at me as I cup my hand on the glass to see better.

Mr Lake lives in the flat above the tailoring shop next door. There’s a young woman sitting in the shop window, dreamily needling some trousers draped on her lap. She pauses with the needle in mid-air as I fetch the key from the keysafe and turn to open the side door. I smile and nod but she doesn’t acknowledge me; in fact, I don’t even see her lower the needle as I push the side door open.

The hallway is dark and cramped, the only light coming from a yellowing square of glass at the far end, and a single, winking point of red from the console of the electric scooter on charge. I can’t see a switch for any hall light, and there’s no room for me to put my bag down and find my torch, so instead I wait a minute until my eyes have adjusted, then slowly creep forwards past the scooter and piles of junk, onto the sagging carpet of the stairs, and head up
‘Hello? Mr Lake? It’s Jim – from the hospital.’
There’s a TV playing in one of the rooms overhead, a rowdy studio debate, raucous shouting and applause – which somehow makes the place feel quieter.
‘Hello?’
A toilet with no door on the first little landing, a twist to the left, a galley kitchen on the right with a glimpse of stacked plates and bulging plastic bags, and then up onto the top landing, where a heavy curtain has been nailed across a doorway.
‘Mr Lake?’
I hook the curtain aside.

Mr Lake is sitting on a high-backed chair, surrounded by boxes and cabinets, piles of old Picture Post and Hobbycraft magazines, crates of clocks and teasmades and novelty telephones. It’s difficult enough for me to find a way through all the mess, so I can’t imagine how Mr Lake manages it. But then, no doubt, he’s used to it all and it fits him pretty well, like a hermit crab making its shell from a tin can or a discarded doll’s head.

I’m here to dress a wound on his leg. It’s not easy, setting up a sterile field, though. I have to move a few things.
‘Temporarily!’ I tell him. ‘If I’d had a pound for every time I’d said temporarily….’
‘You’d have five pounds fifty!’ he says.
‘No doubt.’
We chat whilst I set up. He tells me about his life. How he used to be an engineer.
‘I was always good with my hands,’ he says. ‘Taking things apart, putting them back together, that kind of thing.’
‘That’s a great skill to have.’
‘It kept me fed and watered.’

I glove up.
‘Any family in the area…?’ I ask as I lean in to remove the old dressing. The smell is gacky – the cloyingly sweet smell of decay.
‘No. No family,’ he says, watching me drop the filthy dressing into the waste bag. ‘I was married for a while. But she left. Ran off with the best man. And one day he dropped dead at work. So she killed herself.’
‘Oh – I’m sorry,’ I say, changing my gloves. ‘That’s terrible.’
‘Ah. Well,’ he says. ‘She was always a bit up and down.’

When I’ve finished the dressing and I’m ready to go, I notice some framed pictures on the wall behind the TV.
‘Is that you?’ I say, pointing at the picture of a smiling young man in a smart suit and waistcoat, holding a scowling baby up to the camera.
‘No! That’s my mother!’ he says.
‘Your mother? What? This one?’
‘Where are my glasses…?’ says Mr Lake. He grumbles and fumbles around his chair, the glasses magically appear in his hand, he hooks them over his ears, then screws up his face and leans forward.
‘Oh. Yes. You’re right. That’s me,’ he says.
‘Who’s the baby?’
‘That one? No idea.’
Amongst all the other portraits is one of a young woman in a floppy white hat and wide-collared raincoat. It’s a posed, three-quarter shot, the woman staring sleepily off to the right, her eyes heavy, her mouth slightly open. The odd thing is, she has her right hand raised in mid-air, palm down, off to the side at shoulder height, as if she’s pushing through invisible undergrowth, or maybe working a marionette whose strings she’d dropped but didn’t think anyone would notice.
‘That’s her,’ says Mr Lake. ‘That’s my wife. She made that coat. The day I took the photo we’d gone out for something to eat. We were sitting in the cafe, and the owner of a fancy boutique came over, and he said Where did you get that coat? And she said I made it. So he said Why don’t you come and work for me! We need people like you.
‘And did she?’
‘No,’ says Mr Lake. ‘She didn’t.’

calamity june

I ring Albert to ask if it’s okay to come round and see him. When he picks up I wait for him to say hello or something; when he doesn’t, I say hello instead – but then he talks over me, pretending to be an answer machine:
I’m sorry we’re not here to take your call, but quite frankly, we couldn’t be arsed. So if you’d like to leave your name and number and what you had for breakfast, then – please – do that, but don’t hold your breath for a reply, because quite honestly you’re not going to get one. Thank you very much, and goodbye…
I hear his wife June in the background saying Who is it, Albert? – a scuffling sound as the phone gets handed over – then: Hello? Who IS this?
‘Hi June. It’s Jim, from the hospital. I came round to see Albert the other day.’
‘Yes. Hello. Sorry about that. Albert does like to muck about.’
‘He probably thought it was a nuisance call. The number comes up as private.’
‘We get a lot of that.’
‘Me too.’
‘So what do you want?’
‘Is it alright if I come over and do Albert’s blood pressure again? The GP wanted a few days’ worth…’
‘That’s fine. Come over. It’s not as if we’re going anywhere.’

*

‘Sorry about earlier,’ says Albert, answering the door and shaking my hand. ‘I get a bit carried away sometimes.’
June is standing behind him, leaning against the doorway to the kitchen, wiping her hands on a tea towel.
‘I wish you would get carried away,’ she says.
‘Hark at that’ says Albert.
‘Well I thought it was great!’ I tell them both. ‘I always swear I’ll say something clever or weird next time we get a nuisance call, but of course I never do. I always end up saying Please don’t ring here again. Which is so pathetic it practically guarantees they will.’
‘I’ve had a lot of practice,’ says Albert. ‘I’ve always been a bit of a clown.’
‘Is that what you call it?’ says June.
Albert shakes his head, then turns and walks unsteadily to his favourite chair, lowering himself into it with exaggerated care. June follows behind, perching herself on the arm of the settee opposite, whipping the tea towel over her shoulder, then folding her arms. It’s difficult to figure June out. She doesn’t smile easily, and when she speaks it’s clipped and to the point. It’s understandable, though. The strain must be awful.
Albert and June are a retired couple in their late seventies. June is as fit as you could hope to be – as rootin’ tootin’ as Doris Day in Calamity Jane – but Albert looks twenty years older. He has a palliative cancer diagnosis, and he’s becoming frailer day by day. Symptomatically Albert’s steady, functioning at a reasonable level, the pain controlled pretty well, but the prognosis is bleak. It’s impossible to say when he’ll enter the End of Life phase. One month, six months, a year, two…. I’m not surprised June has her pistols drawn.

I run through the observations. At every point, Albert makes a joke. When I put the tympanic thermometer in his ear (The light’ll come straight out the other side); when I count his pulse (So I’m not dead yet?); when I pump up the cuff to do his blood pressure (Jesus Christ! You’ll have my arm off at this rate); when I scratch his finger for his blood sugar (That’s very nearly an armful).
June sighs heavily each time.
‘Just let him do his job,’ she says.
‘There! All done!’ I say, packing my stuff away.
‘A-one back to the front!’ says Albert.
June fold the tea towel into a square and smooths it flat on her knee.

When I’m ready to go, Albert insists on seeing me to the door. When he gets there, he turns and leans against it.
‘Can you give me some advice?’ he says.
‘Of course. What about?’
‘I don’t want my family coming round any more.’
‘Why?’
His chin starts to tremble. He takes a breath to steady himself, then raps his stick on the carpet a couple of times, summoning the will to speak.
‘I don’t want them seeing me go like this,’ he says. ‘I want them to remember me as I was. So what would you suggest I do about that, hmm?’
‘It’s hard,’ I say. ‘I know what you mean. But I think anyone who loves you would want to see as much of you as they could. I know I would. I think they’d find it hard staying away.’
‘Well. There we are,’ he says. ‘Thank you.’
I give his shoulder a squeeze.
‘Come and sit back down, Albert. I worry about you.’
‘I’ll be alright. I’ll keep on my feet if you don’t mind.’
‘Okay then. You take care. I’ll let the GP know what your facts and figures are.’
‘Thirty-eight, twenty-four, thirty-six,’ he says, then takes out a hankie and blows his nose.
June comes over and leads him back to his chair.
‘Close the door on your way out,’ she says.

the works

There’s a builder’s truck blocking the mews. It’s up on hydraulic stabilisers as the driver operates the winch, dropping off enormous bags of sand and gravel, the engine labouring as the next load gets taken up, the back of the truck lurching with the sudden change of weight. I can’t imagine what building project would require such a massive delivery – maybe one of those basement excavations you read about, an underground pool and cinema and gym, perhaps. A lift shaft to a cocktail bar and viewing platform at the earth’s core. Whatever the reason, the contrast with the ancient backstreet couldn’t be more extreme. Two hundred years ago these would have been a row of stables with offices, lofts and basic accommodation above; now they’re a mixture of chi-chi businesses, full-scale conversions, and the cobbled street curves down right and left not to straw and manure-heaped gutters but expensive planters, artisanal signs and cutely painted old bikes with geraniums in the basket.

We’ve had to park at the far end by the equipment van that’s here to deliver a hospital bed. They could only have beaten us by fifteen minutes and yet they’re already half-way through. Once again I’m in awe of their efficiency and sheer work ethic, like scaled-up ants in yellow jackets. A hospital bed is no light thing. It comes in sections, of course, but the main frame is pretty heavy. A feature of the flats in these mews is a steep and narrow staircase running straight up from the front door – no doubt originally to a hay loft. To make things even more awkward, the house we’re visiting has a stair lift, so really there’s hardly any room at all to get the bed in. When we stroll up, though, they’ve already got the frame delivered, and all that’s left are the mattress, a cantilever table and a few other bits and pieces.
‘What did you do – commandeer the truck?’ I say to one of them, who is so red-faced I want to lean in and loosen his collar.
He laughs, slicks his antennae back.
‘Maybe you could take the table?’ he says.

The whole thing is something of a rush job. The GP had visited George late last night. George is a ninety-five year old man with a recent palliative diagnosis who has declined rapidly and unexpectedly straight into an End of Life scenario. He was refusing hospital, so the GP had prescribed anticipatory meds, made referrals to the District Nurse and Palliative teams, and to us for urgent review first thing in the morning. Katrina had gone straight there from home and was busy by eight. By nine she’d phoned in to make her report: it was bed care only, so George needed a hospital bed with pressure mattress and slide sheet to be delivered the same day, with someone to be there to help with a pat slide; George needed care support four times a day, double-up; he needed pads, pressure cream, foam lollipops for mouth care – the works. I said I could meet Katrina there at lunchtime to get the whole thing done.

George’s wife Valerie greets us at the top of the stairs.
‘Forgive my hair,’ she says, patting it. ‘I must look a fright. But as you can imagine I’ve had quite a night.’
Both Valerie and the flat have the shocked look of something hit by lightning. Everything is essentially as it was – the pictures, the chairs, the collections of antique pill boxes and books, the Moroccan rugs and tables and lamps, the family pictures on the walls – everything so perfectly placed and orderly the housekeeper must have a tape measure in their pocket. But the furthest end of the flat – the main bedroom end – has a sprawled, disrupted appearance, with a wreckage of discarded packaging, plastic strapping and so on spilling across the hallway, whilst through the open door the sound of construction and the movement of heavy furniture adds to the feeling of emergency. The noise from the builder’s truck outside sounds like a fire engine.
‘What a business!’ says Valerie. ‘But you know, everyone’s been so kind. We really are most grateful.’

There’s a large tabby cat staring at me from the middle of the living room rug. It’s as perfectly groomed as Valerie, and I half-expect it to reach up with a paw and pat itself delicately on the head, as she did.
‘Grammaticus is very put out,’ says Valerie, walking over to him. ‘He’s nineteen, you know? Like us – old and worn out. He can’t tolerate the fuss.’
She bends down stiffly and painfully, scooping him up to cradle him in her arms, just exactly as you would a baby, pressing her nose to the top of his head, rocking him up and down, swinging her hips a little from side to side. He maintains his stare, making little adjustments to accommodate the motion.
‘He looks good for his age,’ I say.
‘Do you think?’ she says. Then – still rocking the cat – she looks off towards the window. Down in the street, the noise from the builder’s lorry has eased. It sounds as if all the deliveries might have finished, and instead there are shouts and raucous laughter, the plaintive whining of hydraulic legs being lifted, the off-kilter clattering of a concrete mixer.
‘Good God,’ says Valerie. ‘When will it all end?’

large caliber

‘Shall I take my shoes off?’
‘Oh no!’ says Rita. ‘This is a real home – not a show home!’
I’m conscious that my shoes are sopping wet, though, so I slip them off anyway.
‘I do it at home’ I say. ‘I’d feel bad otherwise.’
‘This is a real home, not a show home!’ she says, repeating herself – whether because it’s a catchphrase of hers, or because she likes the sound of it, I’m not sure.
‘Follow me!’ she says, and leads me through the house.
It certainly has the feel of a show home. Or even a gallery, given the number of paintings of stags on snowy crags and jugged hares lying among bunches of grapes, all in heavy gilt frames. Ernest, Rita’s husband, sits in a chair at the far end of the house, like a decrepit attendant who dozed through his lunch break and on into his nineties.
‘Darling? There’s a nurse to see you!’ says Rita. She waves me over to him, then lowers herself very correctly, debutante-style, into a Louis Quinze chair, her legs angled to the right, her hands folded in her lap.
‘What happened to your shoes?’ says Ernie, peering at me over his glasses.
‘They were soaking wet. I didn’t want to make a mess on your carpet.’
‘I said to him, darling,’ says Rita. ‘I said to him: This is a real home. Not a show home!’
‘Hear that?’ he says. ‘So now you know.’

* * *

All Ernest’s observations are within normal range – his blood pressure, temperature, heart rate and so on..
‘What were you expecting?’ he says. ‘I’m perfectly fine. It’s this damned back.’
‘Let the gentleman do his job, darling,’ says Rita, absentmindedly playing with her wedding ring, slipping it off, then on, then off again. ‘He used to be a sniper, you know. In the war, of course,’ she adds, hurriedly, to clear up any misunderstanding.
‘A sniper?’
‘What of it?’ he snaps.
‘No. Nothing. It sounds fascinating.’
‘Hmm,’ he says, and watches me closely as I fill out his obs chart. To cover the silence – and to find out more about his sniper years – I dig deep for some personal story I could use.
‘I had a go at skeet shooting once,’ I say. ‘It was a work’s outing. I really liked it.’
‘Skeet shooting?’
‘Yes. Clay pigeons.’
‘I know what skeet shooting is.’
‘It was really good! That bit where they chuck the clays along the ground, and they bounce around all over the place. That was fun. You know. Picking them off.’
‘Fun?’ says Ernest, horrified. ‘Fun? If by fun you mean waving your weapon around like a lunatic, blasting in the general direction of where you think something’s going to end up, well, then, perhaps. But I’m not talking about some random spread of pellets. I’m talking about the precise placing of a single, large caliber bullet. I’m talking about controlling one’s breathing, slowing one’s pulse. Taking a clean shot.’
And he glares at me over his glasses again, eyebrows quivering, drawing a bead.
‘It’s my second marriage’ says Rita. ‘Would you like a cup of tea?’

the white handkerchief

As diagnoses go, it sounds pretty gentle. Mixed Dementia. Like a mixed fruit salad. Mixed bathing. A bag of mixed nuts. Casual, essentially benign.

There’s nothing benign about Mixed Dementia, though. Its devastating effects would be more aptly described as Dementia Plus, or maybe Dementia: Perfect Storm.

Joe has Mixed Dementia. To date he hasn’t been too bad, functioning at a reasonable level. Although he’s permanently confused, he tends not to get agitated. Most of the time he sits neutrally and quietly in his favourite armchair, going along with whatever his wife Joan wants him to do. He’s been able to mobilise reasonably well, steady enough on his pins for Joan to manage washing and dressing him on her own. He’s barely on any medication, so that’s not been too much of a problem either.

Unfortunately – for Joe, Joan and the rest of the family – his condition has taken a downturn, particularly his mobility. There’s a Parkinsonian aspect to it these last few weeks. He lists alarmingly to the left when he stands up, leans back to compensate, and if that wasn’t enough, his left leg gets stuck when he tries to move forwards. The result is that Joe’s been falling every day. Luckily for Joe he’s avoided hurting himself; unluckily for Joan, he landed on her a couple of weeks back and fractured some ribs.

The last fall was this morning. An ambulance attended, checked him over. His obs were as steady as ever. (‘He’s fitter than me’ says Joan, dabbing at her eyes with the white handkerchief embroidered with flowers she’s been playing with all this time. ‘Aren’t you darling?’ – Joe directs his grey-blue vacancy in her general direction; they share a hesitant smile; she loses herself in the handkerchief again). There wasn’t anything acute that needed hospital admission. The ambulance crew liaised with the GP, and then the GP referred Joe to us to see what we could do.

The obvious and most immediate thing is to get Joe a respite bed in a nursing home. The trouble is (always the rider these days), he needs an assessment by social workers first. They’re short-staffed, so a delay of a few days even for priority cases is unavoidable. Then, as Claire the duty social worker explains to me, there may not be any beds available. ‘Not much capacity in the system at the moment,’ she says. ‘Best case scenario – a week, maybe two.’
She sounds exhausted.

I’ve spoken to the GP. He tells me there’s been a multi-disciplinary meeting (the outcome of which hasn’t been communicated to the family yet, helpfully). The consensus is that Joe’s mobility problems are symptomatic of his worsening dementia. ‘It’s a palliative scenario,’ says the doctor. ‘And really, if his care is no longer tenable at home, we’ll have to start looking for a residential placement somewhere. We just need time to make that happen.’ We agree that our service can try setting up a micro environment to minimise the falls risk; to send in carers four times a day – for moral support if nothing else; a night-sitter at night to give Joan a break; nurses to keep an eye on things, and generally case-manage until the social workers can come up with a placement.

I’ve put this plan to the family. It hasn’t gone down well.

‘Look at us! We’re at breaking point. Honestly – this is hell,’ says Emma, the daughter. Her face is puffy and her eyes red. She’s struggling not to cry, especially now that Joan has her face buried in the handkerchief. ‘Look at her!’ she says. ‘She’s done her best but she’s at her wits’ end! We can’t go on like this.’

As gently as I can I go over the options, which at this point seem to boil down to two: stay at home with whatever support we can offer, buying the social workers time to find a residential placement, or go to hospital.

‘And sit around in A and E for hours?’
‘I’m afraid so. That’s where everything’s triaged.’
Emma looks at her mum.
‘This is what you get,’ she says, bitterly. ‘You struggle through. You take care of things as best you can. And no-one cares. No-one’s there for you. Maybe Dad needs to have a bad fall and really hurt himself, and then maybe someone’ll listen.’
‘I don’t want Joe to go to hospital, but I can’t cope with him anymore at home,’ says Joan. She gives me a despairing look. ‘What would you do if this was your dad?’
‘I don’t know. I’d try to think what was best. It’s hard to say.’
She sighs, then directs her attention back to the handkerchief.
‘What would you like to happen, Joe?’ I say, leaning forward and stroking his hand. He says a few random words, but it’s impossible to know what he means. His tone is light and disengaged. At least he’s spared the emotional trauma of all this.

I’ve been here two hours already. I’ve spoken to the social workers, the GP, the nurse in charge back at the hospital, but despite all the facts, all the reassurances and negotiations, the essential problem remains.
‘Okay,’ I say. ‘I’m sorry this has been so difficult for you. Something needs to happen now, so let me make the decision for you. Joe isn’t safe here at home. He’s highly likely to fall again, regardless of the things we might manage to put in place. I can see how exhausted you both are. It’s a terribly stressful time and I think you’ve done a wonderful job. Going to hospital isn’t ideal, but it’s the safest option. I’m going to call for an ambulance to take Joe to hospital on a four hour response. At the very least that’ll buy everyone some time to rest and get things sorted. Okay?’
I pick the phone up to dial.
‘Is the patient conscious and breathing?’ says the call taker.
‘Yes,’ I say, smiling at Joe.

Joan buries her face in the handkerchief again.

a tough gig

Turns out, Miriam’s down to Assist the Co-ordinator this morning. She waves me over as I pass through the office, scattering good mornings as methodically and benignly as an Amish farmer sowing corn.
‘They’ve put me down to do an early care call as well,’ she says, looking flushed. ‘I mean – I’m good, but I’m not that good. I can’t be in two places at once! Everyone else is full, so it looks like only me or you that can do it. I’m more than happy to go if you want to hold the fort here a couple of hours… just as happy if you want to take the job… totally up to you. What do you think?’

The truth? I don’t need to think, but I make a polite show of it. Assisting the Co-ordinator sounds easy enough but it’s actually a pretty tough gig. It doesn’t matter how resolved you are at the start to be organised and Zen Master about the whole thing, barely half an hour later you’ll find yourself with a mobile clamped to one ear, a landline playing loud psycho-electro on-hold music in the other, three people hovering close by, checking their watches, stress-paddling foot to foot, someone else waving a piece of paper over in the Hub…. and then you’ll sigh, and hang up the landline, take a swig of coffee instead, and find it’s grown a skin.
‘It’s okay. I’ll do it,’ I tell her.
‘Are you sure?’ Miriam says, a desperate look in her eye.
‘Don’t worry. Happy to help.’
I take the details.

It sounds straightforward. Charles is an elderly patient who’s going into respite for a few weeks to give his wife June a break. He needs a care call first thing to help him get ready for collection by ambulance. As soon as I’ve picked up my other jobs for the morning, I ring their number. It goes to voicemail. I leave a message to apologise for the early call, and to say not to worry because I’m on my way and I’ll be there by half past eight at the latest.

It’s a bright, zesty drive out to their address, a neat red-bricked block on the outskirts of town. There’s a truck parked outside. Three workmen are busy putting scaffolding up, making a stunning amount of noise – pneumatic drills, banging, shouting, laughing, a radio on full volume in the cab. The workman at the top of the scaffolding, hanging on by one hand, actually throws back his head and howls. It’s all so loud and violent, even though I press my ear to the intercom I can’t hear what June says. The door clicks regardless. I go in.

The thickly carpeted hallway is so quiet by comparison with the racket outside my ears actually whine. I walk up three flights of stairs, then knock. After a long pause, June opens it. She’s tiny, frail as an old sparrow in a housecoat and slippers, blinking at me with her head slightly to one side whilst still holding on to the door.
‘Can I help you?’ she says.
‘Oh!’ I say. ‘Good morning. I hope I’ve got the right address. I’m Jim, from the Rapid Response team. I’ve come to see Charles.’
‘Charles?’
She stiffens even more, glances down at my ID badge.
‘To get him ready,’ I say.
‘What do you mean? Get him ready? What for? Who are you again?’
‘Jim. I’m a nursing assistant. From the Rapid Response.’
‘I’m sorry but I think there’s been some mistake.’
‘They asked me to come and help Charles get dressed. Before the ambulance arrives.’
‘I don’t think the ambulance will be coming,’ she says.
‘No?’
‘No. I wouldn’t think so. I’m sorry, but I think you’ve had a wasted journey. Did the nurses not tell you?’
‘What nurses?’
‘The nurses who were with us all last night. When Charles died.’
‘I’m so sorry.’
She stares at me, blinking rapidly.
‘Yes. Well,’ she says.
‘And – how are you – bearing up?’ I say, pathetically.
‘It’s early yet,’ she says. ‘But I’ll be fine. I’m sorry you came all this way.’
‘No, no! I’m sorry to turn up like this. That’s awful. I’ll make sure everyone else knows.’
‘Could you?’ she says. ‘That would be kind. Well – goodbye, then.’
And she quietly closes the door.

Outside the workmen are as furious as before. The one who was howling at the top on my way in is now leaning right out, shouting for a particular clamp.
‘Not the three four, you wingnut! The five n’alf! Ye-es! That one, Rodney! That one! Jesus Christ!’
It gets chucked up to him, and he catches it just as it slows, ready to fall back to earth.
‘Halle-fucken-lujah!’ he says, then swinging round again, gets back to his hammering.