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.

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.’

sad eyed lurcher of the lowlands

It was the dog that brought it back.

I had a sudden and vivid picture of the granddaughter’s English Lurcher, slowly lifting its head out of my bag when I went to fetch my steth. A mournful expression, like it had seen what I had in there and was profoundly disappointed.

As soon as I remembered the dog I had the whole scenario, in every detail: the carers who’d said Edie was off her legs and stuck in the chair; the GP who’d diagnosed an exacerbation of chronic shoulder pain, and prescribed stronger analgesia, referring Edie to us for physio, nursing, equipment, bridging care and whatever else we could think of; Edie herself, slumped over in a high-backed chair watching The Chase on TV; the granddaughter; the dog.

More than anything I remembered how successful the visit had been.

I’d met up with Jason for the double-up. Her obs had been fine, but because of her shoulder pain she’d struggled to push herself up from the chair. The longer she stayed scrunched up like that, the less likely she was to move, until she’d pretty much seized up completely. For a while it had looked as if Edie might have to go to hospital, but with patience, encouragement and some delicate handling, we’d managed to get Edie out of the chair and moving again. We’d put her to bed where she’d be able to rest in a more appropriate position, and mobilise more readily to a commode. It was all fine. The carers would be coming in as before. The stronger meds would ease things along, and a programme of physiotherapy would help Edie recover her strength and confidence. All in all, a very practical and successful intervention.

Which is why I couldn’t understand why Jason was talking about a complaint.

It had come from the daughter, who lived some miles away. Her view was that her mother should have been taken to hospital, or at the very least been given a bed in a rehab facility. According to the daughter we had failed in our duty of care. She had written to her MP. We had a day to write a statement.

‘It’s okay,’ said Jason with a shrug. ‘I don’t think the daughter really understands how things are with her mum. Who knows what the family dynamic is there? Maybe she heard stuck in chair and thought hospital? Never mind. It’ll be fine. We did the right thing.’

I felt aggrieved on Jason’s behalf. I’ve known him ever since I joined the team. An expert physio, he was friendly, positive, empathetic – in fact, a perfect example of what a community therapist should be. I could see him now, taking the whole situation in, crouching beside Edie, one hand on hers, patiently going over the options, how we could help, what we could try. No-one could have done more, and – I don’t think – could have produced such good results. All this at the end of a long and gruelling day. The injustice was crushing.

Jason slapped me on the shoulder and smiled.
‘Cheer up, Jim!’ he said. ‘You remind me of that dog!’

behind the glass

The almshouse cottages are laid out on three sides of an immaculately kept croquet lawn. The white enamel paint is a little chipped on the hoops, showing patches of dark iron underneath. Maybe that’s through being struck with croquet balls over the years, but I’ve never actually seen anyone play. In fact the most life I’ve ever seen on the green is that crow, hopping around in the misty rain like a sexton in a frock coat, his hands under his tails, inspecting the lawn for worms.

Helen won’t be out playing croquet anytime soon, rain or shine. It’s enough of an adventure just making it from the armchair to the bathroom and back. I can imagine she would have been good at it though, sometime before the war, bobbing down to line up the final shot, giving the ball a hearty thwack, snatching off her cap, throwing it in the air, and then jogging over to the judging desk, the croquet mallet balanced on her shoulder. But of course, she wouldn’t have been living in an almshouse then. She would have been in nursing accommodation in London, excitedly practicing the air raid drill, hurrying out to dances, learning her craft.

Seventy years or more have passed since then, and Helen’s world has contracted to the size of a single room. It was small to begin with, but in an effort to stop her from falling the bed has been brought into the living room, leaving just enough room for a commode, a zimmer frame, an armchair and a side table. She still has her shelves of books, of course – one case devoted to Miss Read, whose name is repeated with dizzying regularity up and down the spines – but if you wanted to fetch one out you’d have to move a stack of things first.

Helen has been sitting this whole time with her head resting on the open palm of her right hand. She straightens now and again to look between her daughter Karen and me with an anguished look on her face.
‘I simply don’t understand what it is I have to do,’ she says.
‘You don’t have to do anything, mum. We’re just talking about things we can do to help you get better.’
‘Is it money? I think I have enough. But if you need more I can get another job.’
‘No, mummy. Don’t fret. We’ve got enough money. You’re job is to rest and focus on getting better.’
‘But all these people,’ says Helen, frowning at me. ‘I don’t know who they are or what they want. What do they want, Karen?’
‘They want what’s best for you, mummy. Like we all do. Try not to worry.’
‘But I do worry! I can’t stop worrying!’
Karen goes over to give her mum a hug, but Helen irritably pushes her away and then slumps forward again.

It’s an impossible position for Karen. Not only does she have the grindingly practical business of caring for an elderly mother whilst running a family of her own, she has to do it without the one person she’d naturally have turned to for advice and support, as she did all through her childhood, adolescence and beyond, the single parent who’d trained and worked as a nurse, the woman who’d seen things and suffered things and come out the other side with her hands and her uniform clean, who’d always somehow managed to be just as strong and as resourceful as she needed to be, the woman that was somehow in the room and yet out of it at the same time, as remote as that black and white photograph of a newly qualified nurse in a pristine uniform, sitting with a straight back behind the glass.

‘Anything you could do to help would be great,’ says Karen, smiling weakly at me. Then reaches over to squeeze her mum’s shoulder.

normal on critical

The house has no number, just a name in big white letters above the electric gates that’s either a composite of the people who live there or a tribute to a Klingon commander. I want to ask Ella where it comes from, but she’s so stressed there’s no opportunity. She’s waiting for me outside, still in her slippers, arms folded, glancing up and down the street whilst I lock up the car.
‘Hi Ella. I’m Jim, from the hospital,’ I say walking over.
‘I gathered that.’
‘Are you okay?’
‘No. Not really. Mum’s going downhill and no-one seems to care. Not the doctor, the hospital, no-one. She came to stay with us a couple of weeks ago for respite, and ever since then she’s been wasting away. She’s not eating, she’s not drinking. Crying out with pain all hours of the day and night. Honestly, Jim, I’m at the end of my tether. I just don’t know what to do anymore. I just can’t cope.’
‘I’m sorry to hear that.’
‘She had an appointment at the Elderly Patient Clinic tomorrow but she’s just too unwell. I mean – how was I supposed to get her there?’
‘Well – there’s patient transport. They have a tail-lift on the back of the vehicle. They can take her in a wheelchair.’
‘Can they? No-one told me that. I’d better go and see if they’ll reinstate the appointment…’
She turns and hurries inside, and I follow.
‘Mum’s through there,’ she says. ‘Go and introduce yourself whilst I call the hospital.’

It’s a large, comfortable family house, racks of shoes in the hallway, richly patterned rugs on the floor. Ella’s mum Deidre has her own room, off to the left at the end of the hall. She’s lying in an electric bed with the back raised, propped up on half a dozen pillows and cushions, a warm zebra-striped fleece thrown over the rumpled sheets. When I shake her hand she squeezes it warmly and then resumes her original position, something like wistful forbearance, staring out of the french windows into the garden.
I start by explaining who I am, what my job is and why I’ve been asked to come. She nods, and twiddles her fingers, as if yes, this was exactly as she’d been expecting. I work through my usual questions to see how she is, and to clarify the problem; she answers as if there’s nothing the matter at all, or at least, nothing beyond what you’d expect of a woman of her age. She’s even a little bewildered to hear that people are worried about her.
I check her observations. Everything’s normal, unremarkable. I ask her about her eating and drinking, her bowel habits and so on. Again, she seems fine. She looks fine, too, a healthy colour to her cheeks, decent weight and so on. It’s difficult to see the dangerously ill patient that Ella described, even allowing for the possibility that Deidre is confused about everything. And she certainly doesn’t seem confused.
Ella comes back into the room.
‘They never answer the phone,’ she says. ‘So I left a few messages.’
‘A few?’
‘I kept thinking of other things I wanted to say. How is she?’
‘Well – she seems fine, actually. Sorry to talk about you like this, Deidre.’
‘That’s okay,’ she says, staring out of the window.
‘I’m not surprised,’ says Ella. ‘No-one can ever find anything wrong. They always say the same thing. They always say she’s fitter than they are. But they don’t have to live with her. Sorry mum, but it’s true. They don’t see you when you’re crying out in the middle of the night. The doctor’s bloody useless, excuse my French. The last time he saw her – which is a joke for a start, because he may as well have stood outside with a megaphone – the last time, he just upped her citalopram. But it’s not working and we can’t go on like this.’
‘You said Deidre wasn’t eating or drinking.’
‘Hardly anything. She just picks at her food. And I make all her favourites. I have to nag and nag to get her to eat.’
‘What about drinking? Because that’s more important.’
‘Again, nag, nag, nag. And I hate to do it, because she’s my mum, and I don’t want to go on at her like that. But someone’s got to. The carers don’t.’
‘She has carers?’
‘Three times a day. And all they do is put things in front of her, and clear them away again. That’s no good, is it?’
‘So how much would you say she is managing to drink?’
‘Cups of tea, beakers of juice, fortifying drinks. Everything with a straw, though.’
‘So that sounds – quite good, then.’
‘It may sound good to you but it’s not enough, is it? I mean – look at her…’
And I do, and from her throne of pillows and cushions, she looks comfortably back at me, too.

Deidre hasn’t had any bloods for the past two weeks so I run a set, just to be sure. I put them in as urgent. They come back normal. I ring Ella to let her know, and she tells me that – miracle of miracles – the Elderly Patient clinic has managed to reinstate the appointment.
‘Maybe they’ll find something wrong,’ she says. ‘I mean – something has to happen. Otherwise she’ll die and it’ll be too late.’

watertight

Glenda’s smile is so utilitarian I imagine she keeps it on a hook by the door.
‘Thank you so much for coming,’ she says – then waits in the hall for me to enter.
‘Shall I take my shoes off?’
‘Not many of your colleagues do.’
‘It’s what I do at home,’ I say. ‘It feels weird otherwise’
She watches as I slip them off and line them up with the others.
‘Easy on, easy off!’ I say, although the faux-Cockney falls flat.
Glenda watches me, one hand hooked over the other, a self-conscious and mechanical kind of coupling, like a robot that hasn’t had the soft skills upgrade.
‘What people don’t realise is the toxins they’re tracking through the house if they don’t take them off,’ she says.
‘No. Exactly. And anyway – I like the feel of a wooden floor under my socks. So…’
I wait for her to lead me through to her mother, the patient I’ve come to see, but Glenda stands absolutely still.
‘Take tarmac, for instance. They seal it with a cocktail of chemicals that are severely detrimental to one’s health. The sun comes out, the sealant becomes tacky, it adheres to the underside of the shoe, and you walk it in. Tests have shown the average household dust carries concentrations of harmful toxins such as PAH, which is implicated in respiratory and other illnesses.’
‘I bet.’
‘And then there are the bacteria, of course. E coli. C. diff. Klebsiella’
‘Yes.’
‘Not to mention all the debris and dirt you’d expect to find in the street and the garden.’
‘So – are you a microbiologist or something?’
She flinches.
‘No! I’m a lawyer’
‘Oh.’
I shoulder my bag in a resolute way that’s supposed to indicate I’m ready to move on.
‘You do understand the situation here,’ she says, after a significant pause.
‘Well – I think I do. The basics.’
‘Perhaps I’d better explain,’ she says. I adjust the weight of the bag on my shoulder.
‘My mother is ninety years old, a fully independent person who lives without assistance in a small village in Somerset called Duckton. She was on a visit to us when she became ill with a urinary tract infection, and suffered a minor injury fall, and was taken to hospital, where she spent three days. The hospital deemed her to be medically ready for discharge, on the understanding was that she should have one month of community rehabilitation, with therapy and nursing support, and care three times a day. Which is where you come in.’
‘Okay.’
‘There have been a number of medication changes effected at the hospital, and these have all been ratified by my own GP, who has taken temporary care of my mother whilst she is away from home.’
‘Great.’
‘Now. What I need from you – other than a medical review this morning – is to provide a report detailing all therapeutic programmes undertaken by your department, nursing interventions and so on, and for these to be communicated to my mother’s health authority in Somerset. I want assurances that all possible measures will be taken to maintain her safety when she returns home, provision of all necessary equipments and so on, and continuing care support from agencies in that county. Is that something you can help us with?’
Glenda talks in such a relentlessly steady way that it’s something of a lurch when she stops, like coming down a long flight of stairs and unexpectedly putting your foot down flat.
‘Well…erm… that’s not usually how it works.’
‘Explain to me how it usually works.’
I blush, and cast around for a friendly face. All I can find is a vast, frowning, butterscotch cat staring at me from the cushion of a Windsor chair. It looks so severe I wouldn’t be surprised to see it reach up and place a square of black cotton between its ears.
‘The thing is – Glenda,‘ I say, swallowing drily. ‘We’re an acute team. We get referrals from the doctor, the ambulance or the hospital, and we go in, and we make sure everything’s okay. Nursing, therapy, care or what have you. And when we’re done we refer back to the GP. Or make other referrals for chronic, longer-term needs, to the district nurses and others. And that’s about it.’
She sighs, once, heavily, as if she’d asked for architectural plans and been given sugar paper with a crayon sketch of a house.
‘It’s a question of resources,’ I say, helplessly. ‘A real world thing. We struggle to look after the people who live here, let alone the other side of the country.’
‘As I explained to you,’ she says at last. ‘I’m a lawyer. Now. A piece of paper with a signature on it constitutes a contract. And your service has contracted to provide us with one month of therapeutic, nursing and auxiliary care needs, prior to repatriation.’
‘Has it?’
‘Are you telling me this is not actually the case?’
I pick my bag up.
‘Glenda,’ I say.
She gives a small nod of her head, activating another, thinner smile.
‘I’ve come here this morning to see your mother. To see how she is, do her blood pressure and so on. I have an awful lot of other patients to see today, so I haven’t really got time to talk about the finer points of these things, much as I’d like to. So do you mind if we…?’
The smile flicks off again.
‘For example. If I was buying a boat,’ she says.
‘A boat?’
‘Yes. A boat. There are certain rules pertaining to the transaction that would need to be adhered to in order for that transaction to be properly concluded, to be watertight.’
An anguished voice calls out from the front room.
‘Who’s that at the door, Glenda? Is it the nurse?’
‘Coming!’ I say, shrugging, and holding up my hands. ‘Just losing the shoes…’

waving, and calling

The outside of the building has kept its elegant facade, and the cool black and white tiles of the hallway, the low-hanging chandelier and the multicoloured blaze of the leaded light window are about as perfect as you’d want for a Regency costume drama – so long as you were careful to keep the burnished steel lift out of shot.

The voice on the intercom was pretty direct.
Come inside, get in the lift, don’t touch the buttons.

I do as I’m told, and wait.
Nothing happens.
Did I hear her right? I can’t understand why I shouldn’t press anything. Maybe she thinks I’ll be confused by the mezzanine floors? Maybe when the place was converted into flats there was some architectural kink, and people are always getting lost. I can’t believe it, though. It all seems straightforward.
I wait some more – for what, I’m not sure.
Eventually the lift shudders and I start moving up.

Mrs Rouncewell is there to meet me.
‘Hello!’ I say, slipping off my shoes and then immediately wondering where to leave them.
‘Oh – you don’t have to do that,’ she says, obviously relieved that I have. I put them down as neatly as I can side-by-side beneath the enormous, floor to ceiling artwork that dominates the hallway. We both look at them a moment, in the confused and slightly disappointed way two people visiting an art gallery might look at something they’re not sure is an exhibit or littering.
‘So… what’s with the buttons?’ I say at last, as she leads me through to the lounge.
Mrs Rouncewell gives me a measured smile that I take to mean she’s explained this a few times before.
‘The lift opens directly out into the flat. You have to use a code to make it work, but that’s too difficult to explain over the intercom, so it’s easier just to say don’t touch the buttons.’
‘That explains it!’
‘It’s a security issue.’
‘Unusual.’
‘Unusual? In what way?’
‘Having a lift that opens directly into a flat. I’d never thought about that before.’
‘Yes. Well.’
She waits to see if there’s anything else, then leads me up a short staircase into a gigantic room that must be the footprint of the house, the furthest wall replaced by a panoramic plate glass window, a section of which stands open, revealing an immaculate rooftop garden, bistro table and chairs, and beyond the filigree railings at the edge, a wide city vista of houses and office blocks, all on a shining blue sky.

Her mother is lying in a riser-recliner chair, a halo of fine white hair ruffled by the breeze from the window. She looks comfortable, but her dementia has left her with a flushed and approximate look. She orientates herself to the change in the room like a newly-hatched chick.
‘Hello’ I say, putting my bag and folder down and offering my hand for her to shake. ‘Lovely to meet you.’
She reaches up and takes my hand – then suddenly cups it with both of hers, so strongly it’s quite a shock, and keeps it there, like she’s scared if I let go she’ll rise up and float off through the window, and see the two of us, her daughter and me, hurrying out onto the patio, waving from the railings as she trails helplessly away across the rooftops.
Calling out, maybe.
Waving, and calling.