where’s pepper?

If I hadn’t looked at the notes and seen it written in black and white that an ambulance had been called and taken Maria into hospital where she’d stayed a few days, I’d swear she hadn’t moved since the last time I saw her. The only difference is that her little dog Pepper isn’t leaping around the place in a twitching fury, wondering whether to bite me or throw himself through the window.
‘Where’s Pepper?’ I ask her.
‘He’s sleeping next door with Theo,’ she says. ‘They’re both exhausted. We were all up late last night. Theo came round, for a social. He only popped in to say hello ‘cos I was back and everything, and he ended up staying all night.’
There’s half a chicken leg on the ash strewn table in front of her. ‘I’m sharing that with Pepper,’ she says, as if I’m hungry and on the take. She hides it under some newspaper.

Walking down into Maria’s basement flat is like walking down steps into an Egyptian excavation – except, this isn’t the lavish tomb of a pharaoh, filled with gorgeous sarcophagi, wrapped cats, miniature wooden carts and dishes of carbonised grain. This is the urban degradation version, piles of red reminders, missed hospital appointments, bags of medication, discarded asthma pumps, magazines, grimy throws and crochet blankets, inco sheets, elbow crutches. And the door isn’t protected by an unbroken seal and a curse, but a CCTV camera, securely wedged into the top corner of the hallway like a nuclear bunker for a spider.

I’ve been in to see Maria a few times before. There’s always someone sleeping in the next room. Sometimes it’s Theo, sometimes it’s Clancy, sometimes Giles (none of them sounding like real names at all). But it’s only now I’ve been given the heads up about what’s really going on.

The scheme manager had sounded annoyed on the phone.
‘She’s breaking the terms of the tenancy,’ he’d said. ‘We’ve got vulnerable people living in that place. This can’t be allowed to go on.’
‘What’s going on exactly?’
‘She’s being cuckoo’d.’
‘You know – when someone moves in and takes advantage. Except it’s a little complicated in Maria’s case, because I think she likes the company.’
‘D’you mean Theo and Clancy and the rest?’
‘Whatever they’re calling themselves. They’re using her flat to sell and smoke drugs, heroin mostly, but other stuff, too. The police have thrown them out of there before. There shouldn’t be anyone else staying. We’re trying to get an injunction to stick on the grounds that she’s breaking the terms of her agreement, but these things are always more tricky than they sound. She’s definitely got capacity. But she’s a vulnerable person, though. No question.’
‘Do you think it’s safe for carers to go in? Because Maria is pretty self-neglectful.’
‘I would think so. I mean – it’s not the nicest environment in the world. But during the day it’s fairly safe with regards to ne’er do wells hanging around. And if they are around they’re unconscious.’
‘Not terribly reassuring.’
‘No. But what can you do. I know it sounds harsh, but I’d like to forcibly take Maria out of there, find her somewhere secure, out of the reach of these people, and then maybe she’d come to see how awful they really are. At the minute, they buy her food and keep her company, and I suppose that’s something. If only they wouldn’t deal drugs, though. Or keep a dog. Pets aren’t allowed.’

I decide to be perfectly open with Maria about the concerns that have been expressed about Theo and the rest.
‘I’m always perfectly open and straight with people because I think in the end that’s the best way,’ I say, by way of introduction. Maria looks worried.
‘It’s about Theo, isn’t it?’ she says.
‘Yes. There’ve been reports that Theo and some of the others are smoking heroin and using you and your flat for a base.’
She’s instantly furious. I’m amazed that Pepper hasn’t rushed in to see what the matter is, and can only think he’s in an opiate haze as well.
‘I know what’s happened!’ she says. ‘And it’s not what you think. There was a man round here a few months ago. Xavier his name was. Said he was my friend and everything, but turns out he wasn’t. Oh no! Tried to sell my dog at one point. So Theo turned up and kicked him out, and now Xavier’s got the hump, going around telling everyone lies about what goes on round here.’
‘He tried to sell Pepper?’
‘Yeah! To Theo. That’s the kind of low life he is! I mean – who’d sell someone else’s dog?’

in the house of alma

‘How much do you know about – the situation?’
Charlotte is standing with me and my colleague Olufemi where we agreed to rendezvous outside the house. She seems anxious, her long blond hair tied back in a purposeful ponytail, her eyes drawn and tired.
‘Not much, only that Alma has been going downhill a bit lately, at risk of self-neglect.’
‘If it wasn’t for me she would’ve died already – sorry to be so blunt.’
‘No. That’s okay. It’s good to be clear.’
Charlotte unconsciously moves Alma’s keys from hand to hand, as if they’re too hot to hold for long.
‘The fact is we’re moving,’ she says. ‘And I’ve no idea what’ll happen when we’re gone.’
‘Does she have family?’
‘No. A niece somewhere. I’ve never seen her.’
‘That is a pity,’ says Olufemi. ‘That is sad for the lady.’
‘What about carers?’
‘You’re looking at her. Not that I meant to do it, or even wanted to, really. But what can you do? I used to be a nurse, too. About a thousand years ago.’
‘So you’ve been providing a measure of care for Alma? Doing what, exactly?’
‘It started off just buying her food. Bit and pieces here and there. Clearing up. Domestic stuff. She never paid for any of it, but what could I do? I couldn’t just let her starve. But then lately she’s been unwell and I’ve had to start cleaning her up. She’s started falling, staying in bed. Been incontinent – that sort of thing. I’ve changed the sheets and quilt any number of times. Thrown them out, bought new. It’s been quite stressful. On top of all the hassle of moving. That’s why I had to get social services involved.’
‘Sounds like you’ve done everything you could and more.’
‘You are a good friend and neighbour,’ says Olufemi. ‘The best.’
‘The other thing I need to tell you is – she says hurtful things.’
‘To you?’
‘And I know it probably comes from a place of fear. I don’t doubt she’s scared people are going to take her independence away. It just makes it all even more difficult to handle.’
‘What hurtful things?’
‘Well. No doubt you’ll see when we go in. Don’t get me wrong. Deep down Alma’s okay. A little eccentric, in her own way. But erm…you really have to brace yourself.’
‘Okay. Thanks for the heads up.’
‘Let’s see what she’s like today, then, shall we?’
Charlotte gives us both a brave smile, then pushes open the gate and we all walk in a line down the overgrown path to Alma’s front door.

I’m guessing the house was built sometime in the thirties. A little down-at-heel now, it still has that air of moneyed class-consciousness you see in some suburban homes. When Alma dies I imagine it’ll be sold off and re-developed into separate flats. There’s certainly space for it. Inside it’s hard to imagine one person living on their own here, let alone a ninety-five year old confined to one room upstairs.
‘It’s cold,’ says Olufemi.
‘I put the heating on but she turns it off again,’ says Charlotte. ‘Doesn’t want to spend the money.’
‘But a person needs heating,’ he says. ‘This is not good. Not good at all.’
We’re all of us standing in the gloomy hallway looking round. Archways leading off into dark, unoccupied rooms. It’s early morning, and a thin light sparsely illuminates the kitchen.
‘It’s a mess,’ says Charlotte. ‘I’ve done my best, but…’
She stands at the bottom of the staircase with one hand on the balustrade.
‘It’s no good calling because she won’t hear you,’ she says. ‘We may as well just go up.’
So we do.

The landing is as cold and resonantly empty as the rest of the place. All the doors stand open and dark apart from the door to Alma’s bedroom, which is closed, with a little light spilling out from under it. A radio is playing loudly – a gardening programme, something about azaleas.
Charlotte knocks, then turns the handle.

Alma is lying on the floor.
‘Oh Alma!’ says Charlotte, hurrying over.
‘Get away from me!’ says Alma. ‘And whilst you’re at it, lose some weight.’
‘Don’t be like that, Alma. Look. I’ve brought some people to see you. Some nurses from the hospital.’
‘Nurses from the hospital? Whatever for?’
Olufemi and I go over to her to introduce ourselves and see if she’s alright.
‘How did you end up on the floor?’ I ask her.
‘I slipped! D’you think this is some sort of game? Concentrate, boy! Why not try using your mind for once? You might like it.’
‘Let’s help you up…’
She’s obviously uncomfortable, though, because once we’ve ascertained she hasn’t hurt herself, she lets us gently help her up and back onto the bed.
She’s wearing a t-shirt and nothing else, her withered legs scarcely able to support her.
Alma catches her breath, and when she’s ready, divides her attention between me and Olufemi. It’s like being scrutinised by a giant, partially denuded chicken, her eyes preternaturally bright and sharp.
‘You!’ she says to me, suddenly clawing at the air between us so unexpectedly that I have to lean back. ‘Pah!’ she says. ‘You’re no use.’
‘Please, Mrs Alma. We’ve only come here to help you,’ says Olufemi, kneeling beside the bed.
‘And as for you,’ she says, turning slowly to smile down at him in a horribly leering way. ‘YOU – my little pickaninny friend. You can go and kneel somewhere else.’

a cussed old cat

‘You cat looks exactly like ours. That same splodge of white on his back, like someone threw a paint brush at him.’

The black and white cat slowly raises his head and orientates himself to my voice, his eyes tightly closed, as if he understands the insult – and would like me to see that he understands – but chooses not to respond, conserving his energy instead for the more important things in life, like sleeping. The moment passes; he gets back down to it.

‘He’s a funny old thing,’ whispers Derek. ‘A cussed creature. Does what he likes. Much like me.’

I’m glad about the cat. I mean – I like having animals around anyway, but in Derek’s case it’s a definite advantage. I’d been given plenty of cautionary notes about Derek beforehand. His new diagnosis of Parkinson’s disease, coming at a time of family problems generally. His self-discharge against advice. Self-neglect. Resistance to help. I’m calling round this morning ostensibly to dress a wound on his foot, but there’s more to it than that.

‘Of course, you are the boss of you,’ I’d said to him when he eventually answered the door. ‘You don’t have to do anything you don’t want to do. So long as you understand what it is you’re refusing, and what the consequences might be, you’re perfectly free to say no.’
It’s a speech I’ve used before, the verbal equivalent of putting the gun on the floor and backing up a little. It’s okay. I’m on your side.
‘Yes’ he said. ‘Well. Obviously.’

He talks softly and quickly through a fixed smile, his head tipped back and his eyes half-closed. Maybe it’s a combination of his illness and his natural character, but the effect is peculiarly unsettling, as if he’s using his very last reserves of sociability to maintain a pleasant appearance, like a light bulb connected to a failing generator, flickering on the edge of darkness.
I didn’t expect I’d make it over the threshold, but he’d shown me through to the sitting room, and that’s when I saw the cat.
‘He’s lovely’ I say.
‘There are foxes in the garden,’ whispers Derek. ‘They seem to get along.’

I ask him about his time in hospital while I bandage his foot.
‘Dreadful’ he says. ‘Jabbed and prodded all hours of the day and night. No explanations. No introductions. Bullies and fools the lot of them. I’d had enough. I walked out. Probably should have stayed. So long as they leave me alone. I don’t care.’
He smiles down at me.
‘How does it look?’ he says.

Derek’s wife Barbara comes in and although she seems perfectly pleasant the atmosphere changes. He shrinks a little into himself. She unpacks her shopping bags – sandwich packs, bags of crisps, milk, snacks. ‘Don’t mind me,’ she says.
‘We won’t,’ says Derek.

There’s a knock on the front door and Barbara goes to answer it.
‘Oh God’ says Derek.

Barbara shows someone in, a tall, brisk woman with an armful of files and folders and a blue NHS lanyard round her neck.
‘Oh! Hello there!’ she says to me.
‘I’m Jim from the community health team,’ I say, ‘come to dress Derek’s foot.’
‘Great!’ she says. ‘Excellent! Well – I’m Ruby, the social worker. Do you mind if I put my stuff on the counter?’ She unloads her files and things amongst the shopping, then turns to Derek, looming over him, supporting her weight with both hands on her knees, her ID card swinging in the space between them. She speaks slowly and loudly, for some reason.
‘Hello there, Derek. I’m Ruby. The Social Worker. Lovely to meet you.’
Derek leans away, his smile even more ghastly.
He draws back his foot.
‘Just let me get this last bit of tape on…’ I say.
‘We’re done,’ he says.

portia and the cricket

Portia. Sounds like Porsche – appropriate, actually, because she works so quickly. She’s stylish, too, with a bright, economic kind of aesthetic that perfectly complements her therapist’s uniform: henna-red hair cut in an angular bob; red nails, and a pair of round sunglasses in a turtle green frame.
‘Are you’s okay, eJim? Wha’s the matter? You seems a bit flat.’
‘Yeah – I’m okay, thanks Portia. This patient we’re going to – it’s difficult. And when I got back to the office to speak to one of the lead nurses, everyone was so stressy and snippy. It didn’t help that manager was wandering around with her notepad, giving me the evil eye.’
‘I’m sure she was too a-busy thinking about her looshus ass to worry about poor little Jimminy Cricket’

It’s fantastic that Portia’s agreed to come with me for this follow-up visit. It’s such a depressing case of self-neglect, I feel in need of psychic protection. The patient had cried when I spoke to him quite firmly about what it might mean to his health if he continued to refuse help, slumped on his chair by the window, the room so rank, run-down and malodorous, it felt like I’d been pitched blue-gloves first into an ante-room in Hell.

And of course, Portia is as dynamic and effective as ever. It’s a pleasure to watch her, effortlessly moving through the place, as refreshing and galvanising as the breeze through that window she opened so discreetly. The patient opens to her, too, irresistibly drawn – as everyone is – by her frank and life-affirming demeanour.
‘There you go my lovely!’ she says, shaking his hand. ‘Is a pleshur to meet you. Take care, and we see you soon, okay? Okay!’
And we’re out of there.

Back in the car, she turns to look at me.
‘Feeling not so flat now?’ she says.
‘Yeah! Thanks for helping me out.’
‘Of course!’ she says, then resting an elbow out of the car window, drops her round sunglasses down and gives me a big, lipsticky smile. ‘So come on, Jimminy Cricket! Less’ go!’

ralph’s owl

Ralph reminds me of that paleolithic fertility statue, the Venus of Willendorf, updated for the modern age, with trackie bottoms, steel-rimmed glasses and a wild beard.
‘I just want to be left alone’ he says.
‘I’m sorry you feel like that,’ I say, squatting down near to him, mostly because I don’t want to intimidate him by standing tall, but also because there’s nowhere clean to sit. ‘We’re worried about you. That’s all.’
‘I just …. don’t appreciate … all this fuss.’
I can understand why he feels exposed. Whilst he was away in hospital a deep clean team stripped the place. I hadn’t seen what it was like before, but a trainer they missed is a giveaway. I found it when I moved the coffee table to make room for his zimmer. The trainer is caked in brown matter, a ghastly combination of dust, dirt and accumulated awfulness, the inside of the shoe spilling over with ropes of web so thick even a spider would shake its head and walk on.
‘You can always say no,’ I say. ‘You don’t have to have any of this.’
‘I just wish … I could say … what I want… to say.’
‘Take your time.’
I leave lots of room for him to try, but he’s too distressed to speak. He sits there gripping the arms of the chair, taking anguished gasps of air, puffing his toothless cheeks in and out and rolling his lips.
‘Don’t worry,’ I say. ‘It’s okay.’
I can’t even make Ralph a cup of tea. All he has in his cupboard are cupasoups and instant porridge sachets; the only things in his fridge, a couple of pens of insulin. There’s a scattering of medication strips on the windowsill, which make me question the accuracy of the ‘competent to take meds independently’ description on his discharge summary. In fact, I’d have to question much of what’s on that paper. Ralph lives up a flight of stairs (the paper said basement); he has a keysafe, because he couldn’t possibly answer the door (the paper said no keysafe), his phone number is carefully transcribed (he hasn’t got a phone). You’d hardly think it was the same patient at all.
‘Who does your shopping?’ I ask him, looking around.
‘Alfred. He helps out now and again.’
‘That’s good! D’you mind if I give him a call?’
‘I don’t have his number.’
‘Do you know where he lives?’
‘He’s not far’
‘If you give me the address I could pop round.’
‘I don’t know where he lives. I don’t even know his last name. All these questions…’

It’s a difficult assessment. The thought of anyone living like this is depressing, especially someone with Ralph’s limited mobility, sitting for hours and hours in a dilapidated armchair by the window, his skin breaking down, his only company the radio or the hum of the flies circling impatiently overhead. Ralph could be a poster boy for the Self Neglectful.

One of the most difficult things to accept in community health is the business of mental capacity. Essentially, so long as you understand the consequences of your actions, you’re perfectly at liberty to live however you like, whether or not it’s bad for your health. A free climber is perfectly free to jump up on El Capitan with nothing but a bag of chalk and the strength in their fingers between them and certain death; similarly, Ralph is free to live in this filthy flat with one crapped-up trainer and nothing in the fridge and no-one to see him, and he has every right not be pestered by nurses and therapists and social workers.
‘Maybe you could write a list of the things you want to say,’ I tell him. ‘You could take a while, and have a good think, and put it all in two columns – what I want, and what I don’t want.’
‘Just… I don’t…. oh’
‘It’s okay. There’s a lot going on at the moment. The deep clean must have been stressful.’

They’ve left one thing on the walls, though: a crude, blockish, primary coloured tapestry of an owl, staring out of its grimy frame with an outraged expression. Tucked into the frame is a polaroid of something that looks like a glass owl on a mantelpiece, but the picture’s so faded I can’t be sure.
‘I like your owl,’ I say. ‘How long have you had that?’
‘Thirty year,’ he says. ‘My wife did it. By numbers.’

schatz katze

The key safe is hanging open so I ring the bell instead. I step back and look up at the house whilst I’m waiting – a substantial Regency building, a little down-at-heel and cracking up, perhaps, but still impressive, with a wildly overgrown garden whose depths of shadow hint at stone baths and iron cold frames and other features utterly consumed with ivy.

The door opens and a bright, middle-aged woman in a carer’s uniform steps out onto the cracked mozaic tiles.
‘I’m so glad you’re here!’ she says, showing me in. ‘I think this is one for social services as much as anyone. I’m Karen, by the way!’

I stand with her in the hallway so she can tell me what she’s found so far. Helga is a ninety-five year old with no package of care and generally ‘bumping along the bottom.’ A neighbour looks in now and again. Found her on the floor, called the ambulance, hospital declined, referrals made. Karen points out a sheet of paper sellotaped to the mirror: In Emergency written in shaky green caps at the top, and below it, a handful of names and numbers, the nearest being Munich, the furthest, Hobart, Tasmania.

‘I feel so bad for her, says Karen. ‘There’s hardly any food in the house. Can I leave her with you whilst I nip round the corner and get the basics?’

Helga is lying in bed, stroking a black cat that’s sprawled on top of her, purring so loudly it fills the entire house. In an odd kind of way, it makes the place seem emptier.
I introduce myself, and explain why I’ve come. When Helga reaches out to shake my hand, her hand is so weak and light in mine it’s like the memory of a handshake that happened sometime just after the war.

I start to talk to her about the situation. How she’s feeling, how she’s been coping and so on, gently trying to tease out the facts. Helga doesn’t want to engage, though.
‘Ah! Too tired!’ she says, transferring her attention back to the cat with a philosophical pursing of the lips.
Was ist los?’ she says, feebly waggling her fingers under its chin. ‘Was ist los, shatz? Was ist los?’

character phones

Tony has a range of character phones. Tweety Pie, Hello Kitty, Bugs Bunny and so on. All of them bravely maintaining their expressions beneath the same grimy brown patina that covers everything in Tony’s room. It’s an astonishing thing, a dismal, bristling crust that wouldn’t look out of place on the wreck of a ship at the bottom of the Atlantic. And if this was a ship, I’d guess, through the visor of my mask, that I’d swum into the nursery, because encircling the whole room are three shelves, each of which is packed full of toys and childish souvenirs of every description: elephants, camels, teddy bears and finger drums, Chad Valley projectors and unidentifiable things in snow globes, figurines in decaying boxes from shows I’ve never heard of – the whole, mouldering cargo merging one thing into another, in one great soup of neglect.
‘Quite a collection you’ve got,’ I say as I take his blood pressure.
‘Inherited,’ he sniffs. ‘I had six relatives all die in the space of two years. I got rid of what I could. The rest just stayed.’
‘I’m sorry.’
‘It was a bad time that’s for sure,’ he says, rolling his sleeve down again. He coughs – such a sludgy sound it’s hard to resist the idea that his lungs are coated in the same noxious matter as the rest of the room. ‘I fell ill. And then my support worker died.’
‘How awful!’
‘He dropped dead in this room, right about where you’re standing now.’