hats off

Paul’s flat is an extemporary landscape. Hundreds of empty whisky bottles on the floor, standing up or lying down, a sea of glass around the lifeboat of the sofa; volcanoes of cigarette butts rising from dinner plate islands; a tangled undergrowth of pepperoni packets; squadrons of flies cutting patterns through the air or crawling enthusiastically over everything. And overlooking the dismal scene, glaring like a vengeful god from the top of a filing cabinet, Johnny Rotten’s autobiography: Anger is an Energy.

‘How are you today, Paul?’
He tugs his beard, shrugs.
‘I’m okay,’ he says. ‘More or less.’

It’s a strange feeling, standing amongst the crap, nowhere to put my bag or set up my kit to take blood. So I just stand there a while, and we chat.

‘I’m not going to hospital,’ he says.
‘It’s entirely your decision. So long as you understand the risks.’
‘They keep on about potassium, calcium, magnesium…’
‘They’re all really important minerals, Paul. If you’re low it puts you at risk of serious heart problems. Even cardiac arrest.’
‘Yes,’ he says. ‘They’ve said that. But why?’
‘It’s complicated. I’m not even sure. But it’s something to do with the electrical conductivity of the heart. If your levels are screwed your heart can develop arrhythmias and stop working altogether. So…’
‘But why?’
‘I just don’t know enough about it. You’d need to speak to a cardiologist. Or Google it.’
‘Google it! The paramedics said that! Google it! That’s all everybody does these days.’
‘I know! It’s pretty handy, though. You gotta admit.’
‘Hmm,’ he says, stroking his beard in that classic beard-stroking way thoughtful men have, massaging the pointy end of it with a pulsing motion of his hand like an octopus swimming backwards.

I have to admit, his hair and beard are pretty amazing. He’s so unwashed, they’ve set into a wavy pattern like it’s carved from wood, the hair on his head progressing backwards in defined steps, the beard the other way as a counterbalance.

‘I drink,’ he says, releasing the beard long enough to make a grand gesture at the ruin of the room. ‘It’s an addiction.’
‘I can see that. I know it’s difficult, Paul, but there is help out there. You know – medication, therapy.’
‘Yes,’ he says, back on the beard. ‘Yes, I understand.’

There’s a blue metal chair in the dark of the galley kitchen. I wade through the bottles, tip it clear, wade back and plant my things on it.
‘Shall I take that blood, then?’
‘Be my guest!’ he says, rolling up his sleeve.

We chat whilst I work.
‘The doctor that came the other day? She said she thought I was more intelligent than she was. I said that may well be, but I don’t see what that has to do with the problem at hand.’
‘She was probably thinking about mental capacity. Whether you understood the risks you were running saying no to hospital.’
‘I’m not saying no to hospital as a general principle. I’m merely advancing the idea that it may not be the answer to my particular question.’
‘That’s fair enough, then. But your recent blood results are pretty poor.’
‘I’ve signed the forms,’ he says. ‘All done?’
‘Yep! All done.’
‘Thank you.’
I tape him up.
‘Have you got a cat?’ I say, noticing a flyblown bowl over by the window.
‘Somewhere,’ he says. ‘She’s shy. I’ve also got a collection of hats. How many hats do you think I have?’
‘Ten? That’s not a collection. That’s not even a weekend.’
I can’t imagine him wearing a hat. Maybe a stovepipe. Or a beehive beanie. Nothing else would fit.
‘One hundred!’ he says. ‘One hundred hats!’
And I can’t help looking round.

thank god it’s not friday

Fridays are the worst.

It’s more than just the hospitals clearing the decks before the weekend. There’s something else about the day – an end-of-the-week, last-chance, store-closing, now-or-never vibe that means from shutters up to shutters down the phone never stops ringing and every call is a crisis. Coming to work at eight on a Friday, you feel like stacking sandbags round the desk and putting on a tin hat. As it is, you make a cup of tea, get a fresh notepad, a pen and a highlighter, open up as many useful programs as you have access to on the computer, crack your neck, and wait.

But you can oversell these things, of course. And there’s a certain satisfaction to be had from stumbling from one thing to the next, like a clown fireman at the circus. Once you surrender to the chaos, and focus on the audience, it’s actually quite a rush.

Luckily, I only had to work the phones till three, when I was released to go on a couple of visits. It was so busy, though, thank goodness my replacement actually showed up. If they hadn’t, and I’d had to stay for the rest of the shift – well – who knows what would’ve happened? I’d probably have been found by a cleaner, alone in the office, lit by the ghostly glare of the screen. They’d have tapped me on the shoulder.
‘Are you alright?’
And I’d have swung slowly round. And the cleaner would scream – because they’d see my ears were merged with the headset, my hands with the armrests, my eyes would be flickering like two little plasma screens, and the veins in my neck and face would be spread all over like wires.


The first visit is easy enough. The second is a disaster.

Being exhausted doesn’t help, and the fact that my patient, Mr Reece has only just arrived back home after being discharged from a rehab place, weeks and weeks after he went in. All he wants to do is smoke a fag and watch the wrestling.

His flat is in a wretched state, lit by two shadeless, ineffectual, energy saving bulbs. Mr Reece is sitting in a ruined armchair, an electric scooter to his immediate left, a zimmer frame to the right, and a TV just in front. Around the chair is a scattering of papers, leaflets, unopened mail. In the corner of the room is an unmade bed, the centre of the mattress sagged and seamy. The whole place is suffused with a settled fug of neglect.

‘Hello Mr Reece!’ I say, as brightly as I can, struggling in with all my bags. ‘Sorry to disturb you so soon after you got home, but we’re a short term service and we need to get things started.’
He frowns at me, then pointedly plants a cigarette between his lips and reaches for a lighter.
‘Would you mind not smoking whilst I’m here?’ I say, putting my bags down and then wringing my hands together, like an apprentice vicar leading prayers for the first time.
‘Because I’ll stink of smoke the rest of the day. And it’s not good for me. Sorry! I won’t keep you long.’
Mr Reece twists his lips together with a displeasure so violent the cigarette falls out into his lap.
‘You’ve got ten minutes!’ he snaps, throwing it onto the scooter. Then he jabs his hands towards me, palms flat, fingers spread wide. ‘Ten!’
‘Okay. Thanks. Well – has anyone told you who we are?’
‘No. They haven’t.’
‘Oh. I’m sorry about that. Well – we’re an NHS community health team whose job is to support people being discharged from hospital, or stop them going into hospital in the first place. Mr Reece? Are you okay?’
He’s leaning over the side of the armchair, rootling about in a pile of mail and newspapers.
‘I had £850 there and it’s gone.’
‘Oh. Shall I help you look?’
‘No. You stay there.’
I watch him scrabbling around for a minute. He struggles to get out of the armchair. When I go forward to help he tells me to keep away. He tries using the zimmer, but it gets caught up in the scooter. I offer to move the scooter.
‘Leave it!’ he says. ‘Leave that thing where it is!’
He abandons trying to use the zimmer, and shuffles around the chair instead, using the arms and the headrest as a support. He kicks his bare feet amongst the detritus, like a bad-tempered park keeper through a heavy fall of leaves, peering down.
‘Mr Reece? If you had £850, and it’s not there anymore, do you think it’s been stolen? Shouldn’t we be calling the police?’
‘I don’t know,’ he says. Then he stops, straightens, and – gripping the back of the chair with his hands – draws a bead on me down the sharp crook of his nose. ‘We’ll see if I find it. Won’t we?’

malcolm the robot vs. tina dreadful

Tina’s surname is Redmond but everyone calls her Tina Dreadful.

Nothing prepares you for her. Nothing. Not meditation. Not medication. Not prayer.

You’d have to say Tina is following her vocation. She’s raised nastiness to the level of art. Made rudeness a competitive sport. Transformed vileness and good ol’ fashioned meanness into a spiritual quest. She’s racist, sexist, casually abusive. She’s uncooperative, obstructive, distracting. Now and again she’s content, in the way that torturers turn off the loud television sometimes, to soften you up for the next onslaught. Mostly, though, she’s just a bully.

I defy anyone to visit Tina and keep their cool.

The Dalai Lama would stomp across the road and kick a trash can.
Mother Theresa would storm out of the front door, tear off her headdress, fling her sandals up at the window. (And then swear at you for tutting).
The Pope would hurry outside, kiss his cross, light a fag, jump in his Pope Mobile, and do a doughnut in the street in his hurry to get away.

Tina is on a slowly repeating cycle, a sine wave of sickness and degradation. On the downward phase she self-neglects to the point of ill health, gets admitted to hospital (when she’s so far gone she can’t protest); the deep-clean team goes in to steam-blast the floor, replace the bed, buy in new sheets and towels and so on; Tina gets discharged back with a package of care, and the whole cycle starts again. Over the years, Tina has left many tearful health care professionals in her wake. She’s had umpteen multi-disciplinary meetings between the council, social services, neighbourhood representatives, psychiatrists and police, but no amount of special delivery letters, no amount of signed contracts or verbal consents, have done anything to change her situation or her character. She does have mental capacity. None of this has been found to be an expression of mental illness. It’s just plain cussedness, and no-one seems able to do anything about it.

I met her daughters once. They were the loveliest, most caring women you could imagine. But they’ve lived so long in the foothills of this dark and forbidding personality they can only protect themselves as best they can, apologise, try to make amends, and wait for the next rockfall.

However, I have to say, now and for the record: Malcolm can handle Tina.
And I’ve finally figured out how he does it.

Malcolm is a robot.

Here’s what I think happened.

I think a scientist – mad or otherwise – sat in on one of the multi-disciplinary meetings. I think this scientist patiently listened to everyone moaning on about the latest awfulness, and then when things fell quiet, calmly got up, went to the door, opened it, and invited Malcolm in.

Malcolm is perfect. He’s average height, medium build. He has a hairless, wipe-clean head. He has cool, evaluating eyes and realistic hands. He speaks with great modulation, in phrases designed to advance understanding and minimise flare. He moves with economy – but there’s power there, too, on a graduated scale from 1: puncturing the film on a microwave meal or 2: kicking through a wall. His demeanour is gyroscopically monitored, one hundred and eighty degrees of equanimity and poise. And his battery is good for eight hours.

You might think it’s a bit extravagant to use a robot such as Malcolm in this banal social situation. But maybe this is a field trial. Maybe this is part of the stress-testing you’d want to put such a unit through before you send them off to recolonise Mars or something.

The fact is, he’s amazing.

And the reason I think he’s a robot? Two things.

1: When the other carers see that they’re down to visit Tina they wail and plead and do everything they can short of throwing themselves out of the window to escape having to go. Malcolm just smiles.

2: Reading his notes afterwards. He writes coolly, neutrally, with great measure. You get a sense behind his words of the vile language Tina is using, the awful tenor of the situation, but nowhere does Malcolm rise to it. He describes himself moving through the scene, relaying the facts with a detachment that borders on nervelessness.

But the biggest giveaway?
He talks about himself in the third person.

For example: The Carer suggested that Tina roll to the left a little so he might change the inco sheet. Tina declined to do this, saying that she did not want to. The carer pointed out the negative effect lying on urine soaked sheets would have on the integrity of Tina’s skin. Still, Tina declined to cooperate. The carer asked Tina whether she would like something prepared for lunch. Tina declined, saying there was nothing in the fridge. The carer suggested he look in the fridge. Tina said that he could if he liked, it was a free country. The carer looked in the fridge and discovered a microwave meal – sausage hot pot and dumplings. The carer presented this to Tina. Tina said she was sick of sausage hot pot and dumplings and she would rather starve. She then went on to describe issues she was having with her mobile phone, a Sim card problem the Carer was not able to resolve at this time. Tina made comment about this in a generally abusive manner. Tina then requested the sausage hot pot and dumplings be heated anyway, which the Carer proceeded to do. The carer made tea, which Tina declined in favour of pineapple juice. Then Tina said the tea was not sweet enough, and she required apple juice not pineapple juice, and not in that beaker. Then she spilled the tea and had to be cleaned up. The Carer then presented the sausage hot pot and dumplings in a bowl. Tina used many swear words when the Carer placed the bowl beside the bed, saying that ‘it was no good there, was it’ even though she could easily reach the bowl. The Carer took action to remedy the situation, and with nothing further to be accomplished, left the scene, all being well at that time.

We need more Malcolms.

the cat knows everything

Gary’s shown hostility to health care professionals in the past, and the record says we’re only to visit in pairs. I’m a little early meeting up with Lisa, so I park up outside and take the opportunity to finish off some notes on the laptop. I’ve just settled in to start writing when Gary’s door opens and a woman steps out. She’s tall and pale and pinched looking, wearing a green and black nylon tracksuit, her long hair dragged back in a ponytail. She takes out a fag packet and is just about to have a smoke when she sees me, sitting there. I wind down the window to tell her I’ve come to see Gary and I’m just waiting on my colleague, but before I can say anything she shoves the fags back in her pocket, walks backwards into the doorway, and maintaining eye contact for as long as she can, slowly shuts the door.

It doesn’t augur well.

Lisa turns up ten minutes later. I’d trust any of the team to go on a difficult visit, but if I had to choose, Lisa would be it. The Italians have a word for how she is: sprezzatura – a kind of nonchalance or ease, wearing her skill lightly, with great warmth and humanity, as if it’s really nothing and no trouble at all, and what was it that needed doing, now, and suddenly it’s done, and everyone feels better.

‘How’s it going there, Jim?’ she says, padding along the street. ‘Have you been waitin’ long?’

We go together through the terrible little garden, knock and wait. There are sounds from inside. An exchange of light and shadow in the frosted panes above the door. A clattering of the lock, and suddenly the door opens.
A bare chested man, his eyes squeezed shut, his smile as wide and flat as the Man in the Moon.
‘I expect you’re wondering why I’m half naked?’ he says. ‘Only I was just having a carton of cherry and raspberry squash, and I didn’t want to get any on my t-shirt.’
‘No. That would stain, right enough,’ says Lisa.
‘Yes,’ he says. ‘You’d never get it out.’

There’s a steep, bare board staircase just behind the man. The woman I saw earlier is crouched at the top, peering down at us on all fours.
‘Don’t listen to him!’ she shouts. ‘He sees ghosts!’
‘Okay, now! That’s interesting!’ says Lisa. ‘So… is yer man through in this room, or … ‘
‘Ye-es,’ says the man, stepping to one side and knocking on the door. ‘I say Gary? There are two lovely nurses to see you.’
Show them in but keep Jackie out.

The man pushes the door open and nods for us to go through. Meanwhile, Jackie has started coming down the stairs, slowly feeling with her feet for each tread whilst her face stays as fixed on us as a steadicam.
‘Now, now, Jacqueline!’ says the man. ‘Gary doesn’t want you there.’
Jackie gives a petulant scream, sits down on the step and folds her arms.
‘After you,’ says the man.
We step into the room.

It’s hot as a sauna – the foetid, barrelling kind, where you fling urine on the coals instead of water. I wonder how long Gary’s been lying on his bed like this, his teeth grey and claggy as if he’s been snacking on ash. It’s like we’ve stumbled into a mausoleum, where the occupant took up early residency for want of anything better to do, and his stuff got chucked in after him. There are two posters on the wall: Jimi Hendricks leaning back from a guitar solo; The Beatles all in a line.
‘Wha’d’ya want?’ says Gary.
‘Hello there!’ says Lisa, offering him her hand. ‘Nice to meet you, Gary. This is my colleague Jim. We’ve been asked to come see how you’re doing.’
‘How’m I doing?’ he says. ‘I’m NOT doing.’
‘What’s troubling you today, then, Gary?’
‘I can’t keep nothin’ down. I feel sick all the time. I’ve got no energy. I’m wracked with pain. Is that enough for you?’
‘That’s enough for anyone,’ she says. ‘You poor thing. Let’s see what’s what, then. I’ll just do your blood pressure and whatnot and see how that is, and Jim here’ll take a wee bit o’blood, if that’s okay?’
‘I don’t care,’ he says. ‘You may as well. I’ve got to go to the toilet first, though.’
He nods in the direction of a commode whose pot has been removed so it can fit over a bucket.
‘Do you need a hand getting out of bed, there, Gary?’ says Lisa.
‘I’ll be alright, thanks,’ he says. ‘If you wouldn’t mind stepping outside for a bit.’
‘No worries.’
We leave him to it.

Out in the hall the bare chested man has gone and Jackie is nowhere to be seen. Instead, an ancient black and white cat yowls as it approaches us from the living room. I’m guessing it’s blind because both its eyes are white. It feels its way along the wall, one paw at a time. I crouch down and hold my hand out. The cat stops, sniffs the air, then moves in my direction. When it gets closer I see that its tongue pokes out to the side, too.
‘Poor wee fella!’ says Lisa.
I stroke the cat. It starts purring – a deep, rumbly sound – his tail pointing straight up, as if he’s absorbing the affection and transmitting it somewhere.
‘The cat! The cat knows everything!’ says a voice at the top of the stairs.
Jackie is there, staring down at us again.
‘Oh – they do, though, don’t they?’ says Lisa, smiling up at her. ‘Cats. You’re right there, Jackie. They certainly do.’

drishti’s miracle

Ella’s son John is furious. Not with us, he says, every now and again, like a cartoon bull kicking and raging around the ring, stamping his hooves, blowing smoke through his nose and ears – then stopping in a cloud of dust to bow to the rodeo clown.
‘Look at her! They may as well have fly-tipped her by the side of the fackin’ road. Like a fackin’ fridge or some’ink.’
‘I know it’s stressful, John, but just try to ease it back a little if you can…’
‘I’m not ‘avin a go at you, mate,’ he says. ‘It’s the fackin’ hospital. And the ambulance. I mean – what was they thinkin’? We’re back to square one. This is exactly the fackin’ situation she was in when she went in in the first place.’ He suddenly seems tangled up in all those ‘ins’ and stands there, breathing hard.
Even though John makes you want to take a step back, and maybe even pick up a cushion or something, I have to admit I can see his point. Ella is a bariatric, self-neglecting patient who’d been admitted after being stuck on the sofa for several days. And even though the flat has had a rudimentary ‘deep clean’ whilst she’s been away, it’s still pretty awful, and here she is, back on the same sofa. The two ambulance crews must have sweated and struggled hauling her in their carry chair up that crooked flight of stairs. And I suppose gravity and the relative height of the chair to the sofa must have worked sufficiently in their favour to make the transfer. But since we’ve been on scene to do the initial assessment and see what Ella needs in the way of therapy, nursing and care support, she hasn’t been able to get up, even with the most enthusiastic, hands-on encouragement. To all intents and purposes, John is right. She’s landed back where she started. If Ella can’t get up from the sofa we’ll simply have to send her in again, as a failed discharge.
It’s a difficult situation, made worse by the fact it’s already six o’clock in the evening. If we call for an ambulance they’ll mark her as low priority. We could be here till midnight.
‘Well I can’t stay,’ says John, reading my mind. ‘I’ve got my own family. I’ve got work in the morning. I’m fackin’ Hank Marvin’ and there’s fack all in the fridge. I mean – where’s the thinkin’? Where’s the planning? Hey? It’s fackin’ pathetic. I told ‘em this’d happen. I told ‘em exactly what’d happen. And what happens? This! This happens! Fackin’ unbelievable.’

I’m here with Drishti, the physio. I know how busy she’s been today, and lately. How much it would mean to her today to finish work on time and get home to her family.
‘There’s no point in us both staying,’ I say to her. Drishti is so essentially kind, though, she won’t have it.
‘No, no,’ she says. ‘Let us remain together and see what we can do. It’s never too late for a miracle.’

The thing I need to do with the most urgency now is redress Ella’s leg. She has varicose eczema. At some point she’s pushed the dressings down and been working away at the scabs. From time to time she reaches down, absent-mindedly pulls off another bloody scrap, and puts it in her mouth. It’s difficult to keep an eye on her to stop her doing it, especially with John ranting around the place.
‘Please don’t do that!’ says Drishti, gently guiding her hand back down and wiping it with a tissue. ‘It’s really not a good thing to do,’ she says.
I clean the leg with saline and re-dress it whilst Drishti calls for an ambulance.
‘Four hours minimum’ she says with a sigh, hanging up. ‘They say it is a busy night. When is it NOT a busy night?’
‘I don’t suppose you’d be able to stay with your mum…?’ I say to John.
‘What? You’re havin’ a laugh, mate? Four hours? I’ve been ‘ere too fackin’ long already. I’ve got my own fackin’ life, y’know?’
‘Has you got anyone else? Any siblings?’
‘I’ve got my sisters, but they’ve washed their hands. They don’t want to know.’
‘What about friends? Neighbours?’
‘There’s no-one. That’s what I told ‘em! She hasn’t been out o’ the flat in seven years! I fackin’ told ‘em all this! I can’t stay, mate. I gotta get up early.’
‘Okay,’ says Drishti. ‘That’s fine. You can go.’
And it’s only when he turns to hurry out of the door that she gives me a steady, sorrowful look.

I call the office to let them know what’s going on and to see if they have any brilliant ideas.
Lawrence is co-ordinating.
‘Ah!’ he says. ‘Oh dear. Erm….Well! Yes. I see the problem.’

If I’d written a film script set in the eleventh century, and there was a scene where a troupe of marauding knights were riding towards a monastery, and the monks were frantically running around, and one of them, a particularly tall and ascetic looking monk, was desperately loading up a cart with armfuls of ancient books and scrolls and things, tripping over his habit, cursing mildly, and then the ass gave a jolt and a wheel fell off, splashing the monk head to sandals in mud, just as the knights came clattering into the yard, swinging their swords, and the monk turned to deliver his line straight to camera: ‘Well. Isn’t that just bloomin’ typical!’ – I’d be sure to cast Lawrence as that monk.
(He already has the haircut).

‘Oh dear!’ he says. ‘Damn and double-damn. Okay. Right. Well. I suppose I could relieve you when the office closes. If you like? I live nearby, so it wouldn’t be so bad for me…’
‘That’s kind of you, Lawrence,’ I say. ‘Maybe it won’t come to that.’
I tell him we’ll keep in touch, and ring off.

We settle in – as best we can, given the environment.

Ella says she’d like to watch some TV. We give her the remote and she flicks through the channels, eventually landing on a reality show about a couple looking to buy a house. They’re standing on a terrace overlooking a fiercely blue harbour dotted with yachts.
‘You won’t see that in Bradford,’ the presenter says.
The couple smile but they look uneasy, shielding their eyes from either the sun or the presenter, it’s hard to tell. I suppose the idea is they could live anywhere. Maybe the next place they show them will be underwater or something.
‘That looks nice’ says Drishti. ‘Hot, you know?’
Suddenly a mobile phone rings somewhere. Drishti locates it in Ella’s hospital bag. She hands it to her.
‘Hello…?’ says Ella, still watching the TV. ‘Yeah. About an hour ago…’
I raise my eyebrows.
‘Ella?’ I say. ‘Sorry to interrupt. Would you mind if I had a quick word with them?’
‘It’s the nurse’ she says into the phone. ‘Okay. Jes’ a minute…’ She hands me the phone, then leans to the side to carry on watching the TV.
The caller is a woman called Stella. She works for a befriending service. Apparently Stella had been expecting Ella home and was planning to come round to see she had everything she needed and so on. I explain the situation, and ask if Stella might be able to stay a little longer until the ambulance arrived.
‘Medically she’s okay,’ I say. ‘It’s just she needs someone to keep an eye on her.’
‘That’s fine’ says Stella. ‘No problem. I’ll be straight round.’
‘Thank you so much,’ I say, then hand the phone back to Ella.
‘Who was that?’ says Drishti.
‘That was your miracle!’
I go to the window, draw the net curtains aside, and look out at the night sky, fully expecting to see a star detach itself, glide gently and magnificently down to earth, hop pointedly across the lawn, and ring the bell.

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.’