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.’

you tell me

Charles, sleeping in a wing-backed chair
kippering by a two-bar heater
trousers sliding south,
hernia through an open shirt
like a burr on an ancient beech
or the head of an imp
in a breast-feeding nightmare
What d’you want? he says
his one good eye suddenly wide
like I tripped a wire somewhere
‘Sorry to wake you, Charles’
Hmmm he says, backing into his beard.
‘I won’t keep you long’
The room – oh! The room!
The room is a cliche of neglect
peeling paper – check
seamy bedclothes – uh-huh
everywhere that slow, sad laying-in of time.
Charles won’t agree to a thing, of course
not a temperature check,
pulse count or blood pressure
so I retreat to a plate
of tea and toast
and inconsequential chat
hoping that one word
will follow another
into something like acceptance
‘What did you do before you retired?’
handing him the mug
What do you mean?
‘You know. What work did you do?’
What work?
‘Before you retired?’
He lowers his face to the mug
and gabbles at the lip
like a goat invoking a curse
then, lowering it unsteadily again
to rest on the pate of his hernia,
he fixes me with that eye,
that furious, shining, ineluctable eye
I’m ninety-five! he shouts
You tell me!

clive’s familiar

Clive lives in a grotto
(portmanteau word: rotten, grot and odour)
there’s a foetid curtain hanging across the bottom of the stairs
that reminds me of those doors
you used to bang through on the ghost train
Beware! Horrors ahead!

Clive is not sitting in his armchair
so much as being slowly consumed by it
he’s smoking a fag, artfully balancing
a long and crooked stack of ash
with the wizened fingers of a mummified count
‘hello’ he says. ‘And who might you be?’

Clive doesn’t want any help, thank you
he’s quite happy as he is
he already has a heap of equipment
(toilet aid, perching stool, zimmer frame)
tossed in a bath that last saw water
when Nasser blockaded the canal

Clive has a cat on his lap, a placid brindle coloured animal
(though it’s perfectly possible that, along with everything else,
the walls, the furniture and me, probably,
it’s actually a snow white cat kippered by all the smoke)
‘He’s lovely,’ I say. ‘What’s his name?’
‘She!’ says Clive, losing his ash. ‘It’s a girl. And I call her Thingummy’.

not exactly Lear

Zikri and I have been asked to do an environmental assessment on a patient.

‘What is this environmental assessment? What do they mean environmental assessment?’ says Zikri, saying it so emphatically again and again it sounds like a sneezing fit. He rapidly flips the page backwards and forwards like he’s trying to shake the sense out of it by main force. ‘They’ve already said it’s unhygienic and dreadful. Faeces on the floor etcetera, a terrible mess. What more do they think I can add to that? Hmm? A colour chart?’
I love working with Zikri. He’s a zesty combination of warmly humane and emphatically pragmatic. With his slightly greying goatee and his steel framed glasses, and his habit of staring at you with his mouth slightly open, like he’s savouring everything you have to say, and preparing himself to jump in with warm words of praise or a stinging rebuke. He’s the best teacher you never had. He’d have made a great theatre director, or maybe an oncologist. You could take any amount of criticism from Zikri and still think he’d given you a compliment.
‘He asked Anna to leave. So she did. She wasn’t able to complete the assessment, but she was there long enough to get this much done. Nowhere does it say she thinks he lacks capacity. And now we’ve been asked to go in and do an environmental assessment. I think all we’ll be doing is making him angrier and less inclined to co-operate than he already is.’
Zikri takes his glasses off and pinches the top of his nose.
‘Well, okay, alright,’ he says at last. ‘What time do you want to meet there…?’

*

I’ve been to a great many scenes of self-neglect, both in the ambulance and latterly as a community health worker. But I have to say Mr Frederickson’s basement flat is by far and away not anything like any of those places. In fact, I’d go as far as saying it’s actually very nice. It has a warm, stripped pine floor; walls populated with framed playbills, woodcuts of seabirds, watercolour landscapes, family photographs; quirky, vintage furniture; palms in jardinieres, and a view through a bright sash window of a rich and well-tended courtyard garden. I can’t help thinking we’ve come to the wrong house. In fact I’m so certain that must be the case, I quickly check the paperwork as Zikri makes the introductions.

‘It’s lovely to see you both,’ says Mr Frederickson, shaking our hands and then tying his dressing gown more tightly around his waist. ‘You catch me rather déshabillé, but then I suppose it is the weekend, so perhaps you’ll let me off.’

He’s utterly charming.

Zikri looks at me.

I know exactly what he’s thinking.

Environmental assessment.

‘If you’d be so kind to pass my apologies to your colleague,’ says Mr Frederickson, ‘… the girl who came here the other day. I’m afraid she caught me at rather a bad time. I stood there with my hair all over the place. I must have looked like Lear on the heath. I think I scared the poor girl out of her wits.’
‘No worries,’ says Zikri. ‘We will be sure to convey your apologies’
‘That’s kind of you,’ says Mr Frederickson. ‘Now – how can I help you this morning?’
‘Well…’ says Zikri.

pushed for time

I have an appointment at three o’clock, a double-up with an occupational therapist at the house of a patient discharged from hospital that day. But so long as everything falls into line, and the traffic is only slightly north of reasonable, and I manage to pare each visit down to the barest and most pragmatic interaction permissible by law, three o’clock is perfectly achievable.

Of course, it doesn’t work out that way.

The ECG machine decides to play up, in that almost supernatural way electrical equipment has sometimes of sensing your impatience and transforming it into pure cussedness. And when I try to draw blood from the second patient, I have as much luck as if I’d staggered out into the garden and jabbed the old apple tree. That, plus running into a horrible thickening of the traffic heading west, so inexplicably and uncharacteristically bad it makes me think I’’ve missed an emergency radio broadcast telling everyone to drop everything and clear the hell out of town – all this means that by the time I’m pulling up outside the house, half an hour late.

‘I -am-so-sorry!’ I say, piling in through the door with all my bags.
‘That’s okay!’ says Rick, the OT. ‘We’ve just been taking our time, going through a few things. It’s alright.’
Gil, the patient, is sitting forward on the edge of a sofa. His hair is dyed crow-black, back-combed in Gothic style, which only seems to accentuate the extreme pallor of his face, and the dark hollows of his eyes. Shaking his hand is like scooping a fragile bird into my fingers.
‘Pleased to meet you.’
‘Likewise’
I sit down on a low stool as Rick brings me up to speed. He gives me the discharge summary to look over, too, and I glance at it from time to time. I’ve already been told the basics – the alcoholism, self-neglect, the concerned neighbours, the intervention of the social work team and so on – and the fact that a deep-clean company had been brought in whilst Gil was in hospital. What I hadn’t been told though was the seriousness of his situation now. The discharge summary lays it all out in dry and technical language; beyond it, like seeing a dark and formidable landscape through a formal window, is the hard truth of the thing. Gil has come home to die.
‘If you want to get your bits and pieces out of the way whilst I finish this bit of paperwork…?’ says Rick, as I hand the summary back.
‘Sure! Why not?’ I say, grabbing my kit and going over to kneel by Gil. ‘Is that okay?’
He accedes to it all with a measured kind of passivity, smiling often, but in a gentle way, like someone who’s decided the only thing he can change about the destination is his understanding of the journey.
I don’t push anything. Just the basics. And when I’m done I shake his hand again, gather my things together and leave Rick to finish off.

Back outside, I’m throwing my bags in the boot of the car when an elderly man in a flat white cap, anorak and check shirt stops right by me. He holds a map book almost to the end of his nose, looks up and down the street, lifts his tinted glasses, presses the map book closer, squints, looks up and down the street again, and then takes his cap off and scratches his head. It’s all pretty emphatic,  like watching a modern clown doing a skit called Lost.
‘Are you alright there?’ I say.
‘Me? No. I’m late and I can’t be.’
‘Where’ve you got to get to?’
He brings the map over, hands it to me, then takes an envelope out of his pocket – something formal, a legal appointment.
‘Well don’t worry. You’re almost there,’ I tell him, handing the map book back. ‘Are you walking or driving?’
‘Driving? Me? No! I came by bus. The man there, he said get off here. He said here was where I had to be. So that’s what I did. And now I wish I hadn’t.’
‘He wasn’t wrong, though. You’ve just turned down too early. You want the one parallel to this, over there. You can cut through that little alley if you’re pushed for time.’
‘Are you sure?’
‘Yep. Absolutely.’
‘I can’t afford any more mistakes.’
‘You’re good,’ I say. ‘You’ll be fine.’
‘Righto then. Thanks for your help.’
He gives me a broad, quick smile that seems more like a mechanical expression of the tipping back of his head, then taps me once on the shoulder with the map book, and strikes out for the alley.