Matters for concern

She had been away on business, running a course for some engineering firm in Edinburgh; this entailed three nights at a Travel Lodge. He hated these weeks. He’d have to rush to get Jane and Jason dressed and ready before he handed over to the nanny at seven thirty in the morning. At least the new nanny was more flexible and was willing to carry out mother’s help duties-he felt father’s help a more appropriate term. Then it was a mad forty to forty-five minute drive to reach the office in Leicester by about eight thirty. There he would have to face an insurmountable pile of work. He tried hard to keep focussed on his core tasks so that the workload didn’t get him down but his portfolio was so wide that this was very difficult. He worked through lunch and aimed to leave the office as close to five o’clock as possible and was normally home by just after six, even when Alice was not away on business. When she was, it was a frenetic couple of hours getting the kids ready for bed, keeping up with the washing and giving time to the children. Jane who was six helped out by reading Jason his bedtime story before they both cuddled him to sleep. Alice always frowned at the cuddle session as she felt it was making a rod for their backs, but John saw it as the only protected, quality time with Jason.

 

Once Jason was settled, it was time to hear Jane practice her reading. She was very good for her age and this again was regarded as protected time to be preciously guarded. By the time Jane had read, had had her treat and fallen asleep on his lap John was lucky to get his evening meal by nine thirty. At times he didn’t bother and simply grazed in the evening, crisps, chocolate or a sandwich. Not really a meal and mostly things that were unhealthy but which did not include cooking, and served to give him comfort.

 

Tonight was Friday and Alice would be returning home after an hour flight on an orange liveried Easy Jet aircraft from Edinburgh to Luton. She would collect her black Rover 600 and would arrive home by around seven-thirty. He hated her being away. When she had first ventured into consultancy they had discussed overnight stays as an infrequent possibility but over the first year they developed into a standing monthly arrangement. This was due to end but carried on and days were slowly added for other contracts in Yorkshire and Warwick. He felt Alice didn’t share his family values any longer but he felt guilt at wanting to curtail her activity, as she was good at what she did and enjoyed it immensely. What right did he have to prevent her from developing her career? He had chosen to curtail his own in an effort to stay near her parents and to give time to family, but he felt Alice’s drive and ambition was so threatening. The conflict in him caused resentment and great confusion to build up in his mind. This showed in the way he at times rejected closeness and affection. His response to emotional crises had always been withdrawal to an introspective, and at times of deep crisis, an almost vegetative state.

 

It didn’t help matters that they had been having sporadic sexual problems, although he always thought that their love was strong enough to see them through and she was always so forgiving, comforting him after each episode.  These episodes were usually associated with excess alcohol at weekends when John had taken to secretly topping up his large whiskey.  Whiskey did not agree with him although he had a taste for it.  He drank it to numb the conflicting feelings he had towards Alice and the derogatory way she treated him. It wasn’t in your face stuff but more subtle and far more difficult to deal with, especially in a popular “superwoman” who had her own business she was ambitious to expand and ran a family. And especially as he worshipped her.

 

On arriving home Alice would unload her car before reversing it into the small, narrow garage. Then she would get down to preparing the evening risotto or pasta dish while he and Jane were reading together. She was a whiz at throwing together the most delicious meals in twenty minutes. When Jane was settling down to sleep they would sit on the floor watching television and eat. Then he would carefully carry the sleeping child up the stairs and tuck her into bed before they both moved to either end of the settee, where more often than not he would fall asleep before News at Ten. The weekend would be spent playing catch up with household chores, with some time for the kids and some time for writing professional articles. Most weekends Alice would go off into town with Jane while he would stay at home with Jason and mow the lawn or wash the car or clean the kitchen, or carry out whatever else needed to be done around the home. Alice liked shopping and she coped best without him in tow, besides he hated being dragged round like a dog, particularly as his views on various purchases seldom were met with agreement. No he left Alice to it; she bought everything, including all of his clothing. He never felt confident enough to buy his own for fear it would meet with Alice’s disapproval. Best to stay away and let Alice enjoy herself, besides it was practical and he could get on with “his” chores. Not much time for each other amongst all of it, it seemed.

***

“John I have two faxes for you in the safe haven office…I think you had better come and collect them” Sylvia said over the telephone with more than a hint of self-satisfaction.

“OK. I’ll be straight round” he replied.

 

He stared in disbelief. One of the reports was a follow up to the escape from Bland Ward. The patient had been found hanging from a tree in woods in Northwest Leicestershire. The second told of a further escape from Bland and police suspicion that a body, found on a nearby railway track, was that of the second escapee.

***

Bland Ward was a ground floor ward in the old Tollers Hospital, one of two large mental hospitals serving the county. Once a self-contained village of Victorian/Edwardian construction with its own farm, tailor, cobbler and bakery, it had been allowed to slowly deteriorate since the early 1960s, following the now famous water towers speech made by Enoch Powell, as Minister of State for Health, during which he announced the large mental hospitals would be closed and replaced with care in the community. Over recent years the closure programme had accelerated and Charlton Hope Hospital closed in early 1996, leaving the Tollers to close by the turn of the century. The ward was small-only ten beds-it’s purpose to contain and treat patients too disturbed in behaviour to be housed on open psychiatric wards but not of proven dangerousness to warrant medium secure or high secure care. Some patients were violent and aggressive, others suicidal, and some just too difficult to manage because of the effect of distorted thought processes upon their behaviour.

 

The three of them sat in the room that had been set aside for the visiting team. John McPherson had been joined by Maureen Auld and Miriam Chevaux, a Non Executive Director of the Health Authority. They had toured the ward, spoken to staff and managers and examined policies, procedures and clinical documentation.

“I can’t believe what we have seen” he said shaking his head with incredulity.

“Yes, it’s pretty appalling” agreed Miriam.

“Well, let’s keep it in perspective” interjected Maureen Auld, “The staff are doing their best but the ward was never best suited to the purpose”

“I understand that Maureen, but we have spotted so many major failings despite the remedial action taken by the managers. It shouldn’t take us to come in from outside to spot these areas of risk…OK, lets get them in for feedback.” He said with resignation.

 

The ward manager was twenty-nine, a Leicestershire lad born and bred with five years experience since qualifying, three of these within a locked environment. The consultant psychiatrist was in his late thirties, one of the new breed but with old school prejudices and a faith in his own omnipotence. The manager responsible for the unit, which was within his locality, was in his early thirties, keen and hardworking but not going much further in his career.

 

During the feedback McPherson was critical of the wards compliance with the Care Programme Approach. The Consultant murmured half under his breath that he wasn’t going to waste his time on some Government dictat. That he had far better things to busy himself with.

 

McPherson could not contain his anger after the failings they had discovered on this visit.

 

“I’m not interested in your negativity” he swiped, “The CPA is not negotiable. It is a requirement and as such you are responsible as medical officer for implementing it.”

 

The manager for the locality spoke for the first time.

“Yes, we accept all you have said, and we are grateful for your help in pointing out the areas where we need to make improvements. The best solution for us all would be to have the Health Authority authorise the outline business case for the proposed new Psychiatric Intensive Care Unit. With a purpose built facility most of the problems would disappear. My staff have to work with what they’ve got at present.” He offered in mitigation.

 

“How do you feel about it Martin?” Maureen Auld said bringing the Ward Manager into the conversation.

“Well I agree the new PICU would be our ideal goal. We have had a run of bad luck of late. I’ve considered the four escapes to date and I’m confident that the action we’ve taken will tighten things up” He reassured. “All the staff are very shaken up by the events so far” he added.

 

Despite still harbouring doubts McPherson decided to accept Maureen’s reassurances that Bland Ward was now under control. He accepted that the Authority had its part to play in approving the outline business case so that the ‘reprovision’ plan could move matters forward. There was no other answer as the present building was too old and too outdated. No matter how much was spent it would never be brought up to an acceptable specification. He trusted Maureen’s judgement.

***

He reached the office just before eight thirty, having parked in the staff car park in front of the functional, uninteresting Health Authority building. He wished a cheery good morning to John the security guard at reception. He went to his office at the back of the building on the first floor with its view of a mass of blackthorn bush. He placed his briefcase in the corner between the small table stacked with things to read and the corner of his desk. He switched on the Dell computer and logged on using JANE 7 as his code. He alternated this code with JASON and a sequenced number each time the code required to be changed. The computer took a couple of minutes to run through its set up procedure, so he went to the nearby kitchen and made himself a cup of tea in the old brown coloured mug with the squirrel pattern.

 

When he returned to the office the computer was ready. He checked through the new “e mail” messages that he had received since the previous day, then took the floppy disc from his briefcase and inserted it into the machine. He selected File/Open, A/: and Bland.doc. He began putting the finishing touches to the report that he had worked on at home until after midnight. It was highly critical but stopped short of making the ultimate recommendation that the ward should be closed; having been dissuaded by the reassurances he had been given. He finished the report at just before nine-thirty and asked his secretary to check the spelling and formatting before printing him draft copies to go to Maureen and Miriam for approval.

 

As he was leaving the general office the phone rang.

 

“Its Maureen Auld for you John” his secretary informed him as she switched the call to hold.

“I’ll take it in the office” he replied turning and striding down the corridor.

“Hi Maureen” he said cheerily “I’ve just finished the draft of the Bland report and it should be on its way to you later this morning.

“John I need to speak to you urgently” she said, “there’s been another escape from Bland last night and they haven’t a clue how he got out.”

“Jesus!” he exclaimed. “Maureen-you need to close the ward and close it now!”

“OK but can you please keep the wolves at bay. We could do without a third independent inquiry to add to Brunton and Stamp.” Pleaded Maureen.

“I’ll do my best but you need to move quickly. Close Bland this side of Christmas and get your internal inquiry set up to report early in the New Year….. Jesus! We could do without this” he said in desperation.

“I know, I’ll speak to you soon…thanks John” She said hanging up.

***

“We must put pressure on Janet to keep Maureen Auld in check” said Paul Tanner. Tanner was seen as the most powerful of the clique of consultant psychiatrists within the mental health trust. The clique controlled and manipulated each and every aspect of trust operations to ensure that the doctors retained the ultimate authority. The clique was the power behind the throne.

“Shouldn’t be a problem, Janet knows not to provoke us too much if she values her job” encouraged Tanners lieutenant, Steve Priest.

“The nurses are getting organised and are growing in confidence since the Department of Nursing and Quality developed. Even if Auld’s team is a bunch of displaced misfits” commented Denise Challenger, Chair of the Division of Psychiatry.

“The Nursing Conference looks likely to be a success and that will serve to give them even more impetus” added Pat Weston the Medical Director.

“Look folks, there is really no cause to worry. I shall sit down with Janet Brady and spell out our position. Things will change following the conference. Give them their moment of glory; it won’t last long.” Tanner said with confidence.

***

She sat the children down to their tea, bits, in front of a video. She looked at her watch. Three quarters of an hour until he arrived home. She picked up the cordless handset, checked the kids were occupied and went into the kitchen. She took the pork chops that she had removed from the freezer before setting out for her appointment in Northampton that morning, and placed them in the ovenproof dish. She drizzled some olive oil over them, seasoned them with salt and smeared some marmalade on them before slipping them into the oven. She took the potatoes, which she had cut and scored with a knife, par boiled for six minutes in the microwave, and poured on a little olive oil before placing them in a Pyrex dish on the oven shelf above the chops. She set the table for two. Five-thirty; she looked in on the kids to make sure they were eating and reminded Jason who was absorbed by the video to do so, and then she went up to the spare bedroom which doubled as the office. She dialled the cell phone number and felt a glow come over her when she recognised his low toned south of England accent. He had been expecting her to call.

***

The quarterly strategy meeting between the health authority purchasing team and the mental health trust had just ended. John McPherson stood, left the seat he had occupied for the past two hours and approached Janet Brady. Janet was in her mid forties, a portly figure of a woman with a pretty face and a booming, warm laugh.

“Janet I’m concerned about the range and number of incidents taking place at the Trust” he confided.

Maureen Auld moved to join them listening in silence as Janet replied

 

“John we are the largest stand alone mental health trust in the country. We have to expect things to go wrong from time to time. It’s part of the risk profile and no greater than any comparable trust, as far as I can make out. Please don’t over react.” She soothed.

“I’m just as concerned about the attitude of your managers towards such incidents. They show no humility and seem to think these failures are commonplace and acceptable.” McPherson ventured. “As to comparability I can’t find any evidence against which to benchmark. My benchmark is zero tolerance. No incident is acceptable as such.”

“I can assure you that we take each incident seriously but we have to strike a balance and avoid putting staff unnecessarily under the spotlight. These homicide inquiries are so destructive and demoralising to staff” she concluded.

“Janet is right John. Homicide inquiries and internal inquiries don’t solve anything. They merely put pressure on already stressed staff. The sooner the Department of Health calls a halt to them the better” added Maureen Auld.

Feeling he had failed to make his point he changed tack.

“What progress with Bland Ward?” he asked her.

“It’s been closed since just before Christmas and much of the work will be completed by the first week in February. Dave Sowden is overseeing the work and will keep us updated on progress. He is also heading up the internal inquiry, which should report in about a fortnight” she said.

***

He had been planning his move for some time. He had watched carefully over the last few weeks the pattern of things. He had always been good at observing and putting together schemes. He knew the most vulnerable spots and the most vulnerable times. He had chosen his method and his route. They were not daft, but they were not as vigilant as they should be. At times a little complacent and he knew their weakness to be his opportunity. He had been labelled by the pompous excuse for a psychiatrist as a psychopath; little more than jealousy because of his ability to overcome adversity and stand up for himself. The attack he had carried out was totally justified, the brutal stabbing unavoidable. They had chosen to blame him rather than look at all the facts and the provocation he had endured.

 

The dinner knife had been all too easy to obtain and secrete. It was not sharp but he didn’t need it to be sharp. He had taken it from the kitchen that afternoon and it had not been missed so far. The sharps count was over and the table knife was not likely to be missed until morning now, if at all. He had hidden it in his mattress and spent the afternoon playing pool. The evening had dragged as he anticipated the taste of freedom for the first time since being sentenced six months previously and committed to hospital for treatment under section 37/41 of the 1983 Mental Health Act. He ate supper and helped himself to seconds as he didn’t know when he would have his next meal. He also saved all the spare bread from the table, which he buttered and took to his room wrapped in a paper napkin.

 

The ward stereo was always blaring. It was overbearing at times and even in his individual bedroom there was no escape until the night staff decided that it should be turned off. Tonight he didn’t care. Tonight the loud distorted base heavy music was his shroud, his protection. After supper he sat and watched television and noted all the comings and goings on the ward. He saw the night staff arrive and headed for his room. All patients could lock their bedroom doors but they could be opened quickly by staff with a special key if necessary. He shut his bedroom door, sat on the bed and listened. The music beat at him in a contortion of sound. He knew the night staff would drink their tea and listen to the accounts of the day before taking over from the day staff and carrying out an inspection of the ward and a head count. He put his hand into the slit he had cut in his mattress and felt for the knife. He took the cold Sheffield steel slowly from its resting place. He then moved cautiously to the window and began slowly prising at the window rebates, which he had noted to be vulnerable to attack. The wood rebates were surprisingly simple to loosen with the sturdy hospital issue knife. He prised the wooden strips loose all the way round and pushed at the Perspex flexi-glass window so that it now bowed enough for him to slip it loose from the bottom of the frame.

 

He stopped and listened. The music droned on. He left his room and walked to the toilet. He looked toward the day area and nursing station. Everything was as normal. He returned to his room after urinating. He closed his door, switched off his light and stuffed some spare clothing under the bed sheets so that to the casual observer he was asleep in bed. They rarely came into the room of someone asleep during the night shift. He put on his jumper and his overcoat, changed his training shoes for a pair of army issue boots then stood on the chair so that he could climb over the window ledge. The Perspex bowed easily now he had freed it and he was through the window with ease. The drop to the ground was short. He stopped still for an instant and listened; nothing. He took his bearings and headed for the low roof by the gymnasium that he had marked down as his way to freedom. There were no alarms, sensors or cameras. He knew that all he had to do was climb out of the compound before anyone noticed he was missing.

 

He yawned, stretched and pulled the blanked over his body. His back ached from sitting in the chair for a couple of hours without moving. Dawn was beginning to infiltrate through the curtained window beside him. It had been a quiet night. He decided to make some tea for himself and his two companions who were in the office. He went to the kitchen, switched on the boiler and left locking the door. He took his torch and moved to the bedroom area to carry out an inspection round. The third door he came to was closed. He looked through the spy hole. Something bothered him about the form in the bed. Dawns early light made the shape rather unnatural looking; too short to have legs. He pulled open the door and threw on the light half expecting a stream of abuse from the sleeping form. He was met by silence. He pulled back the blanket and felt a sinking feeling in his stomach.

***

“The police are issuing a press release warning the public not to approach Davies. The press have not been off the telephone all morning and they are likely to make it front page, so we’d best be prepared” warned Janet Brady.

 

The Chairman sat impassively. He looked at his Chief Executive. He thought she lacked certain urgency over the matter but when he talked to other operational managers and even to Maureen Auld he was reassured that such events happen in mental health care.

“We must be prepared to play it down. We don’t want to raise any alarm within the local population and we certainly do not want the Regional Office and the Minister taking too much of an interest. I have briefed Phil at Region and told him this is an isolated incident.” She continued. “I have spoken to the Clinical Director and to the Operational Manager at Arthur Lodge. I have told them I want a report on this incident by the end of the week.” She concluded. He felt a sense of unease. He was out of his depth and he knew it.

***

Mike Farrier had been Chief Executive of the Health Authority for seven years. For a man in his late forties he was a practised political animal and a very astute character. He allowed his directors to have their heads although he made sure that they knew what he expected of them. He allowed them to have their arguments and to deal with each other, he rarely interfered. His mind was set upon his tasks as set out by the Minister of State and the mandarins at Whitehall. He knew how to avoid the heat. He wasn’t exactly a visible figure to the troops on the ground, or a leader of men, but he got the job done without too much bloodshed. Wheeling and dealing was his forte. He listened to the briefing given by Carole McPhail.

 

“The Brunton Inquiry is due to report next week” she informed him. “Early indications are that it will not be too damaging but will make reference, like reports before it, to record keeping, involvement of users and carers, interagency working and communication”

He allowed her to finish and then said

“Carole are we worried that the mental health trust is out of control. Should we be pressing the panic button?

“I don’t think we should panic at this time. John McPherson is keeping a weather eye on things and I trust his judgement. He has a depth of experience of mental health services that cannot be equalled by anyone here at the authority….he does however feel that the Trust should take these matters more seriously. He sees Janet and her managers as too accepting of incidents and too dismissive when questioned about them”

“Ok, I’ll mention it to Janet Brady tomorrow at the Chief Execs meeting. What about the acute services review, where are we on that? He asked.

***

He had managed to get through a pile of work. He cleared all the outstanding ECR requests which he had refused and had dictated all the covering letters. The pile of issues on his desk was however less than dented. He felt like King Canute as he let the tide wash over his feet, except it seemed in recent years to be up to his chin and he was treading water. On many occasions over the past two years he had lain in bed, alone, unable to sleep just turning matters around in his mind. The pattern was plain for anyone to see but no one seemed to see it but him. He felt so isolated. If he made a fuss he would be seen to be a trouble maker-a label that had dogged him for the greatest part of his career. In fact since qualifying he had always seemed to be fighting some just cause or other against the complacency of the system. As a student he was able to be optimistic and to seek out good in all the bad practice he witnessed in psychiatry in the mid to late seventies. But not now; now there was always a cause.

 

His main cause over the last thirteen years had been to fight for a fair system of community care for people with severe mental illness. He had watched the changing scene as dependence on the large state mental hospitals had declined and it had supposedly been replaced with “community care”. He had as a community psychiatric nurse witnessed at first hand, over a four-year period, the sort of suffering that individuals, their families and their communities had to bear in the name of community care. He had seen schizophrenics largely abandoned to their own devices in high-rise squalor. He had seen worried families left to cope and neighbours worried sick about the possibility of fire or other harm caused by someone with severe mental illness. He had started a sort of environmental scanning-a term he picked up while studying for his diploma in management studies. He would cut out all references to mental illness/mental health from his daily newspaper, The Independent. Since starting in 1990 he had stuffed three lever arch files full of articles covering the negative side of community care. He had seen resources diverted to people with less severe mental health problems and knew that such resources were vital to making community care for the insane a reality. He used terms like insanity and madness, incurring derision and scorn from colleagues, because he had also witnessed the secreting of this reality behind comfortable terms that he believed effectively denied madness in society existed. Terms like mental health hid a multitude of sins and allowed professionals to move into less difficult and more rewarding work such as counselling and other therapies; thus relieving them of responsibility for keeping the insane, jettisoned from the shrinking institutions, functioning in the community.

 

He hated sleeping alone and he missed her so much.

***

The workshop had gone well. She felt alive in the world of management consultancy. She knew she made a difference and she enjoyed it. At home things had been very difficult. A running sore rather than constant confrontation but she had begun to feel unloved. She even suspected that he hated her. When she was working she was on a high. She felt respected; she felt needed. It had been a particularly difficult time at home of late, although she suspected he had not even noticed. He didn’t seem to care; too absorbed in his own work. The evening meal had been taken and the small group of participants had left leaving the three of them in the bar. Peter had made an arse of himself again, behaving like a lovesick goat and trying to get her into a relationship. She had made her excuses, something about being fresh for the morning session, and had gone to her room. He had done the same leaving Peter sipping his drink alone. She had waited ten minutes. Freshened up and redone her make up. She took the bottle of wine from her briefcase and went to his room.

 

 

Reviews

[Claire Twinn]

I really enjoyed this chapter John. I love the way it flits from one thing to another and yet somehow all fits together beautifully.

[John Alexander McFadyen]

I tried to make it reflect the sometimes dijointed nature of real life. And to fit in the detail. I hope the rest can be as good for you Claire. Many thanks.