Chapter 107: Twenty-Seven People
The draft report went to the provider in July.
The final version was published on the eleventh of September.
I read it on a library computer because my phone would not open the file.
Sixty-one pages. Five domains.
Two of them rated inadequate, and the service placed in special measures.
Everybody who has told this story since has quoted the phrase from page four, which is “medicines were not managed safely”.
I want to do the other thing, which is to say what happened to people.
There were twenty-seven records. I have to break them into three groups, and only one of the groups is what I thought I had found.
The first group is nine people, and those nine are the reason for all of it.
Cynthia Okwe is in that group.
She was prescribed a sedative to be given only when required.
The chart showed it given on eighty-one occasions in one hundred and forty days, most of them between nine and eleven at night.
There was no record of any review. The review is the whole safeguard.
Without it, when required means whenever the floor is short.
On the thirteenth of November she was sedated at ten forty at night.
At eleven the next morning she went over sideways out of a chair and fractured the neck of her femur.
The report does not say the sedation caused the fall. Reports do not say that.
It says the risk of falls associated with that class of medicine was not assessed or reviewed at any point in eleven months.
She had surgery, then a chest infection, then another one.
She died on the ninth of February in a hospital eleven miles from the room she had lived in for six years.
The coroner opened an inquest and resumed it the following spring.
The conclusion was a narrative one, which is a paragraph of English rather than a single word.
The paragraph contains the phrase “sedation which was not clinically reviewed”.
That paragraph is nineteen months of process.
It is worth exactly what it is worth, which is not nothing and is not her.
Bill Trewin is in the same group.
His Parkinson's medication was recorded as given at six thirty every morning for at least fourteen months.
It was in fact given at the round, which ran between eight and half past nine.
Two to three hours late, daily, for over a year.
He was walking with a frame in the spring.
He was hoisted by the following winter.
The clinical evidence is that some of that decline was the disease and some of it was the timing, and no one on earth can tell you the ratio.
He is alive.
He was alive when I last had news of him, in a different home twenty miles away, with a daughter who drives on Sundays.
The second group is six people where a medicine was given wrongly or not given, with no identified harm.
A woman on the first floor missed her antibiotics for two days. She got better anyway.
That is luck, and luck is not a care plan.
The third group is twelve people, and this is the part I have to write carefully.
Marjorie Hale is in the third group.
Against her chart, on four of my dates, were the initials A.M.
A.M. was an agency nurse called Alan Mowbray who worked eleven shifts at Willow Bank in three years.
He signed his rounds in the clinical room before he did them, because it was faster, and then he did them, properly, in full.
The board in the entrance hall had him down for the floor above, because the board was updated by whoever remembered.
So the record was false and the medicine was given and nothing whatsoever happened to Marjorie Hale.
I was right that the record was a lie. I was wrong about what the lie meant, in twelve cases out of twenty-seven.
If I had stood in a car park in March shouting twenty-seven, I would have been shouting a number that was forty-four per cent wrong.
The wrongness would have been the story.
Nine. Six. Twelve.
Nine is the number. Nine is enough. Nine has names, and two of them are in this chapter.
Priya rang the night the report came out and asked whether I was all right.
I said I was reading page thirty-one for the fourth time.
“Which part?”
“The part where they list the residents by initials to protect their privacy. C.O. Eighty-six. Female.”
“Yes.”
“She had forty-one years at St Brendan's and she made a bed better than anybody I've ever met, and in the document that finally says what happened to her she is two letters.”
Priya said, “That's why people like us write the other thing down.”
I said I would write it down. This is me writing it down.