First Impressions

(First published 7 October 2015)

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I was nine years old the first time I remember visiting a hospital. It was late 1970 and my maternal grandmother just had an operation on her right foot to remove a painful bunion, something my father explained, was a lump on the side of her foot. She had the procedure carried out at the Bridge of Earn Orthopaedic Hospital, a familiar landmark to many, its wartime single storey buildings situated just east of the M90 motorway as it crosses the River Earn, just south of Perth. The hospital was constructed at the beginning of the Second World War to deal with the expected casualties from the fighting and opened in 1940 with space for 1,020 patients. Early admissions came mainly from neighbouring military camps, and the lack of expected air raids led to beds being used by three British General Hospitals, patients with tuberculosis and prisoners of war. The busiest time for the hospital came in 1944, initially from casualties of the V1 and V2 bombing of London, and then the Normandy invasion. Following the war in 1947, an orthopaedic unit from Larbert was transferred to Bridge of Earn and it was predominately for this discipline that the hospital gained its reputation until it finally closed in 1992.

My grandmother had a part time job as a home help and was a fit, healthy woman in her early fifties at the time of the procedure. Her foot had been troublesome for a number of years and it was becoming increasingly painful, especially during her sporting activity, lawn bowls, for which she held a great passion. My father, a chiropodist with the NHS, had spoken to the family doctor, and he arranged an appointment with the surgeon and the bunion was duly removed as an in-patient procedure some time later. I cannot recall much of the visit to see her recovering from the operation other than the smell on the ward of antiseptic, which was quite different to that in my father’s surgery or even the local dentist – and the nurses, who looked pristine in their starched white uniforms. My grandmother was sporting a below-knee plaster cast on her right leg and only her toes were visible and I remember being asked to count them in case any were missing. None were, but she had gained something extra! The operation was a simple arthrodesis; a procedure that corrects the position of the great toe and involves having part of the joint removed and a steel pin or wire inserted through the end of the toe down into the long metatarsal. This pin and the plaster cast would hold the toe in the correct position until the surgery healed in around six weeks and where the pin protruded from the end of the toe, it was capped by a small cork and it was this that held my attention for the duration of the visit. She remained in hospital for a week then returned home to convalesce until the pin and plaster cast were removed around a month later. The operation was deemed a success and a few months later she resumed her bowling with renewed enthusiasm, going on to win a number of championships and trophies in the following years. The operation was carried out on her leading foot as she was right-handed, and as such, the toe joint remained straight with the foot flat on the ground when she released her bowl. By contrast, the great toe on her trailing, left-foot was fully bent back or extended when she released and had the problem occurred on this foot and she had undergone the same procedure, then it would have been much more difficult for her to be able to return to the game she loved so much and in that respect, on this occasion, she was fortunate.

Four years later she was back in hospital for another operation. This time she was in the relatively new Victoria Hospital in Kirkcaldy – a general hospital encompassing the whole gambit of medical specialisms, but this time it was not for a minor joint problem but something altogether more serious. What she would not be aware of at the time was that this episode of ill-health would herald the circumstances of her death a dozen or so years later through a number of simple but completely avoidable mistakes by those she entrusted with her care.

Agnes Wilson was born on 2 October 1916 in the small mining village of Lochgelly in central Fife, midway between Dunfermline and Kirkcaldy. It is a date that would have some significance in my own life some ninety nine years later and is just one of a number of quite remarkable coincidences you will learn about in due course. It was a time of turmoil and slaughter in the middle of the Great War; the Somme Offensive in northern France was entering its bloodiest phase with many casualties from fighting in the Battle of Thiepval. In the collieries and pits of central Fife the outlook was just as grim. Desperate working conditions and real hardship with a dark sense of foreboding saw thousands of young men heading south to help the war effort, leaving behind families struggling to put the basics on the table – a task made even more difficult with the loss of their sons to the battlefield rather than the coalface. The coming decade at the end of the war saw little improvement in their prospects and with so many sons and fathers killed in action the future must have seemed devoid of hope for those left behind. By the time she was thirteen, Agnes had left school and was in work at the Jenny Grey Pit washing and separating coals and rubble at the pit-head where she worked for three years. She was one of five children; two sisters and two brothers and perhaps the only remarkable thing about their formative years was that they survived through into adulthood during times of high infant and child mortality arising from the poor sanitation, not to mention malnutrition and work related injuries down the pits, which were often horrific. By sixteen she had left the pits and went to work ‘in service’ in Edinburgh – cleaning mostly in some of the grand Georgian houses in the New Town where she lived in servant’s quarters before returning home to Lochgelly on her days off. Sometime during the next few years, she met my grandfather, Tom MacDonald, an apprentice blacksmith and a romance started and they were married soon after in 1938 and moved into a ground floor two-roomed tenement next door to the West School in the town. Two years later their first child appeared – my mother, followed two years later with another girl, both born at home with the doctor in attendance.

It is difficult to imagine today what living conditions were like in this working class mining village during either War when both my parents and grandparents were born. From the stories I have heard over the years it must have been unrelentingly arduous; outside toilets, food rations, freezing winters without any heating other than the coal fire – and yet these times are remembered in good terms and with fond memories. The family lived in these sparse conditions throughout the war and beyond until the incredibly harsh winter of 1947 when they moved into a brand new prefab on the edge of the village opposite the golf club. Perhaps unsurprisingly, they endured the usual childhood illnesses of the time – chicken pox, scarlet fever, mumps, influenza were all unwelcome visitors at some time or another, yet I cannot recall my grandmother or grandfather telling me of a time when they were struck down with anything that required a visit to the doctor, never mind a hospital. Until the bunion started to hurt.

I had just started secondary school in neighbouring Cowdenbeath when she started to feel unwell. It was 1973 and we had just returned from a family holiday near Oban where she had experienced several bouts of abdominal pain over the fortnight. I suspect she consulted the family doctor on her return as her first appointment with the hospital consultant coincided with my first day at Beath Junior High. It was ‘woman’s troubles’, my father explained later. And she was to have another operation.

It was over a decade later before I discovered she had ovarian cancer and that the operation was, of course, a hysterectomy, but at the time it was just another mysterious illness attributed to the fairer sex under the guise of ‘woman’s troubles’. Whispered quietly, it was a subject that was to be acknowledged but not discussed and therefore completely misconstrued. An approach that my father took quite regularly whenever a topic came up that he was uncomfortable with. A few days after her operation, I went to visit her again with my mother and father. This time she was on the seventh floor of the new tower block at Kirkcaldy’s Victoria Hospital, which seemed quite a contrast from the wartime buildings at the Bridge of Earn where she was four years previously. I can recall spending most of the visiting time looking out of the window with its panoramic views over the town rather than speaking with my grandmother, but then what thirteen-year-old boy would do otherwise? Besides, she looked in great health and not unwell in the slightest, sitting up in bed and castigating my mother for making a fuss of her. I cannot say I had any worries for her.

There were a number of follow-up appointments at the hospital; check-ups every now and then, but she made a remarkably quick recovery and by the time the following Easter arrived, she was back on the bowling green and as bright and enthusiastic as ever. There wasn’t anything to warrant any concern as far as I knew. In the years following her hysterectomy she attended the outpatient department at the hospital perhaps once or twice a year. Occasionally, I would accompany her, taking the bus down from Lochgelly through Cardenden to arrive at the hospital forty minutes later for the appointment with the doctor. She was always the epitome of great health, always smiling and always unfailingly respectful and grateful with every doctor that she consulted. And they were always content with her, with good reason, as her progress back to full health was excellent and there didn’t appear to be any recurrence of whatever ‘trouble’ she had that required the operation in the first place. On each visit to the hospital she saw a different doctor, whoever was on rotation at the time in the out-patient department she attended, but the result was always the same – “very happy with your progress and we’ll check you again in six or twelve moths time” – and off she would go until the next visit.

Eleven years pass and the operation was a distant memory. I had left school then taken a year out before starting Podiatry College in Edinburgh, graduating in 1983. My first post was based at the same Victoria Hospital in Kirkcaldy where my grandmother had undergone her hysterectomy and where she still visited very occasionally for her ‘check-up’. She was sixty-seven years old now but still full of the energy and vitality she always exhibited – and still winning competitions at the bowling green. Life was good.

Shortly after I started to work in the September I took her down one evening and showed her my new surgery in a wing of the hospital that had been recently built. The Whyteman’s Brae complex consisted of five specialist wards for psychiatric, psychogeriatric and geriatric patients and several clinics for physiotherapy, podiatry and the other professions allied to medicine that were applicable in such a unit, such as speech and language and occupational therapy. I had been very fortunate as my surgery was pristine and fitted out with the latest equipment and I remember the look of pride not to say amazement when my grandmother walked through the door.

“You’re in a lovely place” she remarked “and if you can look after your patients they way I’ve been looked after here, then you will do very well indeed.” Six months later she started to feel “off colour” and by the time the bowling season resumed that Easter she barely had the energy to play the opening tie. But there was other trouble on the horizon. A week or so before the Bowling Green opened the National Union of Mineworkers called a National Strike and the miners’ walked out of the pits and collieries in protest at the proposed closure program by the NCB under Ian MacGregor. My grandfather, had been retired for five years, but had been through the previous National Strike in 1974, which had been quite traumatic. He was, strictly speaking, not a miner but a blacksmith on the surface and responsible for, amongst other things, the heavy steel cables that raised and lowered the pit cages down the shaft and as such he was permitted to undertake essential maintenance work by the Union, but it was not a comfortable situation for him crossing the picket line every day, albeit with his fellow miners grudging consent. If they were fighting for their jobs, some would have to ensure they had a safe pit to return. Ten years later, these bitter memories were reignited against a different background.

A few days after the bowling season started properly in early May, Agnes visited her GP as she was becoming increasingly tired and exhausted by the slightest effort. A blood test was done and a few days later she was in another hospital for a transfusion. Milesmark Hospital in Dunfermline had a couple of medical wards similar to the geriatric unit at Whytemans Brae and it was here she had her first units of blood. I was unaware of these events at the time and only discovered she had been in hospital a few weeks after the transfusion after I returned from a holiday in Ireland. “It was nothing to worry about”, she said, dismissing my questions. “Just needed a little top-up”.

I don’t know if she knew what was really wrong or whether a diagnosis had been made at that stage, but should that have been the case, it would have been so characteristic of her to play things down. I don’t recall hearing any complaints about her health, ever. Even over the coming months.

During the summer of 1984 and again with a backdrop of a National Strike, Agnes was in Milesmark another three times for more blood; the tiredness and exhaustion returning increasingly and more obvious as the weeks passed. More worryingly, just before her final admission, she began to bruise quite readily and in addition, there were several areas of what looked like pin-prick sized spots on her arms and legs. I had assumed, until then, that her malaise was simply because she was anaemic, but I was wrong. The day after she was admitted at the beginning of October, my father telephoned to say that the consultant had requested a meeting with my mother, aunt and grandfather and the news was not good. She had developed acute myeloid leukaemia and it was unlikely that she would make a recovery this time. By the time I reached the hospital that evening she was already heavily sedated and barely able to speak, but still managed to smile. The following morning she slipped into a deep sleep and four days later, she died.

It was the first close relative to me that had died. Both my maternal grandparents were a huge influence in my life, but my grandmother – or Nana – especially. They lived in Gordon Street a hundred yards from our house and I spent much of my childhood with them. I was the eldest grandchild; my sister four years later then our cousin two years after her. My grandfather, being an engineer and blacksmith, had a fabulous wooden garage he built himself, stuffed full of every imaginable tool and implement for all sorts of jobs; a workbench made from railway sleepers and shelves overflowing with jam jars full of screws, nails and three-in-one oil in copper pourers. I used to stay over most Friday nights and on the Saturday morning I helped wash and polish his car – an Austin 1300 – before we started on a job in this magic den of his. He made me my first ice axe from a miners pick welded on to a tubular metal shaft with a bicycle-handle grip to protect bare skin. He was a short, stocky man with a head of bright, thick, white hair lightly bisected with a nicotine-orange streak in his later years. I can still see him standing at his bench in dungarees – an Embassy Red with two inches of quivering, curving ash hanging impossibly above the heavy vice before him. He managed a full cigarette once, the whole ashy length hanging in flaccid surrender whilst he planed some wood. I doubt he even noticed. He was everything you imagine a miner would be; tough as nails, strong as an ox with a dour Fife personality through and through. There is a photograph of the two of us at the stile in the path above the east sands in St Andrews when I was three years old. It provokes both morbid and sobering thoughts when you realise that after the passage of half a century, you have become the same age as your grandparents in faded family photographs.

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But if my grandfather gave me my love of taking things apart and finding out how they worked – a practical influence – it was my grandmother’s inspiration in so many other ways that I still treasure to this day. She was a calm, sagacious woman and although she only travelled out of Scotland on a handful of occasions and never further than York or Blackpool, her outlook was anything but parochial. She was the one person I could tell anything to; an absolute confidante and on the one occasion I did run away from home aged eight (my father first giving me a hand to pack my suitcase) I made it no further than her back door. As I write this, it is thirty years since she died and there is rarely a day that I don’t still think of her, but at the time of her death I felt strangely unemotional and disconnected. Perhaps it was the relative suddenness of it all – I had just a few days to prepare for the inevitability yet it still didn’t seem to sink in even on the day she died. It was a surreal feeling and not uncommon, as I discovered subsequently with surviving relatives who experience sudden death of a loved one. In the blink of an eye she was gone and you are thrown into the aftermath of things to organize and people to call so that the time to allow grief to have the time to form properly is deferred. That is how it seemed in hindsight, but at the time it was as though I had become a spectator in a drama witnessing the incomprehension of my grandfather to the inconsolability of my mother and aunt and realizing immediately that the guiding insipration that was needed at this time was not there anymore.

Four months later, on a Friday afternoon, I had an out-patient clinic running at Whyteman’s Brae in Kirkcaldy when I noticed my penultimate patient of the afternoon had the same name as my grandmother, however her address was in one of the small fishing villages in the Neuk of Fife. But when I collected the patient notes from the front office, I discovered that the records office had sent the wrong notes and had inadvertently sent those of my grandmother instead. Thirty-years ago it took some months to close patient records, especially where care was spread over different hospitals and all the correspondence and ward notes were gathered and filed manually – and it wasn’t uncommon to receive a number of wrong records in any clinic, but it still came as something of a shock when I noticed the address on the front label. I took it back to my room with the rest of the bundle and sat down and began to read.

The first set of notes were from the Bridge of Earn Hospital about her foot surgery fourteen years earlier including the referral letter from her General Practitioner in Lochgelly, Dr Roy Blues, his illegible handwriting immediately recognisable. I could just make out ‘bunion’ and the name of the surgeon, but that was about it. The surgical and nursing notes followed, then the paperwork changed to the Victoria Hospital and her operation for her ‘woman’s troubles’ – the ovarian cancer. This was my first surprise. Even after the passing of the years and her death, I still hadn’t known that her hysterectomy had been performed for underlying pathology so the notes from her gynecologist, Dr Hill were a revelation of sorts. There was a letter to Dr Blues shortly after her hysterectomy informing him that the operation was a success and that she would be put on a maintenance regime of cyclophosphamide and reviewed in six and twelve months time. This was followed by a series of out-patient records that coincided with her annual or bi-annual check-ups before the final tranche of records from Milesmark leading up to her death. But it was the final piece of correspondence that really stopped me in my tracks. It was a letter from a Consultant Haematologist to the doctor in charge of her care at Milesmark during her final weeks. It was a single piece of A5 white hospital notepaper, neatly typed with two short paragraphs; the first, thanking the doctor for asking him to review my grandmother’s case and the second, informed him that she had “developed acute myeloid leukaemia which will be refractory due to the prolonged exposure to cyclophosphamide.”

I hadn’t heard the term ‘refractory’ before, but could easily make an informed guess as to what it meant, given the eventual outcome. Nor had I heard of cyclophosphamide and why she was on such a regime in the first place. There was no internet and no quick answers then, so it had to wait until the end of the clinic and a visit over the road to the hospital library before I found what I was looking for.

Cyclophosphamide is a drug that was commonly used as an adjunct therapy in the treatment of some cancers, including ovarian tumours. One of its actions is as a bone marrow suppressant in particular to the formation of T lymphocytes, a form of white blood cell that are thought to increase the risk of further cancer developing. The literature went on to state:

“Cyclophosphamide is used for the treatment of numerous malignant processes and certain autoimmune diseases. Goals of therapy are prompt control of the underlying pathological process and discontinuation or replacement of cyclophosphamide with less toxic, alternative medication as soon as possible in order to minimize associated morbidity. Regular and frequent laboratory evaluations are required to monitor renal function, avoid drug-induced bladder complications, and screen for bone marrow toxicity. Cyclophosphamide has severe and life-threatening adverse effects, including acute myeloid leukemia, bladder cancer, hemorrhagic cystitis, and permanent infertility, especially at higher doses.”

I re-read her notes again and couldn’t locate a specific entry for the proposed length of the course she had been recommended after her hysterectomy. The letter from her gynaecologist to Dr Blues was the only mention of the drug and that she was due to be reviewed in six and twelve months time, but that was it. Even on her subsequent out-patient reviews there was never mention of the drug again – most of the entries simply noting that she looked fine and had no problems before suggesting a review at some future point, usually twelve or eighteen months time. I then read through her later notes from Milesmark and found a hand-written entry from her first visit the previous year when she received her initial transfusion, made by a ward doctor following a telephone call with the haematologist. Underlined, it read simply, “discontinue cyclophosphamide immediately”. At the time she had been on the drug continuously for eleven years, but I couldn’t find any information regarding recommended treatment courses so I had no way of determining if this was normal or otherwise, but the ‘prolonged exposure’ was sitting uncomfortably in the back of my mind by that stage and I had an inkling that something was not quite right.

I took her records home with me that evening, in contravention of hospital policy, of course, but I needed to find out whether anyone else I the family was aware of this. They weren’t; at least according to my father. Nor did he know anything about cyclophosphamide or its ability to cause AML or what her recommended course was. Rather he was dismissive. “What do you want to know that for?” he asked, with not a little menace in his voice.

It is worth remembering that the issue of medical malpractice was very much under the radar until a relatively short time ago. In the early 1980s, it was generally accepted that mistakes could sometimes happen, but the apportionment of blame and liability for such a concept was entirely foreign in the National Health Service. I have heard my grandmother say on many a time that accidents occur for any number of reasons but providing there was no intent to harm, there should be no blame or recriminations (most usually when waiting for a confession and explanation of any number of misdemeanors by myself) – and so it seemed a likewise philosophy was similarly adopted by my father as he contemplated what to say. He was by then, a district chiropodist, employed by the same NHS Board in Fife as I was and any thought about raising any concern over an incident like this would not have even entered his head. The Health Service was very much regarded as a big family; a close knit organization with a proud tradition in Scotland but with a definite hierarchical structure and it would, with hindsight, have been a formidable prospect for someone even in his position to challenge established medical practice, especially over something he would have little, if any, authoritative knowledge about. “How do you know she was on it for too long?” he asked. And of course, he was right. I didn’t know that for certain. Perhaps she needed to be on a maintenance regime of the drug for that eleven years and it was just an unfortunate consequence that she went on to develop AML, but it was the prolonged exposure that still sat firmly in my thoughts later that night as I pondered what to do.

On the Monday morning I looked through the hospital directory until I found the number for the Consultant Haematologist, Dr John MacCallum, whose office was located in the main hospital block. I wasn’t at all sure what I would say to him or what his reaction might be. I was twenty-three years old and only been graduated for around eighteen months and I remember being extremely nervous when I eventually dialed his extension. His secretary answered and I asked her if it would be possible to see him about a patient later that day. She suggested after his ward round at 11.30am.

Dr MacCallum was a quietly spoken and extremely courteous man who had taken up his consultant’s post a year earlier and welcomed me into his office with typical grace. “How can I help you?” he asked. My hands were shaking as I passed him my grandmother’s records and opened them at his letter.
“I was wondering if you could tell me what this means?” I said, pointing to his second paragraph. He read the letter then looked back at the previous pages then said, “This patient died last year. What is your interest in this exactly?”
“She was my grandmother.” I went on to explain the circumstances of my discovery, courtesy of the patient record department.
“I see.” He said, before he filled in the gaps. He informed me that he had asked to review my grandmother’s records the previous year, shortly after she had her first blood test in the weeks after the opening of the Bowling Green when she started to feel unwell. Her blood test showed abnormally low numbers of both platelets and white blood cells and he had flagged the result up for further clinical investigation. The transfusion she had was not for haemoglobin for anaemia as I suspected, but for platelets. She had a bone marrow aspiration carried out, which again I knew nothing about at the time, and this fuelled his suspicions that she was starting to develop a form of leukaemia. It was at that point he recommended discontinuing the cyclophosphamide. Later, when she began to exhibit the bruising and the pin-prick haemorrhages on her arms and torso, which he called thrombocytopenia, he made the final diagnosis of AML.
“How long should she have been on it?” I asked, acutely aware I was on difficult ground.
“I would think between six and eighteen months.” He replied. “But that would depend on the diagnosis at the time. I’m not sure what happened here with your grandmother, it was possibly an oversight or a mix-up with her prescription, but she had been exposed to this for quite some time and that wouldn’t have helped.”

I tried to take in what he was saying and thinking how to reply when he said; “I’m sorry you had to find out like that and I’m really sorry for your loss.” And I could tell that he was genuine with it. He handed me back the notes and suggested I return them to the medical record department and that was that. I didn’t find out any more. There was no investigation to determine who knew what or why. I’ve no idea if my grandmother was even aware that it had been the chemotherapeutic drug she had been prescribed all those years that was the likely cause of her death. She may have been informed, I forgot to ask, but if she had, it was probable that she would have kept the information to herself anyway, that being the measure of the woman she was. She certainly wouldn’t countenance a fuss.

Trying to determine what might have happened is simply conjecture. The failure, if that is the correct term, could have been in several areas. There was no computerisation then and medical notes were anything but contemporaneous and standard clinical practice was more of a verbal art form handed down from senior consultants to their protégées than in published guidelines and protocols. Certainly someone should have realised that she had been taking the drug for much longer than usual, but who and when? The environment wouldn’t have helped; the continual merry-go-round of registrars, house officers and trainee doctors through the various specialisms in the hospital set-up provides an obvious impediment to continuity of care where records may not be as detailed as they could be. There was no forward review of her medication written up in the notes for guidance in future consultations, just a record of how she presented and how she felt. It was, in all probability, a simple administrative error; an oversight, as the consultant had suggested; an unfortunate error but one with significant and avoidable consequences.

I returned her notes to the records department later that day and filed the slip with the other Agnes MacDonald’s podiatry treatment from before the weekend in the correct patient file. That was the end of the matter. There was nothing else I could have done and even if there was I don’t know if I had the capacity to take it any further and whether it would have done any good. The philosophy was different then and it was generally accepted that the Health Service, as with most of the institutions of the State always acted in the best interests of the individual and where the outcome was not as expected and someone went on to suffer loss, injury or life, it was seen, from my perspective at the time as a tragic mistake; something to acknowledge and learn from rather than apportion blame or liability. Hospital management was simply administrative and supported clinical practice whose principal oversight was through the various consultant committees. However, changes were on the horizon with the recent publication of Roy Griffith’s report on general management in the NHS but his recommendations would take time to filter through, but even then it is doubtful if they would identify simple failings of the kind that compromised my grandmother’s care.

I am being careful with my words as I do not seek to apportion any blame; I do not find the concept helpful in the slightest as we understand in its current lexicon and I think I still share my grandmother’s philosophy too in that providing there is no intent to harm there should be understanding and a learning rather than retribution and punishment, but I am only too well aware such a view is not in fashion much these days. The pendulum has very much swung in the other direction since my grandmother’s death and after the likes of Shipman, Alder-Hey and the countless other ‘scandals’ in our State Health Service, there is an entire industry devoted to medical malpractice with enormous attendant costs. Countless Public Inquiries with armies of barristers, solicitors and traumatised relatives pouring over endless evidence of failings in care has achieved little more than promoting a defensive culture riven with fear and intimidation, not least because of the enormous liabilities the NHS is accruing from an equally expanding battery of claimants. Such are the times we are in, but it would have seemed absurd, even wrong to seek financial compensation or bring someone to task for a simple oversight that had inadvertently contributed to someone like my grandmother’s death, even though such an approach would not be out of the norm today and probably even encouraged. Especially by the industry geared up to profit the most out of it – our legal profession and in particular those concerned with regulation and compliance.

Thirty years ago I was a new entrant into our National Health Service – a lowly foot soldier, as it were, but nonetheless very enthusiastic about my profession and its prospects. It seemed a time of great promise and hope as I was instilled into a great institution founded on tremendous principles – and there was another more personal connection closer to home. The wife of Aneurin Bevan, the architect of the NHS, was Jennie Lee, later Baroness Lee of Asheridge, was born in Lochgelly and very much one of my grandfather’s favourite people and the subject of many a tale. She was ten years his senior and he could well remember her firebrand style supporting the miners through their various struggles in the years before she became a prominent Member of Parliament in her own right. The prospect of a career in the Health Service was something really I looked forward to. It seemed worthwhile and exciting. It was also set in a time of great innocence and naivety, for me at least. But the coming years were about to change all that.

It would take ten years and a completely different set of circumstances before my views about ‘great’ institutions of State and their responsibilities and functions were challenged again and another two decades after that before that any lingering confidence in them finally dispelled.

The Visit

(First published 3 November 2013)

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There is always a danger, when looking back over one’s childhood, of succumbing to nostalgia and remembering only the happy events – those joyful times that leave an indelible mark in our memories to cherish when we get old.

Growing up in Lochgelly during the 1960s and 1970s offered plenty of opportunities to add to the collection. A proud, working-class mining village set amongst the beautiful scenery of central Fife, perched high on its own little hill with panoramic views over the Braes towards the Meadows and Benarty and Lomond Hills, then out along the East Neuk before turning south over the Loch that gives the village its name. But it wasn’t all Utopian bliss. And sometimes the real horrors lie hidden for years.

Like many youngsters in the town, I enjoyed a number of jobs that would help supplement the weekly pocket money allowance from my father. Picking tatties down at Ernies, doing the shopping for elderly neighbours and bagging the monthly one-ton coal delivery at my grandparents. Grandad’s job as a blacksmith with the NCB came with regular extras, but my steady job was as a paper-boy with Dougie Dickson who ran the newsagent on the corner of Auchterderran Road. The early rise could be a real pain at times, especially if I had been reading under the covers the previous night or when the alarm sounds alongside a thunderous cacophony cascading down from the heavens onto the tiles above my head. But it was also a joy – walking into the sunrise down Auchterderran Road then over to Cooper Ha’, along Launcherhead Road and up the Auld Guige on a warm spring morning with the hedgerows teeming with birds before anyone else was up and about was a great place to cultivate a fertile imagination. Most of the time we just delivered the papers and magazines, but for a short time in 1973 we had to collect the money too, so on a Friday, after school, it was out with the bike and a bag of change and round the doors for a second time that day. We had a small rise from Dougie to compensate for the extra round, but the novelty and pay rise soon wore off and it became a chore.

A Friday collection round during November that year took a sinister turn. My ‘home leg’ was MacGregor Avenue, which used to look out over the Plantin (short for Plantation or Planting – which I have never been able to determine). I lived one street up in Stewart Crescent so I had only a few calls left when I turned the corner by the water tank that looked out over the second green on the golf course – and into the west end of the Avenue. A short way down I stopped to collect the paper money from a house, left my bike at the gate and walked the sort distance to the red door. I was about to knock when it opened and Mr King was waiting for me. He was a familiar figure – a regular on the golf course, he would often give the young boys some advice and coaching. Short, stocky with thick arms and legs – he looked like a celtic Gene Hackman. Whilst the coaching was always welcome, there was an edge to him and he had a quick temper and tongue and was never gracious when playing behind, always the first to shout “out the way” if he wanted to play through.

I hadn’t really spoken with him directly though and certainly never one to one, so I was a little apprehensive when he announced, “Come on in, I’ve got something for you.”

At a time when adults were to be respected and trusted it didn’t cross my mind to refuse, so I walked past him into the hallway as he closed the door behind me. Perhaps what unnerved me most was his attire – a short, grey, toweling dressing gown – and as he climbed the stairs I had a good view of his thick hairy calves. “I’ve seen you on the golf course” he said without looking back, “I’ve got some golf magazines for you, come on up..”

The layout of the house was the same as my own and he turned at the top of the stairs I realized he had gone into the front bedroom. His head appeared round the corner and he smiled and said “Come on – you can carry them down.”

When I reached the top of the stairs and turned around he was waiting by a dressing table just inside the doorway. There was a pile of black and white magazines on the table and he gestured towards them. “That’s them there” he said ‘you’ll get lots of good tips from them.” He picked them up and handed them to me, then he leant down and opened the top drawer of the dressing table and pulled out another magazine. This one was in colour and had a half-naked woman on the front cover. I recognised it from one of the top row collection Dougie had in the newsagent shop. “What dae you think of this?”

As I stared at it, he put it down on the table next to a vanity mirror and brush set – the same as my grandmother’s – then he reached round and grabbed me by the back of the neck. “Have you seen one of these before?” he asked, as he reached inside his dressing gown with his right hand and pulled out his semi-erect penis and started to stroke it.

I was transfixed with fear and couldn’t move – for a second or two – then I lurched back and broke his grip before turning and fleeing down the stairs and out the front door. When I was halfway down the garden path he shouted after me, “Tell anyone and I’ll fucking kill you.”

I was a long way down the road when I bumped into a friend of mine, also collecting paper money and I told him what had happened. “What are you gonna do?” he asked. “You going to tell your dad?”

“No way” I replied.

I had forgotten about this incident. Completely. If ever the topic of paedophillia came up, I would have an opinion, of course, just the same as anyone, but I would always qualify it be stating that I was very fortunate and hadn’t experienced anything remotely like it in my life. Like most, I find the practice abhorrent. Like most, in an abstract, detached way. Or so I thought.

One Friday evening in late may during 1998 I was visiting my parents after returning from London for the weekend. I parked my car outside their house at the foot of Boyd Place and started to gather my things. As I opened the door and looked up, an old man was walking towards me on the pavement and as he passed he looked down at me and our eyes met. In that instant a scene started playing in my head, just like a film – and immediately I was back in his bedroom twenty five years earlier. Again I was transfixed and couldn’t move but this time with shock rather than fear. As he walked past me he turned and glanced back and I sensed the look of recognition in his face.

I cannot clearly recall the next few moments but I remember my mother standing at the window looking out with a smile and waving and then I was walking down the road towards him. I pulled up a few paces behind, keeping up easily as he tried to increase his pace. I didn’t say anything for a minute or two – I was still engrossed at what I was seeing in my mind’s eye. Everything had such incredible clarity – as if it was occurring concurrently with the present time. Out of one eye I was watching an old man walking down a pavement and in the other he was standing over me, masturbating. It was the eyes that made the connection.

“You’re Jimmy King” I said. More of a statement than a question. “Do you know who I am?” I asked. “Of course you do.” I answered for him. “I’m your paper-boy – remember me?”

For the next five minutes until we reached his front door I kept at him, asking about what had happened that Friday in November; what he was doing. What he was thinking. He said nothing. Just kept on walking with a studied determination. By the time we reached his house in MacGregor Avenue he was exhausted and shaking like a leaf. “You just fucking keep away frae me.” He said as he reached his door. I had paused as I reached the gate, unwilling to cross the threshold into his garden; his space, again. I looked at him as he walked through the familiar red door and as he turned, I said to him, “If I find out you’ve did that to anyone else, I’ll be back.”

I couldn’t think of anything else to say. It was a bit pathetic, but it was the only thing I could pluck out of the thousands of other thoughts that were racing through my mind at that second. I did raise my voice a little though, which helped. As I walked away I could see another figure walking across the living room to the door. Someone else.

The remembrance of the incident shook me up for quite a few weeks. Let me be clear. The magnitude of the ‘abuse’ was nothing compared to what we know now after the likes of Savile and the explosion of serious sexual abuse cases that have flooded the media in recent times. I wasn’t hurt physically, merely witnessed at close quarters, the infallibility and weakness of the human spirit. A sordid act, for sure, but nothing physically harmful in the strictest sense. What troubled me most was that I had completely erased the memory in the intervening years and it had only returned – with incredible clarity – when visually triggered by a casual encounter with the protagonist. What else may I have hidden away?

Experiences like this are not that uncommon. Spontaneous recall or memory reinstatement often occurs from a trigger stimulation – smell, sound, sight of an entity closely associated with the original memory. With me, it was the look in his eyes.

After a few weeks I reconciled my thoughts a little and was reasonably content there were no other monsters hiding in the cupboards of my deep memory and soon I had largely relegated the experience to an occasional consideration and by and by, other things took over.

Two years later I was in Fife again, this time during May at a Sunday league football match in Cupar watching my two sons play in the last match of the season. It was pouring with rain as both teams chased a sodden ball en masse up and down the pitch to howls of encouragement from the watching parents. Sometime during the game, a woman came across to me and asked how I was. “Not seen you in years” she said and she started to tell me about her son who was playing in the same match. After a minute or two I interrupted her and confessed that I didn’t know who she was, giving the usual excuses of rapidly advancing senility and incompetence. She had been at the same primary school she explained – in the same class – and once she told me her name I could remember her fine. But not quite the same way as I had with the old man.

We were chatting for a good while when we got round to asking about our parents. “I don’t see mine anymore” she said, as a matter of fact. “Haven’t seen them since before I got married about nine years ago.”

“Why not?” I asked, always curious to hear the unusual.

“Well when I was about eight, my mum and dad got a job at Andrew Antennas but on different shifts. Sometime though they would get swapped over and I used to have to stay with my aunt and uncle if they were working nightshift together. When that happened I used to get raped by my uncle and that kept happening until I was about sixteen. When I was going to get married, I told my mum and dad what had happened because they were going to get invited to the wedding. I didnae want them there. But my mum and dad didnae believe me. Didnae want to believe me. So me and Brian did the wedding ourselves and nobody from my family came and I haven’t spoken them since.”

I was at a loss for words but managed to ask what happened to her uncle.
“Nothing” she said, “he’s still in Lochgelly.”

“You’re kidding” I replied. “Where about?”

“MacGregor Avenue….”

Long after the game had finished and the kids were sitting in the car I finished telling her about my encounter with her uncle all those years ago – and more recently. “What are you going to do?” she asked. I just shook my head in reply.
I didn’t return to London after the weekend, instead I stayed on in the Holiday Inn in Leslie for an extra night and sat up most of the night just thinking about what I had learned.

The following morning dawned cloudless and still – a beautiful day in prospect as I looked out over the ‘Cut’ – that long straight section of the River Leven that runs from the loch towards Auchmuir Bridge, on the road between Leslie and Lochgelly. I parked my car on the south side of Loch Leven and walked up Benarty from Vane Farm – the RSPB reserve – up the long incline to the top and as I reached the summit and Lochgelly came into view, I decided then what I was going to do.

An hour later I walked through the ‘close’ – the alleyway or gunnel, between the house with the red door and its neighbour on MacGregor Avenue. It was just after ten o’clock in the morning and most of the residents were in their back gardens making the most of the pleasant weather. On one side, a woman was hanging her washing whilst her husband was preparing the lawnmower. In the garden that concerned me stood Jimmy King, trimming some plants with secateurs in his hand. His wife was by the garden shed and it was she that saw me first. There was a cast iron and wooden garden seat at the back door and I sat down and waved her across.

“Can I help you?” she asked. “Yes, I think you can.” I replied and patted the seat beside me. She sat down and I introduced myself to her. “Do you remember me?” I asked. “I used to be your paper-boy many years ago. I lived just up in Stewart Crescent. Do you remember? My dad was the chiropodist.” I added as an afterthought. There was a vague look of recognition, but perhaps this was only out of politeness. She said nothing. I went only speaking quite slowly and slightly louder, “I was just wondering, Mrs. King, if you knew your husband was a paedophile and child abuser.” It was not the kind of question that would elicit a conversational response, but I did expect something back from her, but instead she just looked at me with a dread, a fear in her eyes that said everything. She knew. I told her what happened. Then I told her about her niece..

By now the neighbours had stopped and were listening and looked just as shell-shocked as the woman next to me. Jimmy came down towards us, brandishing the secateurs and shouting at me to get out. I waited until he was at arms length then with a calmness I didn’t know I possessed, I took the instrument from him quickly and grabbed him by the throat with my left hand all in one movement then lifted him off the ground.

He was an old man by then, probably late seventies but still quite stocky and muscular. He had worked on the railways and the golf had kept him in reasonable condition, but that morning, with my weaker arm, I managed to lift him clear of the ground then walked him down to the close on an outstretched arm, without even thinking about it. Once I got him there I held him up against the wall and came up close to his face. I could see his eyes reddening and beginning to roll and I realized then I was suffocating him and I squeezed ever so slightly harder. “How does it feel, Jimmy?” I asked “How does it feel to be on the receiving end for a change?”

I held him for a few seconds more then released by grip slightly and lowered him to the ground. In these few seconds I thought about what I was doing and quite calmly and detachedly I debated what I should do. I didn’t have an answer. Instead, I said to him very quietly, “I’m going to tell you something Jimmy. You won’t know when or where, but I’m going to come back for you. Maybe when you’re coming out from the golf course one night, maybe when you’re getting your messages or digging your garden. And I’m not sure yet what I’m going to do to you, but I am going to think of something quite memorable. Every night when you go to bed, and every morning when you wake up. I want you to think about that first and last. You got it?”

I dropped him and he fell to the ground and there was some shouting and some threats as I left and got into my car. As long as he lived then I was reasonably confident the police wouldn’t be involved. Not if Jimmy had anything to do with it.

I was left with a sense of disgust by the whole episode – not just for this man’s behavior and the trauma he had inflicted on one of my classmates from many years ago – but strangely enough for my own. Not the threats or the unpleasantness at the house that day, but in the few seconds that I had held him by the throat against the wall I realized then in that instant that that I was using that horrific power – of overpowering someone who is much weaker – in the same way that he had done against me, only without the sexual element – and that appalled me as much as anything else.

I never returned again to MacGregor Avenue and Jimmy King died a few years ago. I don’t know how. I do hope he thought about me from time to time – and his niece too – but sometimes these people just don’t. They have no conscience or guilt – or if they do, they keep it locked away somewhere deep in their innermost recesses. Like we all sometimes do with unpleasant memories. Just kept in a locked room waiting for something or someone to open the door.

Over the Top

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Tommy Patterson was fifteen years old when he signed up for the Royal Scots in 1914 and packed his bags and headed off to join the ranks of the Royal Scots in France on the western front. He was a small but stocky built boy, two years a miner in the pit in the Wemyss Estate near Kirkcaldy since he left school at thirteen and no idea what he was heading into. He was one of the soldiers who took part one of the now famous Christmas Day football games in No Man’s Land near Contalmaison on the Somme, alongside some of the Heart of Midlothian players in McRae’s Battalion. The following autumn, Tommy was sent to La Boiselle to join the Manchester Boys – specialist labourers who had tunnelled the Manchester sewers over the previous decade and were tasked of digging access tunnels underneath the German lines, perhaps because of his stature or previous underground experience. He never said.

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The Lochnagar Crater was formed at 7.28am on Saturday, 1st July 1916 – the first day of the Battle of the Somme. It was created by the detonation of a huge mine placed beneath the German front lines and its aim was to destroy a formidable strongpoint called ‘Schwaben Höhe’.

Close to a British trench called Lochnagar Street, the tunnellers dug a shaft down about 90 feet deep into the chalk. They then excavated some 300 yards towards the German lines, placing 60,000 lbs (27 tons) of ammonal explosive in two large adjacent underground chambers 60 feet apart. Two minutes before the attack began, the mine was exploded, leaving the massive crater that we see today.

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The reason that it is so large was that the chambers were overcharged. This means that sufficient explosive was used to not just break the surface and form a crater but enough to cause spoil to fall in the surrounding fields and form a lip around the crater. The 15ft lip created protected the advancing troops from enfilade machine-gun fire from the nearby village of La Boisselle.

Debris was flung almost a mile into the air, as graphically recorded by Royal Flying Corps pilot Cecil Lewis in his superb book ‘Sagittarius Rising’

“The whole earth heaved and flared, a tremendous and magnificent column rose up into the sky. There was an ear-splitting roar, drowning all the guns, flinging the machine sideways in the repercussing air. The earth column rose higher and higher to almost 4,000 feet.”

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Tommy Patterson had been one of my first patients I treated after I graduated in 1983. He lived in a small cottage literally next door to a dilapidated clinic in Kirkcaldy where I started work – and he was a real character as anyone who can remember him would attest. He was difficult to understand as he had a speech impediment due to his hearing problems – as he was deafened – along with any other comrades who were within three miles of the detonation – from the shockwave. But he was also just ‘difficult’ and stood for no nonsense from anyone. He had his own stool in the corner of the lounge in the Penny Farthing where he would call for a drink most nights at tea time and if he discovered anyone siting on it when he arrived, a quick poke in their ribs with his stick soon dislodged the offender. He never kept any of his chiropody appointments and would usually just turn up in an afternoon, unannounced and wait his turn. After the traumatic experience of our initial consultation, I thought why not!

I got to know Tommy fairly well over the next five years and heard a few stories of his time in the war. Later in 1916 he was sent back after medical leave and became a dispatch runner near Aras, just seven miles north of La Boiselle and would sprint between the trenches taking messages back and forth from whoever thought they were running the show. I hadn’t studied history when I was at school or university and had a fairly limited knowledge of the Great War when I first encountered Tommy, but I was to gain a fairly unique education over the following years from an incredible personal perspective, His disdain and visceral hatred of authority forged from deeply held views of the officer and political class of the day that had sent so many young boys to their deaths and had shot them as deserters when they were to frightened and shocked to go over the top. Those that did survive the experience were consigned to a decade of poverty and squalor when they returned home just before the depression. I didn’t know that had happened and found it difficult to believe at first. I still find it difficult to understand today and I can well imagine the impact it would have on a terrified, shell-shocked boy as he struggled to make sense of it all.

I was just twenty-three when we first talked, seven years older than he would have been during the Somme Offensive. It made a lasting impression as you might guess.

I managed to visit Contalmaison and Aras as well as La Boiselle during my visit in 2013 and walked over the fields which are now beautifully sculpted holding a range of arables amidst picturesque rolling hills and forests, where a centaury ago it was carnage on an epic scale. It is unsurprising the land is so fertile now.

I was pleased to have made the visit and although Tommy had died nearly two decades previously, it produced an enlightened remembrance to many of his stories and somehow that gave me much comfort and a sense of something being complete, although I’m not sure why or what. I made a promise to myself to return to the Somme during the 100-year anniversary, which of course is today – and remember Tommy again. And all the rest.

Unfortunately, however, I didn’t make it.

Readers of this blog will have realised that the appeal against the conviction by the HCPC was held at Preston Crown Court yesterday on Wednesday (29th June). The verdict given by Judge Beech was to uphold the conviction and to reject the appeal. The written narrative is attached at the foot of this post. I wish I could say I was surprised, but that would be akin to claiming astonishment that Dracula had declined the vegetarian option at brunch. I will leave you to form your own opinion of the judgment but ask that you refrain from commenting at the moment as I do not wish to prejudice the chance of an appeal to the higher court or to be held in contempt by hosting a discussion blog that holds offensive or insulting remarks about the case or persons involved in the proceedings. Suffice to say I am not prepared to let the judgment stand without challenge, for obvious reasons. Regrettably, it also means I won’t be travelling across the channel for the commemoration of the Somme Offensive.

I’ve always thought that if you do something wrong, make a mistake or have an accident, it is always best to tell the truth, no matter how inconvenient or embarrassing it might be. If you don’t and then lie about it, then you are simply digging a hole for yourself and eventually, the truth will out.

I’m not sure how big the hole will be in this matter by the time the dust settles, but at this rate, it will certainly give Lochnagar a run for its money and will doubtless be a major tourist attraction in west London for years to come. Thankfully, this time, the casualties will not be innocent young men.

Crown Verdict

Meeting the Needs?

Sanna Bay - ArdnamurchanSome years ago I was working in the lovely west highlands of Scotland, based out of Fort William – looking after patients in an area that stretched from the majestic Glencoe all the way to the most westerly point in the UK – Ardamurchan and the hamlets around Kilchoan – then out to the Inner Hebrides – Eigg and Rhum. It was an idyllic time – surgeries undertaken in the most beautiful of settings – and with my walking boots and fishing gear in the back of the car, the opportunity of running up a hill or casting a fly for some wild brown trout at the end of a clinic list was often too great to miss! But sometimes – these distractions could pose a danger!

The monthly trip to Kilchoan “clinic” was by necessity, a two-day affair. Although only 70 miles or so by road, the drive, through some of the most remote areas in Britain, could take in excess of three hours – a good deal longer if the weather was fine and you had a camera packed – so on these days an overnight stay at the home of the local District Nurse and her husband was arranged. Jessie Colquhoun has run the nursing services inWest Ardnamurchanfor over thirty years – and is well-known to everyone in the community. She is the epitome of what district nursing is all about – thorough, kind, hard-working with excellent clinical skills and knowledge – so when she mentions she has a “little concern” about one of her patients that was booked in with me in the morning – you take note.

The patient in question was a retired hospital matron from my home town in Fife who had moved up to the beautiful hamlet of Sanna about two miles further down the track from Kilchoan. Well into her seventies, she had Type II diabetes and had mentioned to Jessie that she had a “little numbness” at the end of her toes for a few days and was it something to be concerned about? Jessie had remarked on this at supper that evening –with the afterthought that “it was probably her diabetes – but have a look just to be sure..”.

Diabetic neuropathy is a fairly common complication of the disease and can be transient or progressive in nature. Most people with diabetes will experience some neuropathic symptoms at one stage or another – but often these will be mild – pins and needles, slight numbness in the extremities – fingers and toes. Often patients will remark they feel as though their socks have ruffled-up under the toes, but the sensation persists even when the socks are taken off. For some people, the neuropathic symptoms are progressive and can lead to a complete lack of sensation in the hands and feet – and this is often where the real dangers lie as the sufferer will be immune to any sensation – even acute pain – and may be oblivious to any injury, such as a cut or infection, sometimes with disastrous results when another complication of the disease is present – peripheral angiopathy or poor circulation.

The following morning gave an opportunity to examine this lady but at first, she was more concerned with having her toenails cut rather than anything else! “It’s a long time between appointments” she remarked “and I can’t get down to them like I used to” – but once the formalities and necessities has been done I asked her about the symptoms that Jessie had mentioned the previous evening. “It’s about four or five days now” she said when I asked her how long the numbness had been present. “Just the big toes at first but now they’ve all gone numb and I can’t seem to wiggle them anymore!” Closer examination confirmed her observation – she was unable to detect light or sharp pressure and indeed she was unable to move any of her toes. “It feels like my feet have gone really stiff all of a sudden, even my ankles feel stiff. Ah, it’s probably just old age or my diabetes or both!” she added as an afterthought.

But something just didn’t feel right with her. With diabetic neuropathy – sensory loss is usually a slow process and sometimes one can even find a heightened sensory picture in the initial stages. What was present here was a complete absence of sensation – and coupled with the loss of motor control – the ability to move her toes and all within a short period of time, gave a very unusual clinical presentation.

“How have you been keeping?” I asked her. “Oh fine” she replied. I don’t take anything for my diabetes – just watch what I eat. Apart from a nasty wee flu-ey like virus a couple of months ago – I’ve been in the pink for as long as I can remember!”

And therein lay the clue.

As with many medical complaints – the inception or aetiological factors of disease often take place many months – or years – before the first symptoms appear – and often they can seem unrelated.

Guillain–Barré syndrome is an acute polyneuropathy, a disorder affecting the peripheral nervous system. Ascending paralysis, weakness beginning in the feet and hands and migrating towards the trunk, is the most typical symptom, and some subtypes cause change in sensation or pain as well as dysfunction of the autonomic nervous system. It can cause life-threatening complications, in particular if the breathing muscles are affected or if there is autonomic nervous system involvement. The disease is usually triggered by an infection, sometimes months before the symptoms present.

The diagnosis is usually made by nerve conduction studies and with studies of the cerebrospinal fluid. With prompt treatment by intravenous immunoglobulins or plasmapheresis, together with supportive care, the majority will recover completely. However, in the remote and rural environment of the west highlands of Scotland – diagnostic tests and treatment are not readily at hand – and the decision to refer for investigation and treatment is the responsibility of the local clinicians – the district nurse or GP – or, in this case, the visiting podiatrist. Providing they recognise and identify the symptoms correctly!

Perhaps a little nervously, I explained my hesitation in agreeing with her assertion that it was her diabetes or merely an inconvenience of age. I suggested that I speak to her General Practitioner and ask his opinion and I would call her once I had done so. Tat afternoon, I placed a call to her GP – some thirty miles away in Acharacle – and relayed my concerns. “Aye, it could very well be – but it’s your call” he added helpfully. “We’ll have to call the air ambulance and get her flown down to the Western inGlasgowif you’re certain that’s what it is…” he added as an afterthought.

At times like these, one is grateful that, in some areas of medical care, the patient rather than profit is paramount – and the burden of cost is with the provider. I called my patient and told her to pack an overnight bag – before I returned to my digs in Fort William and pondered, nervously, what the number-crunchers in the NHS would say when they found out what I had cost them in air freight! Three days later, during lunch, I received a call from Jessie Colquhoun in Kilhoan. “Aye you were right enough to be suspicious – it’s Guillain–Barré “ she said. “Looks like she’ll be in the Western for a few weeks though – but the consultant says she has a good chance of recovery. Maybe we’ll see her home before your next trip out…”

Ten years later I called into Jessie whilst on holiday in Scotland and she remarked on the case and I was delighted to hear that our lady was still living the life in Sanna – none the worse for her experience. I had been lucky. And fortunate enough to remember the subject when it had been taught during my time at podiatry school a decade previously. Some colleagues in podiatry and other professions consider basic tasks – nail cutting and personal nursing, for example – to be inappropriate jobs for the highly trained professional – and could and should be delegated to carers with fairly basic training in the necessary skills. But the real skill is looking beyond the obvious and presenting needs and being able and proficient in diagnosing those conditions that are not too apparent and very often, not what the patient comes for in the first place.

I mention all of this as once again I hear from a colleague that the NHS is embarking on a new round of discharging patients from their caseloads in an attempt to cut waiting times again – on the grounds that they don’t meet the necessary (and revised) eligibility criteria and have a pre-existing condition such as diabetes or severe vascular disease. If you do, then that’s ok – you might see an NHS podiatrist in around eight months if you meet the revised eligibility criteria. If you don’t and you have a minor foot problem – such as a difficulty getting down to cut your toenails – then you will probably be offered the services of a volunteer from AGE UK who will visit you in your home (for a small charge) to attend to your needs. Which is fine. Providing you have the obvious! Either that you or you are at the mercy of the largely unregulated private sector (of which more later) whether you can afford the fees or not….

Progress?