Little Disasters

by Sarah Vaughan

  She pauses. It’s a perfectly adequate explanation and yet she watches me as if to check she’s given the right answer.

  ‘I just turned my back for a moment. I can’t be watching her every second!’ She is suddenly strident in her self-defence.

  ‘It’s all right. I know what a good mum you are. It’s just – it’s quite a bang: not something that would happen from crawling and falling. I’m wondering whether she hit anything when she fell? If she could have struck anything?’

  ‘I don’t know. I assumed she just hit her head on the floor but she was right by the fridge . . . I suppose she could have pulled herself up on the edge of it and hit her head on that as she fell . . .’

  ‘Yes, that’s possible.’

  I look at the back of her head again. I don’t like this. I don’t like it all. It’s Jess’s evasiveness and defensiveness that bothers me. Why is she behaving like this? As if this accident is an afterthought? As if there’s something that she needs to hide?

  ‘I’m just going to check the rest of her, but there’s absolutely nothing to worry about: it’s standard practice,’ I say, and I peel away the arms and legs of Betsey’s Babygro, scrutinising her body thoroughly. There’s no sign of bruising: no bluish hues; no greens or yellows; no redness either. Not a single indication that she has been harmed. Slowly, methodically, I ease off her heavy nappy and lift up her legs. Her bottom has an angry pimpling of nappy rash, a smear of Sudocrem, but – thank God – there’s nothing sinister around her vagina or anus.

  ‘What are you doing? Betsey hasn’t been interfered with!’

  ‘We just check babies all over. It’s completely routine,’ I try to reassure her.

  ‘My God! You think she’s been molested!’

  ‘No. No, I don’t at all. There’s a little nappy rash but there’s nothing to worry about. She’s absolutely fine.’

  She is momentarily relieved.

  ‘And she will be OK, won’t she?’

  I pause.

  ‘With any head injury we have to be careful and so I’d like to run a couple of tests.’

  ‘What tests?’

  ‘Blood tests, and probably a scan to check if her skull’s been damaged.’

  ‘That’s really necessary?’

  ‘I think so, and I’d like to keep her in a little longer, just in case she’s sick again.’

  She hasn’t anticipated any of this. She glances at her baby, then ducks her head and starts fiddling with her rings. Is she embarrassed? Perhaps if I tread carefully she’ll tell me what’s wrong.

  ‘I know you, Jess. You’re protective. Perhaps even a little overprotective – is that fair?’

  She nods.

  ‘But you left it a while before bringing her in, which seems uncharacteristic . . . I suppose I’m wondering why you didn’t think to bring her in before?’

  Fiddle, fiddle with her rings.

  ‘I suppose I didn’t think it was that serious,’ she says at last. ‘You know what toddlers are like. Kit and Frankie have had worse bangs – so have Sam and Rosa, haven’t they? They fall over all the time when they’re that age. It didn’t seem that bad compared to knocks the boys had when they were starting to crawl. There wasn’t a bump. I didn’t think there was a problem. It was only when she started to be sick that we thought we should bring her in.’

  ‘That makes sense,’ I say, and of course it does, but I remain uneasy as Ronan begins to take Betsey’s blood and I arrange for her to be admitted to the ward.

  Because when any parent presents with a child with an injury, I’m trained to be alert to the possibility that it may not be accidental. That the parent may have harmed their child. Of course I don’t want to think this of my friend. I’ve trusted her with my own children, and I know how she parents; but still, I’m conditioned to ask that question, and it nudges at me, at the back of my mind.

  And so I find myself running through my checklist: am I happy with the interaction between parent and child; was there a delay in presentation; is the parent overly defensive or strangely unconcerned? Do I suspect them of lying? Most importantly: does the mechanism – the way in which the accident is said to have happened – match the injury? Does the story fit?

  I stand by the desk, waiting for the paeds team to pick up the phone and I feel troubled. Why was Jess so shifty when I pointed out the trauma to the back of the head? Why did she hesitate when I asked if Betsey had only thrown up the once? And why – given how conscientious she is about all aspects of parenting – did she wait six hours to bring in her baby, and only then when Ed suggested it?

  I twist the lead of the phone around my fingers, creating welts. With any other parent these would be clear red flags signalling that we should be concerned, but this is someone I know well. A long-term friend. The woman who looked after Rosa when she and Kit had chickenpox and the hospital nursery still deemed her infectious; the friend who searched for obsolete Lego for Sam’s birthday then insisted I give it to him; the mother who loves her children beyond all else; who’s ferocious in her defence of Frankie, once accusing Mel of demonising him when she suggested he’d been too rough with her son Connor, turning on her with a flash of surprising anger; the mother who is so proud of sporty, good-natured Kit.

  I know all this as deeply, as instinctively as I know that Nick won’t be unfaithful. I’m almost completely sure of it, that is to say.

  And yet here I am, admitting her daughter for a suspected skull fracture and perturbed by her behaviour.

  Am I seriously thinking the very worst of Jess?

  LIZ

  Saturday 20 January, 12.15 a.m.

  Four

  Betsey has been admitted and is now lying in a bed by the window, the sides up to prevent her falling. An infant in a protective cage.

  Jess has left the ward to ring Ed. Her daughter’s been crying for her, though: ‘Mum-mum’ the only words she’s uttered. Kath, the nurse in charge of this bay, administers some liquid ibuprofen, the drug and perhaps her gentle reassurance easing her pain.

  I need to ring my boss. A head injury in an infant is something my consultant will want to know about, even though he’ll hate me for waking him to discuss it. At sixty-two, Neil Cockerill’s had enough of the NHS; has no desire to have to come into hospital in the early hours of the morning, or to have his sleep broken by a registrar who should be able to stand on her own two feet. You could argue that’s fair enough: he’s dedicated forty years of his life to this job; has had his fill of departmental politics, not to mention the bureaucratic demands of a government hellbent on raising expectations beyond what their money can buy. He’s tired, too, of the relentless grind that comes with looking after sick, sometimes dying children. I understand, and I could accept his hands-off attitude if I rated him as a colleague. But I don’t – and the feeling is mutual: unfortunately, he doesn’t rate me.

  I first came across Neil when I was twenty-five and a very junior doctor, just a year into the job, and doing my obligatory six months in this hospital’s A&E. I heard him before I was introduced: a tall, patrician man with thick, sweptback hair (he was in his late forties by then and this was his vanity) bellowing across the department at his reg.

  ‘In my day, registrars ran the show – they didn’t scamper to their consultants at every opportunity!’ he blazed as he stormed out of paediatric A&E and all the parents in the waiting room craned their necks to see who was so furious. ‘JFDI!’ he’d added. Justin, the registrar who’d been mauled, was puce with embarrassment.

  JFDI? Just fucking do it.

  My perception didn’t improve when I came back to the hospital and worked for Neil, three years later. I’d had the temerity to get pregnant and two months of my maternity leave coincided with the end of my attachment with him. The trust didn’t replace me, which doubled his workload in clinics and on the wards, and even when I returned to work, he thought me unreliable and not a team player. It didn’t help that Rosa had glue ear when she was tiny and so I was forever being
called to the hospital nursery, where she spent each day from 8 a.m. to 6 p.m.

  Perhaps if Neil had liked me he’d have been more tolerant but he didn’t understand me. I wasn’t like the nurses who flirted with him or indulged him; and I wasn’t like him: a self-confident man from a dynasty of doctors, with a broad cultural hinterland and the ability to converse about cricket and fine wine. I was a nervous young woman from a working-class background who had made his life more complicated and his workload more onerous by becoming a mother.

  And he resented this. There was no reason for him to empathise with me because he had never experienced the tug between work and parenthood. His wife stopped nursing when she had their first son and so never had to walk that tightrope nor ask him to make compromises in his career. I want a wife, I think, when I note his crisply ironed shirt; when he mentions a holiday – something Rosie’s organised in Italy, he’s not quite sure where, that’s her domain, he just pays for it (this said with the self-indulgent chuckle of a man who bought his west London home thirty years ago and has paid off the mortgage). I want a wife, I think, when, at the end of a long shift, I know he’s returning to a freshly cooked meal. I want a wife, whenever the fact that I am a mother, and the subsequent occasional rota swap to accommodate a parents’ evening, prompts him to wrinkle his nose as though he smells something noxious. This is real life with all its messy demands, I want to tell him. But of course I don’t because I don’t want to rock the boat; I need a good reference; and I need a consultant’s post, preferably his when he reaches retirement in a couple of years.

  More than anything, though, I want to impress him. He’s never forgotten a very early mistake I made: the sort of bad call that follows you round in this profession. I desperately want him to think I’m good at my job.

  But this phone call – required because no one wants to give a ten-month-old a dose of radiation unnecessarily – will do nothing to endear me.

  ‘Cockerill,’ he growls, when I finally steel myself to dial his number.

  ‘Dr Cockerill.’ I lower my voice, intensely deferential. ‘I’m sorry to disturb you this late at night.’

  ‘It’s morning now.’ His voice bristles with bad temper. ‘It’s nearly half past midnight. Christ, I was asleep.’

  ‘I’m so sorry’ – I keep my voice low and calm – ‘but I wanted your advice. I’ve admitted a ten-month-old with bruising and a suspected skull fracture to the back of her head so I thought we should scan her to see what’s going on.’

  ‘Mmm.’ His irascibility hums down the line. He asks if there is any sign of a rare fracture to the base of the skull – black eyes; bleeding from the nose and ears – or of a leakage of cerebral spinal fluid, and we discuss her GCS rating, a neurological measure of how conscious she is.

  ‘Anything else we should be concerned about?’ A pause, pregnant with irritation, and I imagine his knees jiggling as they do when he’s frustrated in a departmental meeting: energy pulsing through his legs.

  ‘She has vomited,’ I say. ‘Mum says just the once.’ ‘And did she say how it happened?’

  ‘She didn’t see it – she had her back turned – but the baby was crawling and either slipped, or fell after pulling herself up on the side of the fridge.’

  ‘It would be quite some fall from that low height to create a skull fracture with, what, some bogginess?’

  ‘Yes.’ I need to be honest. ‘There’s something else. Mum didn’t notice the trauma, or mention she’d fallen, until I pointed it out to her.’ The words rush from me as if they will sound less incriminating said at speed.

  ‘And you’ve put a call in to social services?’

  ‘No I haven’t. Not yet.’

  ‘You don’t think it’s a safeguarding issue?’

  ‘No. I know the mum. Don’t worry: I won’t treat the baby once you’re in, and Ronan was present at all times, but she’s a good mother. I just can’t imagine that she would harm her child.’

  His disbelief is clear from his too-long silence.

  ‘And she came in immediately?’

  ‘No. It happened around four . . . She came in at some point after ten.’

  Another pause, steeped in suspicion.

  ‘I don’t like the sound of this, Elizabeth.’ No one calls me Elizabeth, except Neil when he’s angry. ‘I don’t like the sound of this at all. A delay of six hours in bringing the baby in; Mum’s failure to notice a trauma to her head; a mechanism – falling from crawling – that doesn’t necessarily fit with the injury, and a skull fracture to the back of the head? You do realise what that could indicate?’

  I remain silent. Of course I bloody well know what this indicates.

  A fracture to the back of the head is commensurate with a child being slammed down hard on a changing table.

  ‘She should be scanned, and I’ll take over at eight.’

  *

  The radiology pictures are available shortly after Betsey is wheeled down for her scan.

  They seem unequivocal. A depressed fracture to the back of her skull, some bruising, and a subdural haematoma: a pool of blood accumulating beneath the skull and pushing inwards, compressing the brain.

  I so wanted this not to be the case. For there to be no break and the bruising to be superficial. For Betsey to be discharged as soon as possible, and for neither she nor Jess to have to go through this.

  But now this scan, viewed through a series of filters on the computer, confirms this is a head injury and makes the situation far more serious. I flick back to the bone filter. Indisputable: a textbook case. Instead of the nice, curved white line of the skull, there are two black cracks, and a crescent of white, a segment of bone, which has slipped from the skull like a jagged piece of a jigsaw dislodged from its space.

  I switch filters to the one that lets me assess any damage to the soft tissue and shows whether there’s bleeding inside or outside the brain. The white cracks fade out of focus as I assess the patches of grey. Again, it’s incontrovertible: a grey oval blob, one centimetre across, is pushing outside the surface of the brain. I phone the radiologist on call just to check there’s nothing I’m missing and he talks me through his report as we assess the scan together. There’s no anodyne explanation. It’s all as the pictures suggest.

  I feel very cold and simultaneously conscious that I need to remain calm and professional: to not be swayed by the emotions provoked by this. We have this scan showing an unequivocal skull fracture and we have Jess’s odd, evasive behaviour but that doesn’t mean we have to think the worst of her, does it?

  Because most skull fractures are caused by accidents, and though I suspect Jess is lying, there’ll be a reason she has done so and an innocent explanation for all of this. But there’s only a tiny window in which I can help, before Neil sweeps in and claims Betsey as his patient.

  If there’s something Jess needs to tell me, she must do it now.

  *

  Jess is waiting in Betsey’s bay, and sits straight up as I walk towards her. She’s been crying. A silt of mascara clings to her bottom lashes. ‘Is she OK?’

  ‘The CT scan showed what we thought: that Betsey has a skull fracture. There’s no long-term damage but obviously it’s worrying.’

  ‘Oh my God,’ she whispers. ‘Oh my God, oh my God.’ She bends over as if to retch. The vertebrae at the top of her back form a string of small, tender bumps. I want to hold her close to me, just as she held me in those first awful months of motherhood, when I couldn’t cope with Rosa’s inability to sleep. Instead, I crouch down next to her, as she might with her children, and look her straight in the face.

  ‘Jess,’ I say. ‘Look. There’s no easy way to say this but when a child sustains a head injury like this it raises questions, and we have to think about whether this was an accident or whether it could have happened some other way.’

  ‘I don’t understand.’ She looks at me blankly.

  ‘The thing is, it’s quite unusual to have an injury like this caused by this mechan
ism,’ I plough on, reverting in my embarrassment to doctorese.

  ‘This mechanism?’

  ‘I’m sorry. It’s unusual for this injury to be caused like this. Are you sure that nothing else happened? That nothing was different from how you described? I know it’s hard to think about but could someone have hurt Betsey?’ I pause – and she looks stunned that I could suggest it. I touch her on the forearm, and try one last time: ‘Or is there anything else you want to tell me?’

  And this is it, her chance to open up. To say: Look – I didn’t want to say but she was crawling up the stairs and she tumbled when I wasn’t watching, when I wasn’t focused, when I was distracted by the boys arguing. Or, quite simply: Oh, Liz, I’m so embarrassed but she rolled off the bed.

  And, then I would reassure her; would say: Don’t worry. You know you shouldn’t leave her even for a moment at this age, but we all know that accidents happen. We know it’s just an accident. But, perhaps this is a wake-up call, a reminder that it can happen, even to a mother who’s already had three kids.

  But she doesn’t say any of this. She just looks at me, her wide, sensual mouth in a straight line, her defensiveness swapped for a weird blankness as if her usual emotions have shut down.

  She plays with her rings, twisting them round and round the third finger of her right hand, and I realise that her look of blankness is really an expression of denial, motivated by fear. It’s the same look she had when I tried to raise the issue of Frankie’s hyperactivity and whether he should be assessed for a possible diagnosis of ADHD. A look that says she has absolutely no intention of taking on board what I’m saying.

  Her mouth twitches.

  ‘No, there’s not,’ she says.

  LIZ

  Saturday 20 January, 8.30 a.m.

  Five

  Neil is spoiling for a fight.

  I can tell from the way in which he comes into the room where we hold the handover meeting: all bristling energy and brisk movements

  ‘So – Betsey Curtis,’ he says, flinging himself into his chair.