‘Well, he made some progress after he first came to me, of course, when I recommended he undergo cognitive behavioural therapy with Dr Jack Munro. But since then there’s been little discernible improvement in my opinion. And, as things stand at the moment, I can’t see the prospect of any more, no.’
‘When you say there was some initial progress – this would be between three and four years ago?’
‘Yes.’
‘And could you indicate the degree of improvement? Was it small? Moderate? How would you rate it?’
‘I would say the improvement was significant. But not enough to make him anything like a well man. We were of course starting from a low base, after Mr Deacon had suffered a severe breakdown with suicidal tendencies.’
The judge, who was writing steadily, murmured without looking up, ‘Mr Riley, surely this period is covered by the witness statement?’
‘My Lord,’ Desmond conceded with a nod. ‘So, Dr Ainsley . . . you say you can’t see any prospect of improvement? Has your opinion changed since June?’
‘My opinion hasn’t changed, no. I can’t see any chance of improvement while Mr Deacon’s life remains as it is now, basically in ruins, without anything to occupy his mind, living on benefits in a damp cottage. It gives him no chance at all.’
‘What would give him a chance in your opinion?’
‘Two things. Firstly, a conclusion to this case, which should give him some degree of closure. Secondly, practical changes. If he could have a proper workshop to do his woodwork, a decent place to live, and some freedom from financial worries, then – well, I can’t make any firm predictions, I can only say that such changes would offer the best environment for, if not improvement, then at least stability. It would make his condition more bearable.’
Bavistock clambered to his feet. ‘My Lord, surely this is speculation, and therefore beyond the bounds of medical opinion.’
The judge flexed his eyebrows. ‘I’m not sure I follow, Mr Bavistock. I think the medical profession can be allowed to speculate on the outcome of its treatments and interventions.’
‘With respect, my Lord, Dr Ainsley is commenting on a change of lifestyle not a medical treatment.’
‘I would have thought that a change of lifestyle would constitute a treatment, Mr Bavistock, especially in the field of psychiatry.’ The judge turned to Ainsley. ‘Would that be correct, Dr Ainsley? You might, on occasion, advise a change of lifestyle as a form of treatment?’
‘Very much so, your lordship.’
The judge cast Bavistock an eloquent look.
‘As your lordship pleases.’ Bavistock sank back into his seat.
Tom, his head low, slid Hugh a look of avid satisfaction, as if they had just won a significant point instead of a routine legal challenge.
Desmond resumed, ‘Dr Ainsley, you have stated that you think it highly unlikely that Tom Deacon will ever be able to hold down a job again. Has your opinion in that regard altered at all?’
‘No, it hasn’t.’
‘And if his circumstances were to change in the way you recommend, would that improve his prospects of finding work?’
‘At best he might be able to make a few pieces of furniture, but only at his own pace in his own time. In my opinion, he’ll never be able to hold down a full-time job again.’
‘You also stated that you think he’ll never be able to lead anything approaching a full life. Is that still the case?’
‘Yes.’
‘He will always be prone to flashbacks and panic attacks?’
‘Correct.’
‘He will always need treatment?’
‘Yes. But medication can only achieve so much. It can only dull the patient’s symptoms to a limited extent. And of course the amount of medication has to be balanced against the patient’s ability to function. There’s no point in making the patient so drowsy that his remaining quality of life is impaired.’
‘Thank you, Dr Ainsley.’
As Desmond dropped down into his seat, Tom put his mouth to Hugh’s ear and hissed, ‘Is that all?’
Hugh nodded, and Tom’s expression dipped in frustration. For him, the written statements which the court used as its main source of evidence were a poor substitute for evidence delivered in person from the witness box.
Bavistock stood up and began to go through Ainsley’s statement point by point, starting with Ainsley’s qualifications, career, and experience, dwelling for some time on the fact that he now spent a significant amount of time lecturing and appearing as an expert witness.
‘So, you do very little clinical work as such, Dr Ainsley?’
‘I try to see long-standing patients whenever I can.’
‘But new patients – you simply assess them? You don’t treat them?’
‘New patients, yes.’
‘And you assess them for medico-forensic purposes, as an expert witness?’
‘Not always. Sometimes I’m simply called in to give a second opinion.’
‘Perhaps I could rephrase it then – the majority of your work is medico-forensic?’
‘Correct.’
‘Now, there are different descriptions of post-traumatic stress disorder in current use, are there not? Perhaps you could take us through them?’
As Ainsley launched into a detailed explanation, Tom sank lower in his seat and finding a pencil began to sketch on his pad. He drew quickly and confidently. Looking across, Hugh saw a desk taking shape, traditional in design, with pedestals and drawers, shown corner on, with the effortless perspective of a true draughtsman, and was reminded of a summer day some three years ago when Tom had drawn something similar at the lunch table at Meadowcroft. It was shortly after Tom’s wife had left him, and thus a time of particular concern for his well-being. It had been Lizzie’s idea to invite him for Sunday lunch. Tom bicycled over, arriving an hour early, so Hugh suggested a walk. Tom had only one walking speed, which was fast. Spurning the footpaths as too crowded, though there was only a single dog-walker visible in the far distance, Tom struck out across country, leading the way over fences, ditches and boggy pastures, Hugh following as best he could, breathlessly, with the occasional unscheduled halt to extricate himself from barbed wire. After half an hour at the same furious speed Hugh pleaded an arthritic knee and they returned at an easier pace, though Tom had a job keeping to it, often surging ahead without thinking, slowing with an effort. They talked about serious walking, which for Tom was hill walking, the steeper the better, while Hugh told of his early childhood in Llandeilo, close to the Black Mountains, with his schoolteacher parents and two sisters, and moving to Swansea when he was ten, where he had missed the mountains, the sight of them, and the summer walks. Tom preferred winter walks, he said; not so many people and less chance of getting overheated. Then, darting Hugh a faint smile, he declared, ‘It was you being Welsh that swung it.’
‘What?’
‘When I came to see you that first time. You keeping your accent, not having ditched it for something snotty. I thought you’d probably be okay.’
Hugh laughed, wondering at the slender thread by which the decision had hung. ‘It’s a poor Welshman who ditches his accent.’
‘That’s what I mean.’
They had drinks on the terrace. Tom downed his first beer at the same rate he did his walking, seriously fast, but the alcohol did little to lift his mood, which had plunged for no apparent reason, leaving him morose and uncommunicative. Even Lizzie, who had a rare talent for drawing people out, struggled to get more than two words out of him. Nor did the appearance of Lou, in all her freshness and serenity, rouse him; if anything he seemed to retreat further into his shell. It was Charlie of all people who saved the day. Charlie had got home at ten to four that morning; Hugh knew to the minute because he’d heard the voices, the slam of a car door, and had fretted miserably over who was driving and how stoned or otherwise off their heads they’d been. Now, having slept through the best part of the day, Charlie had dragged himself out
of bed at the third time of asking and arrived at the lunch table pale, unkempt, eyes screwed up against the light. Perhaps Tom recognised a fellow traveller, perhaps he sympathised all too readily when the crash of a pan lid caused Charlie to flinch, but after a while the two of them exchanged a few words, and when Hugh next broke off from his conversation with Lou and Lizzie it was to hear them discussing cabinet-making, how much more it was than mere carpentry, how much artistry was involved, and how there was a big demand for bespoke pieces if you could only break into the market. Producing a notepad from his pocket Tom sketched out a couple of designs for tables and chairs, drawing quickly, skilfully, while Charlie made appreciative noises. Hearing him say, ‘Hey, that’s cool,’ Hugh felt a pang, not just for the paucity of Charlie’s vocabulary – everything was cool when it wasn’t a drag – but for the transience of his enthusiasms, which, with the notable exception of dope, came and went with bewildering speed.
After Tom left, Lizzie said, ‘He looks like he’s on the edge.’
‘Yes.’
‘What support is he getting?’
‘As much as humanly possible. But short of hiring someone to watch over him . . .’ And for a split second, in a confusing flight of fancy, Hugh might have been talking about Charlie instead of Tom Deacon.
The definitions of post-traumatic stress disorder having been established to Bavistock’s satisfaction, he moved on. ‘So, in the definition you prefer, Dr Ainsley, the symptoms include flashbacks, panic attacks, depression, guilt, chronic anxiety, insomnia, mood swings, phobias, lack of concentration, stress avoidance. Would you expect to find all of these symptoms in every case?’
‘No. But I would expect to find a good number of them, particularly flashbacks, mood swings and stress avoidance strategies. They’re central to any diagnosis of PTSD.’
‘Would it be true to say that the more symptoms present, the more confident you would be of your diagnosis?’
‘No. The nature and severity of the main symptoms would be the most important consideration.’
‘Now, Dr Ainsley, could you tell us how it was that Mr Deacon came to consult you in the first instance?’
It had always been unrealistic to hope that this issue wouldn’t be explored in open court. Hugh’s error, so easily made at the time, so obviously wrong in retrospect, was already there in the evidence bundle for all parties to see. It would be an inept defence that didn’t bring it more fully to the judge’s attention. The only question now was how much salt Bavistock would rub into the wound.
Ainsley replied, ‘I got a letter from Tom Deacon’s solicitors, asking if I would give an opinion as to his condition.’
Tom whispered fretfully in Hugh’s ear, ‘What’s this got to do with anything?’
Non-essential conversation was discouraged in court and Hugh automatically glanced at the judge before scribbling, My error in original letter. Tom read it and shrugged before crossing his arms tightly across his chest.
Bavistock was saying, ‘Didn’t they go further than that? Didn’t Messrs Dimmock Marsh say in their letter, I quote, “We fear Mr Deacon is suffering from an acute post-traumatic stress disorder and would be grateful for an opinion”?’
‘You may be right – it’s four years ago now.’
‘If I could refer you to page thirteen in the evidence bundle, perhaps you would like to refresh your memory.’
Hugh didn’t need to look at his copy of the letter to see it clearly in his mind, complete with offending phrase and his signature at the bottom.
When Ainsley had read the letter, Bavistock said, ‘So having received this letter you were in no doubt as to the diagnosis they wanted?’
Desmond got to his feet. ‘My Lord, could it be noted that the letter also asked Dr Ainsley for advice on treatment and rehabilitation?’
The judge nodded. ‘It is noted, Mr Riley.’
It was a loyal effort on Desmond’s part, but there was no escaping the basic mistake. Bavistock hammered it home. ‘It was clear what they were hoping for in the way of a diagnosis?’
‘Given the nature of Mr Deacon’s experience, such a diagnosis would always be a possibility. That said, I would never be influenced by what people were hoping for,’ Ainsley said with a puff of self-importance, ‘only by what I find.’
‘Indeed,’ Bavistock said with a fleeting mechanical smile. ‘But of course post-traumatic stress disorder is actionable under the law, while a grief reaction, however intense, is not. When the patient is aware that grief alone won’t be sufficient to win him compensation, that only PTSD will do, could that not influence him, consciously or subconsciously, into emphasising certain symptoms that would improve his chances of getting the more advantageous diagnosis?’
Ainsley paused before saying with obvious reluctance, ‘In theory it’s possible, yes. But I don’t believe that happened in this case.’
At Hugh’s side Tom was rubbing his forehead in harsh repetitive movements, the tension radiating from him like a heat.
‘And is it also possible that a patient who has learnt about the symptoms of PTSD might persuade himself he has new symptoms that weren’t there before?’
‘Again, it might be possible in theory. But in my opinion it didn’t happen in this case.’
‘Oh? And why would that be?’
‘The descriptions he gave of his symptoms were too spontaneous, too vivid.’
Bavistock looked doubtful. ‘How would that rule out the possibility of exaggeration or amplification?’
‘Well, it would have required an extraordinary degree of imagination on his part to describe the symptoms with such accuracy.’
‘What, even if he’d studied such symptoms in depth?’
‘I would say so, yes.’
Bavistock raised his eyebrows slightly. ‘Now, you have described Mr Deacon’s symptoms in your statement – if I can refer you to page seventeen, paragraph three.’ When Ainsley had found his place, Bavistock went on, ‘Mr Deacon seems to have every possible symptom of PTSD. Nothing missing at all. What you might call a textbook case. Would you agree?’
‘Well . . . In simple terms, yes.’
‘In any terms, surely?’
For the first time Ainsley showed faint irritation. ‘Yes,’ he said shortly.
‘Isn’t it odd that one person should have such a comprehensive list of symptoms?’
‘Not at all.’
‘But you’ve just told us that you wouldn’t expect to find the full range of symptoms in every case.’
Ainsley seemed to falter, and for a moment Hugh thought he was going the same way as the cognitive behavioural therapist Munro. But then Ainsley straightened his back and said crisply, ‘I meant only that it was uncommon. I didn’t mean it was impossible.’
‘You didn’t think it strange at the time?’
‘No.’
‘It didn’t occur to you that Mr Deacon might have imagined a fuller range of symptoms than he actually had?’
‘As I’ve said, I think it unlikely.’
Adopting one of his coping strategies, Tom hunched forward over the table and, resting his forehead on his fingertips, screwed his eyes tight shut, as if to blank everything out.
Moving on, Bavistock leafed through his notes. ‘Now, you have diagnosed Mr Deacon as having severe PTSD. Could you tell us what other degrees of severity there are?’
‘After severe, there’s moderately severe, moderate, and minor.’
‘Could you define the moderate category for us, please?’
Ainsley thought he must have misheard. ‘Moderate?’
‘Yes, moderate.’
‘This is when the injured person has largely recovered, and any continuing effects are not grossly disabling.’
‘Not grossly disabling?’ Bavistock echoed.
‘Correct.’
‘So a moderate case could be more difficult to diagnose?’
‘It could be. But the critical factor is the exposure of the patient to a traumatic event that falls
outside the normal range of human experience. If the patient’s condition can be traced back to that, then they can said to be suffering from PTSD.’
‘But if this link isn’t spotted, if the patient himself doesn’t realise why he’s unwell – or indeed is in denial about it – then a moderate case might well go undiagnosed?’
A minute hesitation. ‘It’s possible, yes.’
‘Could indeed be misdiagnosed?’
‘That’s possible too.’
‘It might be diagnosed as depression, for example?’
Ainsley had the wary look of someone who realises he’s being backed into a corner. ‘It’s just possible, yes.’
‘Only “just possible”? Surely if a diagnosis of post-traumatic stress disorder is missed, then depression would be the obvious alternative?’
‘Depression is only one of several alternatives.’
‘Name a few, if you would.’
With the confidence of someone returning to safe ground, Ainsley went briskly through his list. ‘Adjustment disorder, acute stress disorder, obsessive-compulsive disorder, conversion disorder – not to mention any number of psychosomatic disorders.’
‘But these are diagnoses that would only be made by a specialist like yourself, would they not? An ordinary GP would not be qualified to give such diagnoses?’
Ainsley was forced to agree.
Behind the spread of his hands Tom still had his eyes squeezed tight shut, but the dampness had reappeared on his temples and his jaw muscles were flickering angrily. Hugh signalled to Isabel for water and, touching Tom’s arm, put the glass by his elbow, but if he noticed he gave no sign.
Bavistock was saying, ‘If the patient doesn’t get as far as a psychiatrist, if he only gets to see his GP, then depression would be the most likely diagnosis, would it not?’
‘It might be.’ Then, relenting, Ainsley added, ‘Yes, it would be the most likely.’
‘Now, in the annals of medical history, PTSD is a fairly recent condition, is it not?’
‘The term itself is relatively recent, yes. But medically, the condition has been recognised for a long time, since the nineteenth century in fact, but under different names.’
Unforgotten Page 3
