by Rob McCarthy
‘OK,’ said Harry. ‘Let’s get an infusion ready, and we’ll need chlorphenamine and hydrocortisone. And it might be wise to start some vasopressin, too.’
Dr Rashid burst into the room, his brow sweaty.
‘Got here as soon as I could,’ the consultant said, tying his apron around his back. ‘What’s going on?’
‘Full-blown anaphylaxis,’ said Harry. ‘Had to give him two rounds of adrenaline. He went into VT, systolic dropped to fifty, then he lost his output. We shocked him once and now he’s back in sinus tachy, BP’s up to eighty.’
‘Where’s his allergy band?’ said Rashid.
‘What allergy band?’ said Faraway.
Harry looked down at Idris’s wrist. Patients with drug allergies had red ID wristbands instead of the normal white ones to remind people to check when they gave drugs. Idris’s was gone. There was meant to be a red sign, too, at the head of the bed, but there wasn’t.
‘Is he allergic to penicillins?’ Faraway said.
‘Yes,’ growled Harry. ‘Yes, he fucking is.’
Faraway’s face went white as a sheet.
‘I prescribed him the co-amox,’ she said. ‘The AM plan said give him micro prophylaxis. I didn’t realise! It wasn’t in his notes! I checked, I swear!’
Harry glared at Faraway, all the morning’s anger and contempt packed into his expression, his disregard for this fuckwit a year and a half out of medical school who’d come close to killing Solomon Idris with mere laziness.
‘Doctors’ office. Now. I’ll deal with you later,’ Rashid said, before turning to Harry: ‘Have we set up that infusion? Let’s get the hydrocortisone up as well, and then we’ll recheck everything. Another ABG as soon as we can, please.’
Harry went to prepare the infusion while Saltis drew up the steroids, and Rashid checked the ventilator settings. In silence, Faraway turned and shuffled towards the office.
‘Dr Rashid, I promise, if I’d made a mistake I’d admit it!’
An hour after Idris had almost died, Dr Faraway’s protestations were starting to strain her voice, and Harry was trying his best to keep his eyes on the floor, rather than show her how angry he was. They stood in the ICU doctors’ office, the door locked, a Do Not Disturb card over the door handle. Rashid was on the swivel chair by the computer, Harry perched on the desk. After a good forty-five minutes of graft, Idris was stable, and Aoife Kelly was under strict instructions to fetch the consultant if he went off again.
‘You told me to sort out prophylactic antibiotics for all of the patients who needed it. Micro opinion had said to start broad-spectrum for bed ten to cover for secondary bacterial pneumonia. I checked his allergy status on the system, there were none, and so—’
‘You’re sure you checked?’ interrupted Harry.
‘Absolutely sure. And he didn’t have a sign. I looked! And I looked for an allergy band, and he didn’t have one!’
Harry looked at her, his sense of fury beginning to fade. Idris’s wristband should have been red, and that wasn’t her fault. But there was no way that Faraway would have missed the allergy if she’d checked the computer system. The Ruskin was a university hospital in London, and as such the junior doctors’ jobs were highly competitive. You had to be good to get in. Faraway had been in the top decile of her class at Edinburgh. Harry had worked with her only for the six weeks or so since she’d been attached to the ICU. Viewed her as no superstar, but diligent, good at her job.
But even decent doctors sometimes made mistakes.
‘Bring up the records!’ said Faraway.
Rashid sighed. Harry could tell he hadn’t wanted to do that, to humiliate Faraway by showing her how wrong she’d been. He’d been hoping she would admit to an oversight, a lapse of concentration, then at least they could move forward. Harry watched as Rashid selected Idris, Solomon from the list of patients on the surgical ICU, clicked ‘patient information’, and scrolled down to the allergies part.
‘What the . . .’
Harry didn’t even finish his sentence. It was staring back at him from the form on the screen, in the old-fashioned type the patient records system used.
this patient has no known drug allergies.
‘That’s impossible,’ said Harry. ‘I handed over in A&E. They would have written that down! And it would already have been on the system from either 2009 or 2011.’
Rashid refreshed the page, perhaps thinking that it would change. Double-checked the date of birth, that this was the right Solomon Idris. His nine-digit hospital number. The very same.
‘I told you I checked,’ Faraway muttered.
‘We don’t doubt that you did,’ said Rashid. ‘Go get me Aoife, if she’s free.’
Faraway unlocked the door and started off into the main ICU corridor. Harry watched the door close behind her, and turned back to Rashid.
‘What the hell’s going on here?’ said Rashid.
‘I’ve got no idea,’ said Harry. ‘But I don’t like it one bit. We ought to let Patient Safety know.’
Any event as serious as this one would have to be investigated by the hospital’s Patient Safety Directorate, whose managers were probably the most feared of all of the trust administrators. Rashid groaned wearily and picked up the phone.
‘I’ll call them now,’ he said. ‘They’ll want to speak to us all, so why don’t you go and check on Idris, then gather the troops.’
Harry stood up from the desk.
‘Sure thing.’
Later, in the coffee shop by the hospital’s main entrance, he called Noble.
‘Hello?’
‘It’s Dr Kent.’
‘Can this wait, Harry? I’m right in the middle of something here.’
‘We need to meet,’ said Harry. ‘There have been developments with Solomon Idris. Something happened. He almost died this morning.’
‘OK. I’m stuck at a scene at the Coral on Peckham High Street, so if you could meet me up here that’d be great. I should be free by seven, alright? I’ll keep you posted.’
She hung up before Harry could reply. He would have called her sooner, but Patient Safety had kept them all for two hours, taking statements, putting the stories together, trying to figure out what had happened. Idris was on the mend, but the anaphylactic reaction had given his circulation a bit of a bash, and he’d been put on a careful programme of fluid replacement.
What they knew was that at some point the allergy had disappeared from Idris’s medical records. Possibly it had happened between his previous admissions and Sunday night, but even so it should have been added when Harry had turned up with him in A&E. Something had gone seriously wrong. The managers from Patient Safety had seemed most worried about some kind of glitch in the electronic records system deleting patient allergies at random, which could have wide-ranging consequences. Harry was worried about something equally serious, but much less random.
It could have been an accident, he told himself. If it hadn’t been, then Christ knows what that meant. Before he had left the ICU, though, he had showed the police officer on guard how to wash his hands and don an apron and gloves, and given him a chair right next to Idris’s bed.
Cappuccinos in hand, Harry headed downstairs and found the cellular pathology lab with no difficulty, just along the corridor from the mortuary. It was one of the international constants of hospital design that the dead have no right to be up above ground with the sick, and are temporarily buried along with those who work on them. As he passed the mortuary, one of the assistants was clipping an identification tag around the toe of a recently deceased elderly lady. The assistant, herself of reasonably advanced years, made the sign of the cross as she zipped up the polythene bag. Harry looked across at the cadaver, noted a red spot on the dark-skinned forehead, and wondered whether she would have wished to be blessed in such a manner, but decided to let it pass.
Dr Wynn-Jones was not the mousy middle-aged woman that he had expected. A ponytail of blond hair draped down over a tight maroon swe
ater, and she couldn’t have been older than her late thirties. Not bad at all for a consultant histopathologist who’d also managed to get on the Home Office register.
‘Hi,’ said Harry. ‘I wasn’t sure if you wanted chocolate sprinkles.’
‘I’m impressed,’ said Wynn-Jones. ‘I was wondering where you’ve been, I’ve been done for an hour.’
She finished sending the email she’d been working on then turned her attention to Harry, picking up the coffee and sipping from it.
‘Four o’clock finishes,’ he said, shaking his head. ‘I should have gone into pathology.’
‘Quarter past four every day, I go straight to the sunbed to make up for all the Vitamin D I miss out on down here,’ said Wynn-Jones. ‘And I’ve done my share of late-night call-outs. This Saturday gone, actually, three in the morning down in bloody Swanley, of all places. Hedge fund manager decided to suffocate his wife and sit in the car with a couple of disposable barbeques.’
Before Harry could even begin to process what she’d said, and regret his off-the-cuff remark, Wynn-Jones had reached into her desk drawer and pulled out a bound laminated report.
‘I thought I’d bring up the file,’ she said. ‘Jog my memory. Remind me again why you’re interested in this poor soul?’
Harry briefly explained what had happened with Idris in the Chicken Hut, leaving out most of the graphic details but saying that Idris had claimed it had all been for Keisha. They killed her, and the feds didn’t give a shit.
‘Any idea who “they” might be?’ said Wynn-Jones.
Harry shook his head.
‘Not First Capital Connect, then? Because the cause of death was fairly obvious. Most jumpers get hit side-on, but Keisha . . .’
Wynn-Jones stopped, and Harry thought he’d seen a lump form in her throat. A lot of medics used gallows humour as a psychological coping mechanism, but every now and again things pierced the armour. It had happened enough times to Harry himself that he could spot it easily in someone else.
‘Keisha was standing up, facing the train when it struck her. The impact threw her about eight feet into the air and she landed head first on the opposite track. She would have died immediately. Broke her neck, caved her skull in. The worst internal injuries I’ve seen in many a day. But it all fits with the picture, the witness accounts, the CCTV. It would have taken some gall.’
Harry thought again about the parallel with Idris’s actions the previous evening.
‘She would have had a chance to save herself,’ Wynn-Jones continued. ‘When she was standing, facing the train. She stood there for a good few seconds.’
Harry nodded. If Solomon Idris had gone into the Chicken Hut intending to die, then his conviction evidently hadn’t been as strong as Keisha Best’s. He didn’t know what to make of that.
‘You said earlier that it wasn’t a straightforward suicide, though,’ he said after a while.
Wynn-Jones nodded and started leafing through the report.
‘We did a routine toxicology screen. Vitreous, blood and hair samples. Nothing apart from alcohol and cannabis in the blood and vitreous.’
‘But the hair?’
‘Long-term cannabis usage, as well as benzodiazepines and ketamine. Traces of crack, too, and GHB. No evidence of injecting drug use, though, and that’s interesting.’
‘How so?’ said Harry.
Wynn-Jones flicked the report over to some of the later pages and tapped a table of results with her fingers.
‘Keisha was HIV-positive,’ she said.
‘So’s Solomon Idris,’ said Harry. ‘He’s got a PCP pneumonia at the moment, in fact. Poor kid.’
‘Keisha Best’s viral load was about four hundred thousand,’ said Wynn-Jones. ‘But her CD4 count was still quite high. I’m no immunologist, but it suggests she’d been recently infected.’
‘What’s recently?’ said Harry.
‘A matter of weeks or months, rather than years.’
So Idris and Keisha Best had been either romantically or sexually involved, unless they’d both acquired HIV independently, which seemed like a massive coincidence. Both had been recreational drug users, but there was no evidence that they had ever injected.
‘So Keisha’s disease was early-stage,’ said Harry, after thinking for a while. ‘And Solomon’s is fairly advanced. That would make me think that she got it from him.’
‘Perhaps,’ said Wynn-Jones. ‘After the initial infection, she wouldn’t yet be at the stage where she’d have symptoms. Maybe she didn’t even know about it. Or maybe she found out, and that was when . . .’
Wynn-Jones didn’t finish the sentence, but merely shook her head again. Every time she did it, her ponytail bounced from shoulder to shoulder, and her sweater rubbed against her skin. She was for sure the most attractive pathologist Harry had ever met, but he wasn’t looking. He was picturing a young woman climbing down onto a railway track.
‘So she was an HIV-positive long-term drug user,’ Harry said. ‘That’s still not much to write home about in a seventeen-year-old girl from North Peckham.’
‘But this is,’ said Wynn-Jones. She slid over the post-mortem report, open to the sixth page, where it described the weight of all the organs removed from Keisha Best’s shattered body in the mortuary of the Ruskin on the night she had died, and any notable characteristics. Such as the presence of a small, totally benign stone in her gall bladder. Or the fact that the lower part of the bowel was ‘not present in the body cavity on examination, likely due to traumatic removal at the scene’.
‘Sorry, what am I looking at?’ Harry said. He was scanning over the organs. The stomach was unremarkable, and had contents including ‘tomato, cheese and a dough-like material’ as well as a noted smell of unabsorbed alcohol. Keisha Best’s last meal, a pizza washed down with vodka.
Wynn-Jones tapped the last item on the list removed at the post-mortem. Harry read. Keisha’s uterus had weighed in at 150g, above the normal range. Wynn-Jones’s notes suggested that the reader see page ten, and the subsection ‘Hormone Analysis’.
Harry looked up at the pathologist.
‘She was pregnant?’ he said.
‘No,’ said Wynn-Jones. ‘But she had been. Recently. From the histology, I’d say she’d been at least twenty weeks gone. Could have been as many as twenty-six.’
‘And she miscarried?’ said Harry.
Wynn-Jones shook her head and shuffled in her seat.
‘Well, maybe she did,’ she said. ‘But we analysed her Beta-HCG levels. If you’re pregnant and it fails, for whatever reason, your Beta-HCG keeps rising for a bit and then falls, gradually. We put her levels on the curve and it looked like the pregnancy ended between four days and two weeks before she died.’
‘The pregnancy ended? Not, she miscarried?’ said Harry.
Wynn-Jones sat up. ‘Sorry?’
Harry looked across at her. She was too young to have kids of Keisha Best’s age, so that wasn’t why it was affecting her. Maybe she was pregnant herself, or recently had been. Or maybe it just troubled her that an eighteen-year-old girl could lose a baby and throw herself under a train. No, Harry corrected himself. Climb down to the railway tracks and stand in front of one.
‘You said the pregnancy ended. You didn’t say she miscarried.’
‘Well, that’s because I’m not sure that she did,’ said Wynn-Jones.
Harry leant forward. He wanted to sound empathic, rather than accusatory.
‘Do you think she had an abortion?’ he said.
Wynn-Jones spent a few seconds looking down at the wastepaper bin beneath her desk, then slowly rolled her head up and nodded.
‘I think so. But I don’t have any proof, any proof at all. If she was twenty, twenty-two weeks gone, then that’s past the threshold where you can safely use the abortion pill. I did tests for the usual termination drugs anyway, but they clear out of the system after forty-eight hours. They wouldn’t show up after that. And if it was a surgical abortion, the evidence w
as destroyed when the train hit her.’
Harry leant back, leafing through the rest of the post-mortem report.
‘So it’s not clear?’
‘The last time Keisha Best went to see a doctor, as far as all the records show, was in 2008, when she was thirteen. Ear infection. She didn’t go when she got pregnant, and when she either miscarried or had a termination, she didn’t go through her GP, or through the Ruskin. And I checked the other local A&Es, too, Lewisham, Tommy’s, George’s, as well as every GP and pharmacy in Lambeth, Southwark & Lewisham. No one saw her.’
‘If she did get a termination, it wouldn’t necessarily show up on her medical record,’ said Harry. ‘She could’ve gone to one of the anonymous clinics. Marie Stopes, the Havens?’
‘Not anonymous,’ said Wynn-Jones. ‘You can’t get an abortion without giving your name. Especially not at twenty-two weeks. She could have been past the limit, even. And we checked around the clinics. Me and one of the Sapphire detectives, you know, from the sex crimes unit. Nothing. They’d release the records after a death. We had a coroner’s order.’
Harry sat back and looked at the woman across from him. The calm, clinical demeanour that Wynn-Jones had possessed when Harry arrived had evaporated, and her cheeks flushed red with an infectious rage. His head was like a thunderstorm, thoughts bursting through the clouds, and he forced himself to stick to questions rather than trying to lead her to his own conclusions.
‘And what do you make of all that?’
‘Ever worked in Obs & Gynae?’ Wynn-Jones said. ‘Bet you’re military, aren’t you?’
Harry was struck silent, his surprise at being read so easily turning to indignation. He got the impression that he wasn’t the first person to underestimate the young pathologist sitting across the desk from him. He nodded quietly.
‘Then you probably haven’t treated a pregnant woman in years,’ Wynn-Jones lectured, a lock of hair falling over her forehead. ‘Let me explain. If you lose a baby at twenty weeks, even if you never knew you were pregnant, you’ll bloody well notice. Keisha would have had significant bleeding, maybe even a stillborn delivery.’
