‘So potassium chloride’s a possibility.’ He made a note in his book. ‘What about the nurse who killed those children with insulin?’
‘Yes,’ I said grimly. ‘In Thatchbury. And she tried all sorts of methods, including potassium chloride as well as suffocation and air embolism. That’s injecting an intravenous bubble of air,’ I added in response to his quizzical look.
‘So that does actually work, then?’
‘It’s a bit of an old chestnut really, since you have to inject a hell of a lot, at least a hundred mil. In her case, she didn’t inject enough, and it only made the victim ill.’
‘So probably not that, then.’ He made another note. ‘You mentioned suffocation — is that really possible?’
‘Certainly, if the patient’s unconscious. You pinch the nose and put your hand over their mouth.’
‘But I imagine it would be pretty obvious if you were seen doing it? Which would be quite likely in ITU.’
‘Yes, and it would also cause the alarm to go off when the heart stopped — if the patient were connected to a monitor.’
‘That’s a point,’ he said. ‘How many of them were connected to monitors at the time they died?’
We went through the printouts while we finished our sandwiches. Peters hadn’t been on a monitor, of course, nor Mr Thorpe or Mr Goldman, who’d both been transferred to Coronary Care. The others all had, which didn’t tell us very much.
‘Shall I make some coffee?’ I said, and got up without waiting for an answer.
‘Let’s get back to insulin,’ Tom said as I handed him a mug a few minutes later. ‘How did they find out that insulin was the agent used in the Thatchbury cases?’
‘A post-mortem on one of the victims.’
‘So it’s detectable on PM.’ He made another note. ‘How does it cause heart failure? I only know it as the stuff diabetics use.’
‘It’s a hormone which controls the amount of sugar released into the blood. Diabetics can’t make it, so they have too much sugar. Conversely, if you have an excess of insulin, the blood’s starved of sugar and that leads to heart failure.’
‘How long does it take to work? After you’ve injected it.’
‘It varies. Soluble insulin acts in a minimum of thirty minutes, but it can take up to several hours.’
‘And if you injected it intramuscularly …?’
‘It would presumably take longer — I don’t know. But, Tom, the killer wouldn’t have to do that, since there are delayed action forms of insulin.’
He groaned. ‘What are they and how long do they take to work?’
‘Er — well, there’s insulin zinc, which takes a bit longer, and there’s protamine zinc insulin, or PZI, which takes longer still.’
He was busily scribbling. ‘How much longer?’
‘I’ll have to look that up when we get back. It’s a long time, though.’
‘OK. So insulin’s a strong possibility.’ He looked up. ‘Are all these various forms easily available?’
‘Yes, they’re just kept in a fridge.’
‘I wonder if these could be copycat killings,’ he mused. ‘Should we be looking for a nurse with a similar sort of personality defect to the one in Thatchbury?’
‘She had Munchausen’s syndrome, and also Munchausen’s syndrome by proxy.’
‘Which means?’
‘In the former, you gain attention by inventing symptoms of illness in yourself; in the latter, you bring about symptoms in those under your care. She had both. Also, she was inadequate.’
‘Is there anyone like that on ITU?’
‘Not that I can think of at the moment.’
‘We’ll bear it in mind.’ He made another note. ‘What other drugs are there which affect the heart?’
‘Well, there’s digitalin, or digoxin, which is used to reduce blood pressure. Reduce it enough, and you’ve got heart failure. Although it’s usually given by mouth rather than by injection.’
‘But it can be injected?’
‘Yes.’
‘Is it easily available?’
‘We keep it locked away, although nothing like so securely as we do controlled drugs.’
‘So a nurse or a doctor could lay their hands on some if they wanted to?’
‘Yes, although not as easily as insulin.’
‘D’you know how long it takes to work?’
‘I’ll check when we get back.’
‘Is there anything else?’
‘The other heart regulators we use are tenoret and propanolol, but they’re administered orally.’
He stopped writing and looked at me. ‘We’ve been assuming up till now that the agent was injected, but there’s no reason it couldn’t have been given orally, is there?’
I thought for a moment. ‘Not in the case of digoxin, no. But with the others, tenoret and propanolol, you’d have to get the patient to swallow a hell of a lot of tablets.’
‘So, not really practical?’
‘I wouldn’t have thought so.’
‘Good,’ he said, scribbling again. ‘But would orally administered digoxin result in a high blood level?’
‘I’m sure it would, yes.’
‘I’ll mention it to the lab. What about an overdose of sleeping drug — nembutal and seconol, stuff like that?’
‘You could certainly use them, but they are controlled drugs. They’re kept in a double-locked cupboard in my office.’
‘OK. So potassium chloride, insulin and digoxin are the clear favourites. I’ll ring Guy’s now and let them know.’
When he’d finished the call, he said, ‘They’ll try those, but they’re going to have to dilute the sample, so we probably won’t get a result until tomorrow.’
I said, ‘We’d better get back if we’re not going to be late for Miss Shenstone.’
*
She was a small, dried-up woman with a wrinkled face — I think she was about sixty, but she looked older. Until you saw her eyes, that is. They were a bright, clear blue, and when she smiled, they took ten years from her.
She was smiling now as she stood up and reached across her desk to take Tom’s hand.
‘It’s very good of you to see me at such short notice, Miss Shenstone,’ he was saying. ‘I appreciate it.’
‘Not at all. I happened to have these few minutes free, and I always like to help the staff of ITU if I can.’ She had a brisk, clear voice, slightly deep for a woman, with an attractive Irish lilt. ‘Won’t you sit down?’
‘I’ll leave you, then —’ I began.
‘I’d as soon you didn’t, Sister,’ Tom interrupted quickly. ‘So long as you don’t mind, Miss Shenstone?’
‘Not at all. Now, time is short, so how can I help you?’
‘My department is looking into ways in which costs might be cut in units such as Intensive Therapy —’
‘When are they not?’ Miss Shenstone inserted drily.
He smiled. ‘I’m looking at several ITUs throughout the country, particularly with regard to their relationships with other departments, which is why I’m here.’
‘We do indeed have a relationship with ITU, and a close one, but I confess I can’t imagine where savings could be made …’
‘Nor I, at this moment,’ he said. ‘But you’d be surprised how often, when we collate all our results, that ways of economizing do emerge.’ He wasn’t playing the silly ass so much, I noticed.
‘I’ll take your word for that,’ said Miss Shenstone, glancing up at her clock.
‘Perhaps I could ask you some direct questions? To save time.’
‘Of course.’
He took out his notebook.
‘How many operations — transplants — would you say you carried out in a week? On average.’
‘It varies. Sometimes none at all, occasionally as many as five, should five suitable organs become available.’
‘You say organs: do you transplant anything other than kidneys here?’
‘Occasionally liver,
but mostly kidney.’
‘Average patient stay?’
‘Anything. As little as two days in some cases, weeks in others.’
‘How often would you need to use ITU, say in a week?’
‘That’s variable too. At the moment, we have two patients in the isolation rooms — do we not, Sister?’
I nodded. ‘Yes.’
‘That is more than usual — it just so happened that two of our patients required higher than usual doses of immunosuppressive drugs, which renders them more susceptible to opportunistic infections — am I losing you, Mr Jones?’
‘Not at all. How long will they stay there?’
‘Once again, it varies. Perhaps a week, perhaps longer.’
‘What would have happened, had there been no room in ITU?’
‘Then we would have approached the transplant unit in Birmingham, which is much bigger than this one.’
‘I see. Do either you or ITU keep records of how often you use their facilities?’
‘Indeed we do,’ she said grimly. ‘For purposes of cross-charging. Now that St Chad’s is to become a trust.’ Her tone told us what she thought about that. ‘I would imagine that this is the sort of thing your department is involved in.’
He smiled without making a reply.
‘I’d like to turn now to the other usage — the keeping of er … patients who have died on life support for purposes of transplant. I noticed earlier today —’
‘Yes, I know,’ she interrupted. ‘But I don’t think you could charge that to us. You see, it’s most unlikely that any of my patients will benefit, since a match will almost certainly be found in another region and the cadaver sent there for transplant.’
‘Even so, ITU facilities are being used for the benefit of transplant patients. There is a cost implication.’
‘But who would be responsible for that cost, since it is not any of my patients who is the beneficiary?’
‘Ultimately, I imagine the receiving hospital. But since it is your department which has instigated the usage, I think ITU should be charging you, so that it then becomes your responsibility to recover the cost from the authority in question.’
By this time, I was staring down at the floor with shame.
‘But that would mean —’ She broke off suddenly and I looked up to see her smile at him again. ‘Mr Jones, I believe you are trying to provoke me, presumably in the hope that I will let something slip. Something to the detriment of my department. Would that be the case?’
He met her gaze. ‘Why ever should I do that?’
‘I don’t know, Mr Jones. You tell me.’
He smiled back. ‘I must apologize if I’ve given you the wrong impression, Miss Shenstone. I’ve been told that I sometimes have an unfortunate manner. What will have to be done in your case, I think, is an audit of your finances to see how best the cross-charging exercise can be implemented.’
‘But wouldn’t the bureaucracy involved in doing that cancel out any savings?’
‘Not in the end, no. However it may seem to you, we at the Department of Health really do try to work for the benefit of the NHS.’
‘I’ll have to take your word for that,’ she said. She looked up at her clock again. ‘However, I’m afraid that we really must bring this discussion to a close now.’
‘One more question. Sister Farewell told me earlier today about your policy of organ recovery. Aren’t you making a rod for your own back? In that you are doing a lot of work, not to mention incurring expense, for the benefit of other regions?’
Before she could reply, there was a knock on the door, which was then immediately opened.
‘Oh, I’m sorry, Marie — I didn’t realize you had company.’
‘That’s all right, John, just finishing. Come in.’
Dr Cannock eased his large frame into the room.
‘In fact,’ she continued, ‘you might be interested. This is Mr Jones from the DOH. Dr Cannock, director of Pathology.’
Jones got to his feet and offered his hand, and after a fractional pause, Dr Cannock took it. He was a heavily-built, tough-looking man of about fifty with a wide, powerful face and short, grizzled hair, but with a surprisingly persuasive voice.
‘Mr Jones is here looking at the relationships between ITU and other departments,’ Miss Shenstone said. ‘He has just asked me why we incur the work and expense of our transplant policy when it is of no direct benefit to us. I believe he thinks we should stop doing it.’
Cannock gave a laugh, creasing the flesh round his widely-spaced, dark brown eyes.
‘If you would care to come along to the talk Miss Shenstone is giving tonight,’ he said, ‘I can assure you that not only would your questions be answered, but you would see for yourself the benefits of Miss Shenstone’s policy.’
‘I’d like that very much,’ Jones said. ‘When and where?’
‘Lecture theatre at seven o’clock.’
‘Thank you very much. Dr Cannock,’ he continued quickly, ‘I believe that your department has a relationship with ITU as well. Is there any chance I could speak to you about it sometime this afternoon? Briefly, of course.’
Cannock looked slightly taken aback. ‘Well, er — I don’t see why not.’ He glanced at his watch. ‘Three o’clock? So long as it is brief.’
‘Thank you very much.’
‘And now, Mr Jones, I really must ask you to excuse us,’ said Miss Shenstone firmly.
13
As soon as we were in the corridor, I turned on him.
‘What were you thinking of,’ I demanded in a low voice, ‘being so rude to one of this hospital’s most respected consultants?’
He manoeuvred me into an alcove and looked round before speaking.
‘Do you, or do you not want this bugger found, Jo?’
‘You don’t have to swear at —’
‘Do you?’
‘Of course I do.’
‘Then let me do it in my own way.’
‘Your own way — it was certainly that! Why did you insist on having me there with you?’
‘So that I could check on what she said, if necessary.’
‘But she didn’t say anything —’
‘She might have. I’m sorry, Jo, but in this job, you have to push if you want quick results. And in this case, we do want a quick result, before anyone else gets —’
‘All right. But has it got you any results?’
‘I don’t know,’ he said. ‘Yet.’
I took a breath and tried to calm down. ‘I’d have thought it would just put people on to you. Or put their backs up so much they’d throw you out.’
‘It has been known,’ he admitted with a grin. ‘But then again, I’ve had some good breaks through what people have told me when I’ve wound them up. The great thing is to know just how far to go.’
I looked at him curiously. ‘Yes … you seem to take on a different character with each person you meet.’ We started walking again.
‘The thing is,’ I continued, ‘you didn’t even succeed in winding her up, did you?’
‘No. I wonder why not?’
‘What do you mean by that?’
He shrugged and changed the subject.
‘You told me earlier that she was one of the founders of transplant surgery?’
‘Yes. She carried out some pioneering research here at St Chad’s in the ’sixties.’
‘Then I wonder why she is still here. I mean, I don’t want to be rude, but —’
‘Ha!’
‘But that unit is pretty small beer,’ he finished. ‘Isn’t it?’
‘Yes, I suppose it is. Latchvale’s not big enough to have its own transplant unit, not with Birmingham so near, but for some reason, she didn’t want to move away, so the unit stayed. Although it’s subordinate to the one in Birmingham.’
As we arrived back at ITU, Viv emerged from the air-lock looking slightly flustered.
‘Jo, could you come and sort out Mr Rogers?’ she said. ‘He
thinks he’s dying.’
‘I’ll be back in a minute,’ I said to Jones as I followed her. Actually, part of me couldn’t help being a little pleased; Viv did have a tendency to make one feel dispensable sometimes.
‘Sister, you gotta help me,’ said Mr Rogers. ‘Get me a doctor, I’m having another heart attack …’
The other patients, those who were able, were staring on in morbid fascination.
I summoned my sunniest smile. ‘No, you’re not, Mr Rogers. Look —’
‘But I got this terrible pain —’
‘Yes, I know. Just here, I expect.’ I put my hand on his chest.
‘Yeah, that’s right, it’s —’
‘You always get pain there. It’s a sign that the drugs are working; that you’re getting better. Look’ — I pointed up at the cardiac monitor — ‘that’s your heartbeat. See?’ I traced it with a finger. ‘It’s exactly as it should be. Your heart’s doing fine, and so are you …’
Back in the air-lock, Viv said, ‘I told him exactly the same things, but he wouldn’t listen.’
‘It could have been the other way round with a different patient,’ I said, but I think we both knew that wasn’t true. Viv was a good nurse, but she sometimes found it difficult to conceal her impatience with time-wasters, as she called them.
‘You seem to be getting on very well with Mr Jones,’ she remarked suddenly.
‘How d’you mean?’
She shrugged. ‘I don’t know. It’s almost as though you knew him before.’
‘Well, I assure you I didn’t.’
‘I didn’t think so.’ She hesitated. ‘He is a bit of a dickhead, isn’t he?’
‘Not as much as you think,’ I said. ‘Not when you get to know him.’
‘I’ll bear that in mind.’
By now, we were back at the Duty Room. He was in my office. I don’t know why I’d defended him. It probably wasn’t doing him any favours.
‘Shouldn’t you be with Dr Cannock?’ I said, glancing at the clock.
‘I was waiting for you.’
‘Me? Why?’
‘I’d assumed you were coming with me. To show me where it is, apart from anything else.’
‘It’s left down the corridor, then second —’
‘Besides, I like having you with me, Jo.’
Sisters of Mercy Page 9
