Sister

“How long is an NHS appointment?”

“I’d rather have more time with each patient but—”

“With a waiting list of four months, you must be under a great deal of pressure to get through them.”

“I spend as much time as I possibly can with each patient.”

“But it’s not enough, is it?”

He paused a moment. “No. It’s not.”

“Puerperal psychosis is an acute psychiatric emergency, isn’t it?”

I thought I saw him flinch because I knew this, but I’d done my research beforehand.

“Yes, it is,” he replied.

“Requiring hospitalization?”

His body language was rigidly controlled, arms held determinedly at his sides, his corduroyed legs a little splayed, but I knew that he wanted to cross his arms over his chest and put one leg over the other to give physical expression to his mental defensiveness.

“Many psychiatrists would have interpreted Tess’s symptoms as I did, as indicators of depression rather than psychosis.” He absentmindedly reached down to stroke his dog’s silky ears as if he needed comfort, and continued, “Diagnosis in psychiatry is far harder than in other branches of medicine. There aren’t any X-rays or blood tests to help us. And I didn’t have access to her notes, so I didn’t know whether there was a history of mental illness.”

“There isn’t any history. When was her appointment with you?”

“The twenty-third of January. At nine a.m.”

He hadn’t consulted his diary or looked at his computer.

He had come prepared for this meeting, of course he had. He’d probably been on the phone all morning with his medical defense union. I saw in his face a beat of some genuine emotion. I wondered if it was fearfulness for himself, or genuine upset about you.

“So you saw her the day she died?” I asked.

“Yes.”

“And you thought the morning she died that she was suffering from depression not psychosis?”

He could no longer hide his defensiveness, crossing one leg over the other, huddling into himself. “At the time, I didn’t see any indicators of psychosis. And she didn’t show any signs that she was considering hurting herself. There was nothing to suggest that she was going to take her life.”

I wanted to scream at him that of course there were no signs, because you didn’t take your life; you had it violently cut from you. I heard my voice sounding distantly quiet against the shouting in my head. “So it was her death that rewrote your diagnosis?”

He didn’t reply. I no longer found his rumpled face and corduroys endearingly scruffy, but hopelessly negligent.

“Your mistake wasn’t that you diagnosed her with depression when she was actually psychotic.” He tried to interrupt me but I continued, “Your mistake is that you didn’t once think that she might be telling the truth.” Again he tried to interrupt me. Did he interrupt you too as you tried to tell him what was happening to you? I thought psychiatrists were meant to listen. I suppose in an emergency NHS appointment, probably shoehorned into a full clinic, there’s not much time for listening.

“Did you even consider that the phone calls threatening her were real, just as the man who followed her to the park that day and murdered her was real?” I asked.

“Tess wasn’t murdered.”

I thought it strange he was so adamant. After all, murder would have let him off the misdiagnosis hook. He paused, then forced the words out as if they physically pained him.

“Tess was having auditory hallucinations, which I’ve told you about, and we can disagree about the interpretation if you wish. But she was also having visual hallucinations. At the time, I interpreted them as vivid nightmares, not uncommon for a patient who’s depressed and bereaved,” continued Dr. Nichols. “But I’ve reread her notes and it’s clear they were hallucinations, which I missed.” The beat of upset in his face I’d seen earlier seemed to spread across his features. “Visual hallucinations are a clear signifier of acute psychosis.”

“What were the ‘hallucinations’?”

“I have to respect patient confidentiality.”

I thought it strange that he suddenly thought of doctor/patient confidentiality when it hadn’t hindered him up until now. I wondered whether there was a reason for it, or whether it was just another incidence of his incompetence.

“I asked her to paint what she saw,” he continued, and his face looked kind. “I thought it would be helpful to her. Maybe you could find a painting?”

The secretary came in. Time was up, but I didn’t leave.

“You must go to the police and tell them you have doubts she had puerperal psychosis.”

“But I don’t have any doubts. The signs were there, as I said, but I missed them.”

“You’re not the reason she died, but you could be why her murderer gets away with it. Because of your diagnosis, no one is even looking for him.”

“Beatrice …”