Tristan’s Inquest

I’ve been meaning to write a second piece about Tristan’s death, but haven’t known where exactly to begin. Things have certainly moved on since the first post. I just re-read it, so I can say that emotionally, my landscape is different, and in terms of knowledge and information surrounding his death, I am better equipped. This is because he died in a psychiatric unit, so there was an inquest.

According to the Coroner, when someone dies in prison, or in an institution under someone else’s supervision, they have to hold a sort of mini kangaroo court to make sure that person wasn’t murdered, neglected, or dodgily deaded in any way. However, the fine points of Tristan’s care under Norwich mental health facilities would not be on trial; this wouldn’t be about pointing fingers, just ascertaining that he killed himself and that there was nothing more than that going on.

I had a phone conversation with the Coroner first, and then he sent me a stack of stuff, testimonies from staff who were with him on the day and in the months leading up to his death. Some of them were handwritten by staff on the day, spidering across the pages in wobbly shock, beginning formally with their names and professions and the details of the morning, breaking down into startling imagery when describing the incident. One nurse wrote of breaking into the bathroom to find him hanging by his belt, grey and blue. ‘It looked like he’d been in the river for a week,’ the nurse wrote, and I felt sorry for him, seeing that. There were descriptions of the chaos – a nurse yelling ‘He’s ligatured!’ and racing to find the ligature hook to get him down. Descriptions of Tristan falling to his knees, then being laid out on the wet floor, and descriptions of him having used his own black belt to hang by the shower cubicle’s window handle, and how that merges in with my sense of what a shame, what a pity it is, because his belt matched his shoes and coat and wallet, he dressed stylishly and softly.

On that day, Tristan thought he was going to be made to go home. He didn’t want to go home, because he was so happy on the ward. He spent the morning anxious, he played scrabble in the afternoon, and then, feeling low, he headed for his bedroom. In the hallway he told a support worker, who described him as ‘super low’ that he didn’t want to go home, that he was upset. Midway through this conversation, another patient interrupted to say she needed help with her laundry. The support worker went off with her, and Tristan went into his room. Then he went into the shower cubicle, and locked the door.

Half an hour later his therapist came looking for him. Together he and the same support worker looked for him in the garden, and in his bedroom, before trying, then unlocking, the shower cubicle.

There was material about his care in the months leading up to his stay in the mental health wing of the hospital which pointed to a disturbing inconsistency in his care by the home care team, complaints his GPs had had to make when they were obstructed from getting him re-registered with the home care team, notes about how Tristan had felt dismissed, how one panicked night, when he called them for help, saying he felt unsafe, he was told to go to bed. He subsequently took a massive overdose. That’s the one me and Lizzie went down for, the first time. As I read, I kept seeing the acronym NSFT, for Norfolk and Suffolk NHS Foundation Trust. Not Safe For Tristan.

The inquest itself was such a peculiar ritual.  All stood for the Coroner, all sat down, and the couple of staff members who could testify or who had not yet left the country read from a piece of paper. There were only two of them. One was a nurse who was manning the front desk that day. She shook like a leaf throughout her testimony. The other was his therapist.

He was interesting. He said Tristan was not in his opinion bipolar but that his problems were complex and rooted in trauma. Tristan’s emotions were too raw for therapy, which he refused to attend, because he could not talk about his problems.

As I sat listening to the therapist I thought about how what he was saying tallied with what I knew to be true.

As an adult Tristan drank too much, had long term relationships but could not remain faithful to anyone, and would routinely go into states of utter terror and shame. He supposed these to be bipolar episodes but I think he had post-traumatic stress disorder. He preferred to treat his problems with drugs for depression, and told me his memories of his childhood were ‘in a box.’

The therapist said Tristan thought he might be bipolar because his mother had been diagnosed as bipolar, but I clarified that this was something that had happened when she was 19, that she had not been reassessed since then. Tristan was a complex person with complicated problems, I said.

At the end of his testimony I was allowed to ask questions, so I asked if his medication could have been a factor (probably not) and then I asked why nobody noticed he was spiralling that day, why he was let down, why that support worker went off to help with laundry when Tristan was standing there, crying, telling him he didn’t want to go home. The therapist said everyone in that hospital was sick, as sick as Tristan was. Everyone did their best that day.

This was my chance to say this was not true, that nobody did their very best, that Tristan was let down, his impulsiveness underestimated, but I knew the therapist was right. He was right. Everyone was doing their best, and even though that wasn’t good enough, even though Tristan died while they were looking after him, what he said was true.

I said ‘That’s reasonable,’ into the little black mike in front of me, and then I went deaf, for about ten seconds.

The inquest ended, and I sagged and began to bawl, quietly, into the table in front of me. Someone gave me a tissue. Then everyone stood up. The Coroner had stood, and because it was an inquest, the ritual demanded that everyone must rise, while the Coroner shook the hands of the family. My hands were sticky, so when she came to me, I thought you have got to be kidding, but I put my snotty hand in hers anyway.

Then the therapist came to me and offered me his secretary’s number, telling me I could call and ask him anything. But I don’t think I will.

And that’s it. A line should have been drawn now, lots of little mysteries solved so we can all get on with living, but when I’m awake my mental retreat is still with Tristan in his kitchen. I am making him pasta, and preparing to make him better.

In dreams he is there with me, my constant companion, alive and beside me even when the dreams are about him, dead. He looks into my eyes and they are grey and his expression is that of someone who is just holding on, but he’s with me and we’re together and ok.