Thursday 31 October 1996
„You‟ll get piles, sitting on that damp bench. It rained here yesterday, you know.‟ The
old lady paused for a moment, leaning on her stick, looking down at Eileen, her head tilted.
„You‟re probably right,‟ Eileen said. „But I won‟t be here much longer.‟
„Ah. Well, that‟s all right then.‟ The woman moved slowly on, crisp brown leaves
whirling round her unsteady feet. Eileen smiled to herself, remembering similar advice from
her mother forty years ago against sitting on damp door-sills. She looked at her watch.
Ten minutes. Ten minutes, and then I’ll go in.
Two small children came hurtling past her, through the mounds of leaves swept up
earlier by the park gardener. A girl of about eight years, wearing a flapping black shiny cloak,
a tall pointed black hat, and a hideously warty and misshapen plastic nose, raced ahead of her
younger brother, from whose fair curls sprouted two crimson horns. A matching cape hung
from his shoulders, and his pudgy fingers gripped a red plastic trident. A few yards behind
came their mother, a young woman pushing a buggy with a well-wrapped sleeping baby in it.
As she passed Eileen she gave her a smile of faintly guilty indulgence.
Hallowe‟en seemed an ironic date for an inquest. Natasha had obviously thought so too.
„Someone‟s got a funny sense of humour, Mum,‟ she had said as they sat in her tiny,
bright kitchen, sipping coffee, a few days after Eileen had received the letter inviting her to
„Probably completely accidental,‟ Eileen said. „The cogs of the legal process grinding
„Are you going?‟ Natasha asked. „To the inquest? You don‟t actually have to, do you?‟
„No. But maybe I will. I‟ll see how things are.‟ She glanced up at the kitchen clock,
which was in the shape of a bright yellow sunflower. „I‟ll have to be going, Tash. I have
things to do in my flat. I‟ve still got loads of boxes lying around.‟ She got to her feet and took
her empty cup to the sink. „Anyway, I‟m not too bothered about Hallowe‟en. The next day is
All Souls, which kind of makes up for it.‟
„I think it‟s when saints and martyrs are celebrated. Talking of saints, did I tell you
about the girl on the floor below me? She‟s a funny kid, perhaps not a hundred per cent all
there. She has a bit of an obsession about ecclesiastical things, even named her baby after the
„St Augustine‟s. The baby‟s called Gus. He‟s a charmer, all chubby toes and toothless
„Is that the church you‟re thinking of going to?‟
„Yes, probably. It‟s a nasty Victorian pile, but it‟s the nearest.‟ She put on her coat.
„See you soon, Tash. Give my love to Sean.‟
Natasha followed her to the door. „I can‟t see me and Sean naming any of our kids after
„Oh, I don‟t know,‟ Eileen said, smiling. „What about Polycarp, for instance?‟
„You‟ve got to be joking, Mum! Sounds like a cross between a fish and a parrot!‟
Eileen was still grinning as she slammed the car door shut and drove slowly down the
She looked at her watch again. Time to go in. She stood up stiffly, brushed a leaf from
her coat, and threw the remains of her lunch in the bin.
The Council offices in Lambury were reached by broad, imposing steps. Eileen climbed
them slowly, feeling her reluctance increase. What was she doing here? She didn‟t have to be
here. But she carried on, through the swing doors, across the deep-pile purple carpet, to a
small sign with an arrow pointing to the right. „Coroner‟s Court, Waiting Room.‟
It was a large room, and the small number of people in it seemed lost. They stood or
sat, singly, in pairs, in small tight-knit groups, murmuring to each other, but avoiding the eyes
of others waiting. Eileen positioned herself as far away as possible from the nearest group
After a few minutes a door opened at the far end of the room and a tall, grey-haired
man in a sober suit ushered in an elderly couple. The woman, weeping, clutching a large
white handkerchief, leaned on the arm of a red-cheeked man who looked out of place in his
tight suit, his feet in great black boots, his meaty hands seeming too big for his body.
The grey-haired man accompanied them across the room to the exit. Eileen heard him
say softly, „Will you be all right, Mrs. Edwards? There‟s a vending machine in the foyer if a
cup of tea would help.‟ The woman nodded dumbly, mopping her face. Then they were gone,
and the grey-haired man crossed the room again and disappeared through the inner door.
Eileen shivered, thinking of the human misery, the waste and tragedy, recorded within these
walls on the first and third Thursday of every month.
The grey-haired man reappeared and coughed. „Would all those attending the
Arrowsmith inquest please come in now.‟
Hearing Christopher‟s name gave Eileen an unexpected jolt. She stood, waiting for
others to go first. The coroner‟s clerk smiled at her as she passed. She felt awkward, alien,
but somehow driven. I don’t want to be here. I’d like to run. But I have to be here. No use trying to explain. I don’t understand it myself.
The room was arranged in broad semicircles of chairs and desks, facing a long bench
with an ornate chair, presently empty, behind it. Eileen found herself a place at what she
hoped was a discreet distance. A few rows ahead, with their backs to her, sat Brian and
Geraldine Arrowsmith, huddled in winter coats, silent, but every so often turning to one
another with a painful smile. On the far side sat a young woman, thin, sharp-featured, her
wrists clanking with bangles, her pen poised over a jotter. Eileen assumed she was a
journalist. In the centre, facing the coroner‟s empty chair, sat a policeman in uniform, a thick-
set, pleasant-faced thirtyish man with cropped hair and prominent pink-tinged ears.
Immediately behind, and leaning forward to speak quietly to him, was a tall young man in
dark-rimmed spectacles and smart striped suit, complete with buttonhole. Behind him,
towards the back of the room, a group of five sat together: three men, one middle-aged, two
young, and two women. All were smartly dressed, and all looked nervous.
There was no sign of the coroner. The clerk, sitting immediately in front of the bench,
looked at his watch, stood up, and left the room by a small dark door at the far side to
In the silence, broken only by occasional whispers, Eileen let her thoughts range back
to the day, three weeks before, when she knew she had to be here, at Christopher‟s inquest.
She had just had a convivial lunch with Marie and Philip at their house in the Close, a meal
awash with wine and punctuated by the Abbey bells marking the quarter hours, and had left
feeling benign, very slightly drunk and more than a little envious. On her way home she had
decided to call in at a hardware store for a tin of emulsion and had to her surprise met
Charley, her former foster-son Michael‟s social worker, on a similar errand.
„Eileen! How nice to see you,‟ Charley said. „Are you OK? I heard you were ill.‟
„I‟m fine, thanks, Charley. Quite recovered. How about you?‟
„Well, you probably haven‟t heard all the scandal, as you‟ve been out of circulation,‟
Charley said. „I‟m on my way out, as it happens. Got a new job. I‟m going to Wales in a few
weeks, going to run a children‟s home with my boyfriend, Al. Might even get married, who
„Oh. Was this a sudden decision, Charley? You‟ll be missed at Caxford.‟
„I‟ve been getting itchy feet for a while now. Thought I‟d try something different. But
all the trouble at Social Services has sped up the process.‟
„You really have been out of it, haven‟t you? It‟s been in the local press.‟
„I‟ve been busy, too,‟ Eileen said. „Starting a new life, really. I sold my house in
„Are you in a hurry? Time for a cup of tea and a chat maybe?‟
„Fine, why not, Charley? If you‟re decamping to Wales it may be the last chance for a
Over tea Charley leaned forward confidentially. „Things have really gone crazy at
Social Services. It‟s all to do with that poor lad who topped himself in your woods, the one
you found. There‟s an internal inquiry going on right now, and the social worker is in the
frame. I know him slightly: chap called Mick Cohen. I‟d be surprised if he even met your
tramp guy more than a few times. Don't suppose he was much of a priority with the caseload
Mick's got. None of it‟s anything to do with me, I know: I‟ve never been on the mental health
team, but mud sticks, and I aim to be well out of the way before any of it gets thrown.‟ She
„Guilt by association, you mean,‟ Eileen said.
„Something like that. It‟s a health issue really, of course, and I imagine something very
similar is happening in the NHS. That‟s where the psychiatrist is based, and the CPN, and
probably the care support worker as well. Heads may be about to roll.‟
„I don‟t know how it all started. Maybe the fellow‟s family kicked up. Bottom line is,
Eileen, what‟s a young guy supposedly in the joint care of the NHS and Social Services doing
holed up in the woods – and dead into the bargain? Seems like nobody knew. It does make
you think there was some neglect, doesn‟t it?‟
„But there‟s more,‟ Charley said. „One of the other residents of that house has vanished,
and nobody knows where he is. The house has been closed and all the residents sent
elsewhere. The Press have been snooping round, but everyone else has been trying to keep
the lid on it. It's been a real mess.‟
„Will anything come of it?‟ Eileen asked.
Charley shrugged. „Who knows? I‟m out of it, anyway. I feel sorry for Mick, though.
OK, so he didn‟t do what he should‟ve, but I guess he‟s got fifty or sixty clients to deal with,
and some of them very time-consuming. Anyway, Eileen,‟ she said, brightening, „enough of
„Oh, not much,‟ Eileen said. „I‟ve got a nice little flat, and I‟m job-hunting.‟
„Not really. Just anything to pay the rent till I find something I‟d like to do.‟
They fell silent for a few moments, and then started talking together.
„Got to go, I‟m afraid.‟ „Lovely to see you.‟ „All the best. Hope it goes well.‟ „Good
Then she was alone again, the silence washing in like waves onto a deserted beach.
Walking back to the car, she realised with a pang that she had forgotten to ask Charley about
Michael. She asked herself guiltily how she could have forgotten a boy who had been her
almost-son for three years. Charley might have had news; certainly no one else would. It was
The clerk had reappeared unnoticed. People shuffled to their feet as the coroner, a tall,
slim man with receding hair and half-glasses, came in and took his seat.
„Coroner‟s Court taking place at Lambury in the county of Essex, 31st October 1996,
Mr. Richard Somerville presiding,‟ said the clerk. „Please be seated.‟
The coroner moved papers, then looked up and around the assembled company. „This is
the reopening of the inquest, first opened and adjourned on 24th June 1996, into the death of
Christopher James Arrowsmith, born in London on 8th January 1973, a single man, the son of
the Reverend Canon Brian Arrowsmith and Mrs. Geraldine Arrowsmith of Barnwell in this
county. At the time of his death the deceased was resident at 16, Denbigh Street, Caxford,
also in this county.‟ He paused for a moment and turned over a page. „The body of Mr.
Arrowsmith was identified in Lambury mortuary on 18th June 1996 by his father.‟ Somerville
turned to the Arrowsmiths, nodded, and said to them courteously, „Canon and Mrs.
Arrowsmith, I have your statement here and other depositions, but should you wish to share
any other information with this court you are at liberty to do so. You also have the right to
question witnesses, should you think it necessary and appropriate.‟
Eileen thought she saw Brian Arrowsmith move convulsively. Perhaps she imagined it.
His wife laid a hand on his arm, and he subsided.
The coroner gazed around the court, leaning back slightly in his chair. „Mr. Arrowsmith
left notes to his family and to the designated authorities, notes which leave little doubt that he
died by his own hand and fully intending to take his own life. However, the content of these
notes makes this case more complex than it might at first appear. I feel it is incumbent upon
me to inquire further into the circumstances leading up to this young man‟s tragic death. The
peculiarities of Mr. Arrowsmith‟s situation may have a bearing on other, related, matters, as
will become clear. In addition, I have received from Canon Brian Arrowsmith, the deceased‟s
father, a letter drawing my attention to certain issues which, in my view, merit the attention
„I must make it clear at this juncture that the purpose of this court is not to apportion
blame. There is no question of any individual or group being under interrogation. Our
purpose is to arrive, as far as we can, at a true understanding of the circumstances of Mr.
Arrowsmith‟s death. However, all those called to witness are obliged under oath to tell
truthfully what they know and to conceal nothing that could be helpful.‟ Again he looked
around the room, as if assuring himself that everyone present had heard and understood the
„Very well. Let us proceed to the witnesses. Sergeant Weston, please.‟
The clerk rose and swore in the policeman, who coughed and referred to his notes.
„Sergeant Gary Weston of Caxford Police, sir. At 1pm on 17th June this year I was alerted by
a passer-by by telephone to the presence of the body of a young male in Holton Woods. I
called paramedics who attended, as did the Police Surgeon, Mr. Harris, who confirmed death,
giving the time of death as approximately 7am that morning. The body was undisturbed
except for the effects of a resuscitation attempt. An empty medicine container, an empty
vodka bottle, and two notes were found at the scene.‟
„Thank you, Sergeant Weston.‟ The coroner addressed the court. „Mrs. Harding, who
found Mr. Arrowsmith‟s body, has given a statement which I will paraphrase. Mrs. Harding,
a local resident, was taking a stroll in the woods near her home, as she often did, when she
came upon Mr. Arrowsmith‟s body. Although she thought it likely that he was dead she tried
to resuscitate him. She observed the bottles of alcohol and tablets but left everything
undisturbed and called the police. Mrs. Harding confirmed that she had seen Mr. Arrowsmith
around the woods once or twice in the preceding weeks. At the time of this incident she was
resident at 5, Church Cottages, Holton, but now lives at Allerton in Hertfordshire. Is this
correct?‟ He glanced at Eileen. „Thank you. Could we now call Dr. Manser, please?‟
The tall young man with the buttonhole was sworn in. „Dr. Joseph Manser, Hospital
Pathologist. I carried out a post-mortem on Christopher James Arrowsmith, a Caucasian male
twenty-three years old, 1 metre 75 in height and weighing 70 kilos. There were no signs of
illness or injury to the body except for a small scar on the left thigh. The toxicology report on
the pill residue in the stomach was inconclusive. There was alcohol in the blood but no real
chemical indicators of the cause of death.‟
The coroner interrupted. „Dr. Manser, are you aware of the substances that the deceased
„I am, sir. I believe he was on a regime of chlorpromazine and a tricyclic
antidepressant, to which he added vodka, and seconal, a barbiturate‟.
„In your opinion would this cocktail have been sufficient to cause his death?‟
„What, then, would you say was the probable cause of death, Dr. Manser?‟
„Acute heart failure, stemming from alcohol and drug overdose, sir.‟
The pathologist resumed his seat. The coroner wrote a note or two. His pen sounded
scratchy in the silence. Then he looked up, laid down his pen, and cleared his throat.
„I have no intention of reading Mr. Arrowsmith‟s notes to the court. As to the one
addressed to his family, that is a private matter. However, the other was addressed “to the
authorities,” so I feel it is in order for me to refer to its contents. I am concerned about Mr.
Arrowsmith‟s access to seconal, a barbiturate which nowadays is rarely prescribed, and
clearly was at no time prescribed for him. I am also concerned about the stockpiling of
antidepressants which he should have been taking regularly, and which, in conjunction with
the chlorpromazine present in his system, and alcohol, would have been sufficient to cause
his death, as Dr. Manser has told us. It is clear also from Mr. Arrowsmith‟s notes that he
himself was quite aware of the probable result of this mixture that he had taken. In view of
the questions arising from the issue of medication I feel it is my duty to call the professionals
involved in Mr. Arrowsmith‟s care to give the court a clearer understanding of his situation at
the time of his death. Dr. Partridge, please.‟
The clerk swore in a man in his fifties, sporting a yellow bow tie.
„You are Dr. John Partridge, a Psychiatric Consultant based at Osewick Hospital?‟
„I believe you had the general responsibility of Mr. Arrowsmith‟s medical care. Could
you please tell the court how this was managed?‟
Dr. Partridge seemed to stutter a little. The coroner waited, smiling slightly.
„Hm, yes, I had the overview of Mr. Arrowsmith‟s case, for about five years.‟
„How often did you yourself see him?‟
„I see. Just a week before his death. How did he seem to you?‟
John Partridge looked at the ceiling, his lips pursed. „I thought he seemed anxious and
restless. There was also a tendency to be withdrawn. I mentioned to him the possibility of
involvement in a self-help group, but this was not well-received.‟
„Tell me, if you will, Dr. Partridge, about Mr. Arrowsmith‟s medication.‟
„Chlorpromazine was administered by injection monthly, by a member of my team.‟
„Did Mr. Arrowsmith attend regularly for this injection?‟
The psychiatrist shuffled his feet. „He was on an antidepressant originally prescribed by
the hospital. He was registered with a local GP in Caxford, Dr. Lowe, who provided repeats.
This drug regime was administered by the Community Psychiatric Nurse. I myself was not
aware that the prescribed drug was patchy in its effects. Mr. Arrowsmith never mentioned it.‟
The coroner wrote a note on his pad, then glanced up again. „Could you tell us, please,
something of Mr. Arrowsmith‟s medical history?‟
„Certainly. Mr. Arrowsmith suffered from a form of schizoaffective disorder following
a catastrophic breakdown at the age of eighteen. I came to the conclusion that, after some
considerable time of treatment and supervision, he was sufficiently stable as to be able to live
semi-independently. In my opinion, there was nothing to indicate that he was suicidal.‟
„Thank you, Dr. Partridge. You may stand down, but I may consult you again if the
Dr. Partridge went back to his place, sat down heavily and wiped his handkerchief over
his face. The silence in the room was almost audible.
The older of the women of the group of five, sitting next to Dr. Partridge, a short, slight
woman with dark eyes and heavy features, took the stand.
„You are Mrs. Sandra Leach, a Community Psychiatric Nurse of the Lambury District
„Yes.‟ Her voice was very quiet, and the coroner looked up from his notes.
„Christopher Arrowsmith was your client?‟ he said.
„Could you tell the court about how you managed his medication: in this case, the
antidepressant prescribed by the hospital?‟
Sandra Leach cleared her throat. „There was a case conference, right at the beginning,
months ago, when Christopher – Mr. Arrowsmith – first went to Denbigh Street. It was
agreed by everyone that he could manage his own medication on a daily basis. He was very
„Well, if he needed more tablets he told his care worker. She would organize it and pick
up the prescription. He kept his pills in a locked box in his room, and he knew he had to keep
the key with him at all times, to keep the other residents safe. He was careful and reliable.‟
„How often did you yourself see Mr. Arrowsmith?‟
The CPN looked down. „I was supposed to see him every month.‟
„Supposed? When was the last time you saw him?‟
A muted buzz greeted this statement. Mr. Somerville raised his eyebrows. „That‟s three
months before the date of his death, Mrs. Leach. Why the gap?‟
Sandra Leach leaned on the table, as if for support. „I didn‟t regard Mr. Arrowsmith as
a problem, to be honest. I had, and still have, a caseload of almost sixty patients. Some of
them have obsessive/compulsive disorders and ring me constantly. That‟s in addition to
meetings and paperwork. Patients like Mr. Arrowsmith, who gave no trouble, just don‟t get
seen as often as I would like. There aren‟t enough hours in the day. I have been off work this
year with a stress-related illness, and when I returned to work the backlog was enormous. I
tend to rely on care support workers to let me know if anything is amiss. Miss Gibson saw
Mr. Arrowsmith frequently. She would have told me if there was a problem.‟
„Thank you, Mrs. Leach. One more thing: there had been, I believe, a change in Mr.
„Yes. He was on clomipramine at first. It helps people with phobias and obsessive
states. Mr. Arrowsmith had nightmares at one time. Then, when he settled down a bit, he was
switched to doxepin. He was anxious and uptight, and doxepin has tranquillizing effects.‟
„Did Mr. Arrowsmith comment on this tablet at all?‟
Sandra Leach shook her head. „Not to me. Miss Gibson did, I believe, once mention
that it made him feel woolly-headed, kind of out of touch.‟
„Thank you, Mrs. Leach. Stand down now, if you will. I may have to ask you more
questions later. Miss Gibson, please.‟
A fair-haired young woman with a placid expression was sworn in.
„You are Miss Jacqueline Gibson, a Care Support Worker?‟
„And Mr. Arrowsmith was one of your clients?‟
„Were any of the other residents of Denbigh Street your responsibility?‟
„Yes. David Rimmer and Sylvia Courtney.‟
„How often did you see Mr. Arrowsmith?‟
Jackie Gibson seemed to think for a few moments. „Well, mostly my job was to take
him to his appointments. If he was at home I sometimes saw him when I was helping one of
the others. He was very independent, though, and no trouble. He hardly ever asked for
anything, and he was always neat and clean and punctual.‟ She sniffed and brushed a tear
The coroner paused for a moment. „Can you tell me about his medication, Miss
„Yes. He kept it locked in a box. He always kept the key on him, even in the bathroom.
He was very good about his medication.‟
„Can you recall when you last saw him?‟
„On 10th June. I took him to see Dr. Partridge.‟
„How did he seem to you on that day?‟
„On the way there he was quiet as usual. After the appointment he seemed a bit
„Were you aware of any particular friendship between Mr. Arrowsmith and the other
Jackie Gibson frowned. „He was friendly with everyone, but there was no one special
friend. Until Maurice came, that is. Mr. Bentley, I mean. They seemed to strike up quite a
friendship for a while. But then I had the impression it tailed off.‟
„Thank you, Miss Gibson. You may stand down.‟
For a long moment the whole room was silent. Mr. Somerville wrote at some length.
Then he took off his glasses and laid them down. „Miss Gibson has mentioned Mr. Maurice
Bentley, and I would like to pursue this line of inquiry further.‟
There seemed to be a general stiffening round the courtroom. Eileen leaned forward.
She had begun to think that nothing would come out regarding Maurice Bentley, but now her
The coroner continued. „A relationship of some kind has been noted as having existed
between Mr. Arrowsmith and Mr. Bentley. I am able to tell this court that, by his own
admission, Mr. Arrowsmith had been, over a period of several weeks, purloining barbiturate
tablets belonging to Mr. Bentley, who had himself stored them from a previous prescription.‟
A buzz followed this announcement. Mr. Somerville waited patiently for it to subside.
Eileen felt the hammering of her heart. This man knows what he is doing.
„Mrs. Leach,‟ the coroner said, „would you please resume the stand, bearing in mind
that you are still under oath?‟ As she stood Sandra Leach was visibly trembling.
„Mrs. Leach, may I inquire if you are also responsible for Mr. Bentley?‟
„Yes.‟ Her voice was barely above a whisper.
„Thank you. Am I right in saying that Mr. Bentley is the subject of a supervision order,
and that he is currently in breach of that order?‟
„Are Mr. Bentley‟s whereabouts known?‟
„I see.‟ Somerville looked steadily at Sandra Leach, whose face was moon-pale. „To
„Can you give me the date of his disappearance?‟
„He was last seen around Denbigh Street on 29th June.‟
„So he has been missing for four months?‟
„Please stay where you are, Mrs. Leach, while I address the court. Let me remind
everyone that we are not here to inquire into the background of another person, except insofar
as it might impinge on the life and death of Christopher Arrowsmith. Mr. Bentley‟s medical
details are, of course, confidential, and as far as this court is concerned, will remain so.‟ He
turned again to Sandra Leach and smiled kindly, noting, as did everyone else, her pallor and
her laboured breathing. „Mrs. Leach, were you aware of Mr. Bentley‟s medical history?‟
„Were you aware of the reasons for the supervision order?‟
„Were you aware of any particular friendship between Mr. Arrowsmith and Mr.
„They seemed to strike up a bit of a rapport when Mr. Bentley first came to Denbigh
Street. I didn‟t think there was anything in it. Mr. Bentley was much older.‟
„Did you at any time regard Mr. Bentley as a threat?‟
„Not at all.‟ Sandra Leach‟s voice rose, sounding suddenly defensive. „He was only at
Denbigh Street as a temporary measure. In fact he should have moved on earlier. The
circumstances of his original breakdown were quite different and long ago. Mr. Arrowsmith
always seemed level-headed, well able to take care of himself.‟
„Thank you, Mrs. Leach. That will be all for now. Before we go on I would like to call
as witness another professional involved with the deceased‟s care. Mr. Michael Cohen,
Eileen looked closely. This was the young man Charley had mentioned. As he took the
„Mr. Cohen,‟ said the coroner, „you are, I believe, a social worker employed by
Lambury Council in the Caxford district, where you are a member of the mental health team.‟
„Can you tell the court what your responsibilities were towards Mr. Arrowsmith?‟
Mick Cohen took a deep breath. „I had to arrange case conferences to decide how to go
on. I was responsible for day-to-day things, like accommodation, managing money,
relationships with the family. I had planned a meeting between Mr. Arrowsmith and his
family, but he never seemed keen on the idea.‟
„Did Mr. Arrowsmith tell you what his own wishes were?‟
Cohen shrugged. „He said he wanted his own flat. I was looking into it.‟
„I see. Did you regard Mr. Arrowsmith as a high-priority client?‟
„Not really. He seemed OK at Denbigh Street, and he never made a fuss. I have a huge
number of clients, and some of them are very demanding.‟
„Yes, I am sure they are. Were you aware, Mr. Cohen, at any time, of trouble between
„No. Mr. Arrowsmith was not very forthcoming.‟
„Thank you, Mr. Cohen. You may stand down.‟
Again there was a brief pause while the coroner made a note, hesitated, then wrote
again. He put his pen down, adjusted his glasses and straightened himself in the high-backed
chair, lacing his long fingers together. „So, ladies and gentlemen, we are arriving at a picture
of a seriously disturbed young man, disturbed enough in the end, it would appear, to take his
own life, and yet the professionals responsible for his care think he “seemed OK”, was “not
suicidal,” and was “well able to take care of himself”; someone who, it seemed, never made a
fuss. I do not doubt that Christopher Arrowsmith, despite his illness, was an intelligent person
capable of giving to other people an impression of greater stability than he truly enjoyed. Nor
do I discount the considerable demands made on the attention of these same professionals.
However, we must still ask ourselves certain questions: what was Mr. Arrowsmith doing in
Holton Woods? How long had he been living there? And perhaps most importantly, why?
What drove him away from Denbigh Street? I refer again to his note, which I take to be
addressed to myself. In essence, he says that, while he does not want to get anyone into
trouble, in his view Maurice Bentley is a very ill and potentially predatory individual about
whom more should be known by the professionals involved.‟
The coroner looked towards the group of five at the back of the room, and everyone
else‟s eyes followed. Sandra Leach looked stricken, her face paler than ever. The coroner
inclined his head towards her and said, „Mrs. Leach, you have given your opinion, supported
by Dr. Partridge, that one of the former residents of Denbigh Street is capable of giving his
evidence to this court, and that to do so will not be to his mental detriment.‟
Sandra Leach gulped and nodded, clearly unable to speak.
The coroner looked up. „Will Mr. David Rimmer take the stand, please.‟
Eileen leaned forward, remembering how, under the rustling summer trees, Christopher
had described to her his fellow-residents. This was Dave, the man with the infallible lottery
system, now taking the oath, dressed in shirt, tie and jacket, his light hair neatly combed.
„You are David Arthur Rimmer, formerly of 16, Denbigh Street, Caxford, currently
residing at 45, Moulton Street, Lambury?‟ Somerville said.
„How long did you live at Denbigh Street, Mr. Rimmer?‟
„So you saw both Mr. Arrowsmith and Mr. Bentley arrive?‟
„How well would you say you knew them?‟
„I knew all of the residents. We looked out for each other.‟
„What, in your opinion, was the relationship between Mr. Arrowsmith and Mr.
Dave Rimmer glanced around, seemingly aware of everyone‟s eyes on him. He blushed
a little and grinned, a sly grin which he tried at once to suppress. „Well, sir, Chris, Mr.
Arrowsmith, was already there when Mr. Bentley came. I think Chris was going through a bit
of a bad patch. He had some new pills he didn‟t like much. Maurice was only supposed to be
there a few weeks, till they found him somewhere else. That‟s what he said, anyway. He
reckoned he shouldn‟t even have been in our area. Anyway he was that much older than most
of us. He seemed a real nice chap, bit of a cut above, if you get me. Turned into a kind of
father figure almost. After a while him and Chris seemed to get quite matey.‟
„It all happened over a fair period, months maybe, but in the end we all knew what was
going on. Sometimes we‟d see Chris in all his gear.‟
„Maurice made out Chris was a girl, sir. He called him Tess. Don‟t know why he picked
that name. He made Chris dress in girls‟ clothes as well – not just ordinary girls‟ clothes, but
really frilly stuff, lots of pink, you know. Chris‟s hair got ever so long too. He never looked
like a proper girl, of course. Blokes don‟t, do they? But I guess it served Maurice‟s purpose.‟
„What was his purpose, in your opinion?‟
„Well, he had Chris as a kind of sex-slave, I‟d say, sir.‟
From somewhere in the courtroom came a muted groan.
„Do you have any concrete evidence for this opinion, Mr. Rimmer?‟
„Depends what you call evidence, sir. All I know is, Chris was always in Maurice‟s
room. If they ever came down to join the rest of us, Maurice behaved like Chris was his
girlfriend, always got his arm round him, stroked his hair, called him “my poppet”, “Tess
„How did Mr. Arrowsmith respond to this?‟
„Chris seemed out of it most of the time. I think it was those new pills. He didn‟t talk a
lot, just hung around, staring at nothing. But we didn‟t see him all that much anyway. They
„I don‟t know. Quite a while. Then Chris seemed to snap.‟
„Could you tell the court about that?‟
„His mum rang him up. He answered the phone in his full gear – jewellery, make up,
the lot. He knew we thought it was funny. He went mad at his mum, yelled and screamed,
then slammed the phone down and ran upstairs. Maurice wasn‟t there at the time; I can‟t
remember where he‟d gone. Next thing we knew, Chris came haring down the stairs waving a
pair of scissors around. We were in the lounge, a few of us, watching TV. We were a bit
scared at first, but Chris wasn‟t violent, not ever. He just wanted someone to cut his hair.
Sylvie did it in the end. About half an hour later I heard the front door slam and I saw him go
out. He was running, just like someone was after him. But he was looking quite normal. I
mean, he was wearing men‟s clothes, and he‟d got rid of the makeup. After that I didn‟t see
him again, except once or twice, and then not really to speak to.‟
„Did you not think you should have told someone?‟
Dave Rimmer shrugged. „We thought it was his business.‟
„I see. And what about Mr. Bentley? Did he remain at Denbigh Street?‟
„Yes, but I didn‟t see a lot of him. He used to go out most of the time.‟
„When you did see him, how did he seem?‟
„Same as usual. If anything, more kind of confident than ever.‟
„Did he mention Mr. Arrowsmith‟s absences?‟
„How did you learn of Mr. Arrowsmith‟s death, Mr Rimmer?‟
„Sandra told us all. Mrs. Leach, that is.‟
Dave shook his head. „It was weird. He changed completely. He went pale and never
said a word. I didn‟t think about it at the time, because we were all really shocked, but
Maurice was like he‟d had the stuffing knocked out of him. Then, a week or so later, he
„What happened after you were told of Mr. Arrowsmith‟s death?‟
„What, at Denbigh Street? Everything seemed to go nuts. Poor old Chuck had to be
taken back into hospital. Then the rest of us were moved, to separate houses. Jackie and
Sandra were in a terrible state. We‟re all right now, though.‟
„Thank you, Mr. Rimmer. You may stand down.‟
Eileen saw Dave take his place and exchange a few whispered words with Sandra
Leach. There was a general fidgeting in the courtroom, as if people were easing stiff limbs.
The coroner bent over his paperwork for some minutes, wrote briefly, then paused, tapping
his pen gently on the documents before him. Finally he looked up. „Ladies and gentlemen, I
understand that at the present moment internal inquiries are under way at Social Services and
within the Health Service to determine to what extent these bodies failed to protect
Christopher Arrowsmith and contributed to the state of mind which led to his death. As I
made clear earlier, it is not the work of this court to apportion blame, but in view of what we
have heard today interested parties, in particular the deceased‟s family, may see fit to take
legal advice, which is, of course, their right.
„To sum up, then: we have been given a factual cause of death as acute heart failure,
brought on by an overdose of drugs and alcohol. Given all the circumstances, there is no
doubt in my mind that Christopher James Arrowsmith committed suicide, knowing that his
chosen cocktail of drugs and alcohol would kill him. There is also no doubt, in my view, that
the reason for his state of mind was, to whatever extent, and allowing for other effects of his
illness, his inability to cope with the relationship with Mr. Bentley – one which was, in Mr.
Arrowsmith‟s own words, “predatory”. The fact that his medication was, in the case of the
chlorpromazine, uneven in effect, and in the case of the antidepressant, not being taken at all,
would no doubt have added to his confusion and anxiety. It only remains for me, while
recording a verdict of suicide, to express my hope that the inquiries I mentioned earlier may
arrive at conclusions and result in actions which will protect those most vulnerable in our
society; and to offer, on behalf of this court, my sincerest condolences to Canon and Mrs.
The coroner pushed his chair back. The clerk, getting to his feet, said, „All rise!‟
Everyone stood up, and the coroner walked briskly to the side door and was gone. There was
a moment of hesitation, almost of suspension; then the clerk began to usher people out, back
into the waiting room, where another small group of people sat tensely by the wall. Eileen
slipped out as unobtrusively as she could, into the foyer, through the swing doors, down the
The sun had come out, a weak autumnal sun with little heat in it, and in the park small
children were playing and dogs were chasing scents, and the bench where Eileen had been
sitting was now occupied by two young mothers, each with a pram. Eileen looked at her
watch. There was still plenty of time before her train went. She had come by train partly
because her ancient car needed attention and was unreliable over anything but short distances,
partly to give herself time to think. She walked slowly through the busy streets of Lambury,
seeing little. She bought a cup of coffee at a small, rather pretentious café, and sat by the
steamed-up window, staring into her cup.
Where was Maurice Bentley now? He had been missing for several months. Was
someone sheltering him? Was he still dangerous, still compulsively trapped in his own
obsessions, or was he broken by the tragic chain of circumstance in which he had been so
instrumental? And who was Tess? Eileen felt sure that she was a real person, real and
important to Maurice Bentley. As she drank her cooling coffee she wondered about the
fallout for the Health Service and Social Services. She had seen the young journalist leave the
Court, brisk and determined. What, if anything, would be in the papers? Would Brian
Arrowsmith find some comfort in blaming those who should have cared for his son, perhaps
She sighed, finished her coffee and got up. She walked to the station and sat on a seat
on the draughty platform, waiting for her train. The sun had disappeared behind a wall of
grey, and the day was chilly. As her thoughts circled and settled she felt some satisfaction,
however small and bleak, that, finally, Christopher‟s last weeks were better understood and
that something of his life was known to others beside herself. For good or ill, Maurice
Bentley had been unmasked. Someone had poked the nest with a stick, and the wasps were
angrily buzzing. But whatever happened now was nothing at all to do with her. She got to her
feet, watching the Allerton train thunder into the station, and feeling somehow far from
certain that Christopher‟s benign shade, for herself and for others, was yet completely laid to
Sitting in the speeding train through the darkening afternoon, Eileen watched the
countryside flash past. As the evening closed in and the shadows lengthened, swallowing
everything in their path, the suburbs crept forward, becoming higher and denser and dirtier as
the train slowed on its way to rest in the dark heart of the city. A thin grey rain streaked the
windows, blurring the view. Eileen felt herself torn forcibly away from the past, thrust
unwillingly into the realities of the present. For a moment she clung on, feeling Christopher‟s
reality slipping away into death‟s mysterious kingdom. Fading images of him appeared
briefly before her mental view: sitting on the tree stump, devouring the food she had brought;
in her house, asleep on the carpet in a patch of sunlight; appalled and shaking as he told her,
in fits and starts, the story of his descent into hell; and, finally, Christopher under the grey
Then the present and practical reasserted itself, as it must. With no great enthusiasm she
thought about the weekend ahead: finishing the decorating in her first-floor flat, part of a tall
Edwardian house in a dusty unremarkable street; then Sunday at her new church, St.
Augustine‟s, where she thought the vicar might prove interesting, but where she knew almost
no one, except Penny, the girl from the flat downstairs, and someone to whom Penny had
introduced her, a woman called Maureen Parry, who seemed friendly. It was not a big
congregation. She thought, with a small shudder, of Monday, when she had an interview at a
shop selling women‟s clothing. Decidedly not me. But I have to pay the rent. As the train
slowed to a stop she prayed. Thank you, Lord, for the inquest, and the fairness of the coroner. Whatever happens as a result, let it be just. Please, may the right things happen for everyone’s good, including Maurice Bentley. Be with the Arrowsmiths in their continuing pain. Be with me, and guide me, and teach me, hour by hour, to depend on you and not on
Buttoning her coat, she made for the door, and climbed down from the train. She sighed
deeply. It was, she supposed, an ending. Of a sort.
Case reports Rescue of acute refractory hypercapnia and acidosis secondary to life-threatening asthma with extracorporeal carbon dioxide removal (ECCO R) We report a case of life-threatening asthma associated with profound hypercapnia and acidosis that was refractory toconventional medical therapy but was managed successfully using an extracorporeal carbon dioxide removal (ECCO R)device (
Cardiolite StreSS teSt 1.800.345.5016 | www. SaintthomasHeart .com Cardiolite StreSS teSt Your doctor has ordered a Cardiolite stress test to evaluate the blood supply to your heart. Most results are available within 48 hours. The doctor who ordered your test will discuss the results with you. See the page 2 of this sheet for IMPORTANT instructions on food, drink and medications. Please