Donor

FOUR

It was Sunday evening. Steven Dunbar took the airport bus from Glasgow Airport into the centre of the city. Outside it was dark and it was raining. That and the general gloominess of the dark Victorian buildings — made to seem even blacker by the rain water — did nothing to inspire good feelings in him. He was due to begin his attachment to the Medic Ecosse Hospital on the following morning.

It was something he certainly wouldn’t have bet on when he’d heard the Scottish Office contingent refuse to modify in any way their demand for swingeing cuts to James Ross’s research budget. Their intransigence had come as a complete surprise to almost everyone at the meeting. In retrospect it had been embarrassing that the Scottish Office had not seen fit even to make a token gesture in the interests of making the negotiations seem genuine. The feelings and work of an eminent surgeon had been of no importance at all.

Dunbar had fully expected Ross to tender his resignation and, in doing so, set off a train of events that would have led to the closure of the hospital and a backfire of the whole gamble, but it hadn’t happened that way. Instead, and to everyone’s surprise, Ross had acceded to the Scottish Office demands, taking it philosophically and saying simply that he understood the awkwardness of their position and the financial constraints they were operating under.

Dunbar supposed that some kind of behind-the-scenes deal between Ross and the Medic International group must have been done to retain Ross’s services and to avoid closure of the hospital, but there had been no official acknowledgement of this or of continuing research funding for Ross from an alternative source. Ross had simply stated that, as a doctor, he felt obliged to carry on with his work at Medic Ecosse. He had a waiting list of patients he felt responsible for and couldn’t let them down. It would be business as usual as far as the transplant unit was concerned.

It was clear that the Scottish Office people had pulled off a major triumph in the re-negotiation of terms of their involvement at Medic Ecosse. The look of surprise and relief on Bannon’s face when Ross had swallowed his pride and acceded to what he must have thought were impossible demands was only fleeting but Dunbar had seen it. Now it wouldn’t be known if he had ever intended to back off at the last moment. The injection of more public funds into the hospital would now be offset by the much more favourable terms of the agreement and by greater public access to the Medic Ecosse facilities. Even the Labour opposition at the meeting had been forced to concede that it was a good deal.

As part of the agreement there was, of course, his own secondment to Medic Ecosse as the government’s man on the ground, the overseer of public funds. His masters’ subterfuge had worked well. He was now in place to begin his investigation.

Sci-Med’s involvement had been precipitated by a complaint from a staff nurse who no longer worked at the hospital. She had maintained that there had been something improper about the treatment a transplant patient had received at Medic Ecosse some five months before. The young patient, Amy Teasdale, had died after rejecting the kidney she had been given during what was thought to be, at the time, a routine transplant operation. The staff nurse, one Lisa Fairfax, maintained that there had been a serious mix-up resulting in her patient being given the wrong organ. She was unable to be more specific, stating only that the sub sequent rejection had been so severe that no other explanation would suffice. In other circumstances her claims would almost certainly have been dealt with at local level but what had caught Sci-Med’s attention was the fact that a similar complaint had been lodged only months after the hospital opened, almost three years before and again by one of their nursing staff.

That time Sister Sheila Barnes had said much the same thing after a young boy in the transplant unit rejected the kidney he had been given. She had subsequently resigned in protest at what she saw as being ignored by the authorities, who had interviewed her but refused to take her claims seriously or to mount an internal investigation. She had maintained at the time that the authorities were keen to dismiss her complaint because they feared the bad publicity would damage the new hospital. Sister Barnes had never retracted her claim. She had intended to press for further investigation, but shortly afterwards had contracted cancer and had had to abandon her campaign. She was now in the terminal stages of her disease, a resident at The Beeches, a hospice for the terminally ill down at Helensburgh on the Clyde coast. She and her allegations had been largely forgotten until Staff Nurse Fairfax made her own complaint and Sci-Med’s computer had drawn attention to the similarity as part of its collating programme.

All reports of allegations of wrongdoing in British hospitals were recorded, filed and collated on the Sci-Med computer, however trivial they might seem. Most of them were indeed trivial, usually disgruntled patients making unfounded accusations, or staff with grudges against their employers making equally spurious allegations. But occasionally the computer picked up something that might otherwise have been overlooked. This time it had noted the remarkable similarity between the two nurses’ allegations. Both women maintained that their patients had rejected their transplant because they had been given the wrong organ. Now one of these women was currently dying of cancer and the other, Staff Nurse Fairfax, had been dismissed from her post.

Dunbar checked into his hotel near the city centre and found it pleasantly anonymous. It was also warm, which was a bonus because he was feeling chilled. Scotland always seemed to be three or four degrees colder than the south of England, where he lived. He had noticed this again as soon as he had stepped off the plane. The raw dampness of early March made things worse. He threw his briefcase on to the bed and walked over to the window to look down at the traffic moving slowly below in the wet city streets, their lights reflecting in the puddles that were proliferating as the storm drains struggled to cope.

After a few minutes he closed the blind and turned away. He picked up the phone, called room service and asked for a large gin and tonic, some chicken sandwiches and a pot of strong black coffee. After that he would have a warm bath before getting down to reading through his notes and deciding on a plan of action.

As he lay in the bath with the water lapping just below his chin, Dunbar closed his eyes and wondered about James Ross’s decision to stay on at Medic Ecosse. Ross was by all accounts a popular man, a brilliant surgeon and a highly regarded researcher in his field. But, although clearly dedicated to his patients and well liked by his colleagues, he was still a human being and therefore subject to the laws of human nature. Dunbar set great store by these laws and recognized them as the driving force behind almost everything that happened in society. Very often he had to pick away at various levels of veneer applied by clever, self-seeking people in positions of power but always, underneath, the same rules applied, whether it was on the factory floor or in the boardroom, the operating theatre or the accounts department.

Ross was a proud man — he had every reason to be. He was also a surgeon with the typical extrovert tendencies of the profession. Timidity and surgery did not go hand in hand. Self-doubt had no place in the operating theatre. According to Dunbar’s rules, it didn’t befit such a character to lose face in public as Ross had done. The humiliation of having such savage cuts applied to his research funding with not the slightest suggestion of compromise should have pushed him into a dignified resignation, but it hadn’t.

Of course, it might have been the thought of his colleagues losing their jobs if the hospital closed that had weighed so heavily on him. Being single-handedly responsible for the closure of a hospital would be a heavy burden for anyone to bear. The man, of course, might also be a saint and therefore outside Dunbar’s rules.

He supposed it would be easy enough for him to check on alternative sources of research funding once he had access to the accounts at Medic Ecosse, and he would like to know if a deal had been struck behind the scenes with Medic International; but that still wouldn’t answer his question about why Ross had acted out of character. That was the more important thing.

Having been thinking about Ross, Dunbar decided to go through his notes on the surgeon as soon as he was out of the bath. He didn’t intend going out again or even downstairs in the hotel, so he just pulled on a sweater and jeans and didn’t bother with socks or shoes. He sat cross-legged on the bed with his papers spread out in front of him, the bedside lamp angled to provide light.

James Ross’s career to date had been nothing short of outstanding, with prizes and awards punctuating his progress from medical school in London through appointments at a succession of top hospitals both in the UK and the United States. Early on in his studies Ross had been transferred to a leading medical school in New York, where he had been admitted to a programme that had enabled him to do a PhD at the same time as his medical degree. His research for his doctorate had been in immunology. This explained his intense interest in transplant research, thought Dunbar, and his high standing in the scientific community as well as the medical world.

Many doctors played at being researchers, but the days of significant discoveries being made by candlelight in the ward side room had long since gone. Those times had largely disappeared with frock coats and brass, monocular microscopes. To succeed in the extremely demanding and competitive world of medical research in the late twentieth century, you had to be a trained researcher to start with, with all the background knowledge that that entailed. Ross was just such a person. The fact that he had obtained both a PhD and a medical degree concurrently suggested that he was exceptionally gifted intellectually.

He could, of course, still be a lousy administrator, thought Dunbar. There were lots of intellectually gifted people who ended up in charge of university departments when they didn’t have the managerial capacity to run a pie stall. If Ross was an ivory-tower researcher, it was conceivable that the running of his unit might suffer but, again by all accounts, this was not true. The transplant unit at Medic Ecosse was regarded as one of the most successful in the country and Ross was no absent-minded professor. He was very much a hands-on leader, not at all the sort of man to preside over a unit where a patient could mistakenly be given the wrong organ.

There was some information on Ross’s personal life in the file. He had been married to an American woman, a radiologist he had met while working in Boston, but things hadn’t worked out and they had divorced four years ago after three years of marriage. There were no children. His ex-wife had returned to the States, where she had since remarried. Ross lived alone in Glasgow in the penthouse flat of a modern block of flats in Kelvingrove, although he made frequent working trips to Geneva as a clinical consultant.

In the year to April last, Ross had earned?87,000. He drove a two-year-old ‘5’ series BMW and was a member of two clubs. He held an honorary senior lectureship at the University of Glasgow on account of an agreement to deliver a series of four lectures a year on immunology.

Attached to the file were reprints of four of his most recent research publications. One dealt with something called ‘Immuno-preparation’; the other three were on the possible use of alternative species as donors of organs for human transplant. Dunbar put them aside to read when he had more time. They’d probably demand a deal of concentration. Immunology and transplant surgery were a far cry from his own area of medical expertise, which was field medicine.

The only son of a Cumbrian schoolmaster and his music teacher wife, Steven Dunbar had grown up in the Lake District, in the small village of Glenridding on the shores of Ullswater. He’d studied medicine before completing two residencies, one in Leeds in general surgery and the other in Newcastle in Accident and Emergency. It was around this time that he’d started to question his motives for entering medicine and begun to consider other options. He felt as if he’d been on a treadmill since leaving school. Teachers and parents had been delighted at his success in gaining entry to medical school and he’d been swept along in the approval and pleasure of others. None of them, including himself, he had to admit, had ever considered if he really wanted to be a doctor. It wasn’t until a friend suggested he think about the army that his future had taken shape.

He opted for the rigours of life in the Parachute Regiment and had been extensively trained, first as a soldier and then in field medicine. The next few years brought all the physical challenges he could have ever dreamed of as he served with units of the regiment and occasionally on secondment to Special Forces. It was, though, a lifestyle that couldn’t continue indefinitely, and when the time came for him to stop he knew and accepted it. The big question had been what to do next.

The army ran courses for officers returning to civilian life but Dunbar wasn’t included. He was a doctor; it was assumed he’d be returning to medicine in civvy street. Luckily, he had confided in a fellow officer that he had no wish to continue in medicine, for a while at least. This had led to a suggestion through a friend of a friend that he might be suitable for a job with the Sci-Med Inspectorate. Now, after four years with Sci-Med he felt settled and content.

No two assignments were ever the same; each was demanding in its own way and, being concerned exclusively with problem areas in medicine, he was obliged to keep abreast of the latest advances in his profession. His readiness to move to assignments at a moment’s notice was part of the job, wherever they happened to be in the UK.

The only real drawback to his lifestyle was that he was seldom in one place long enough to establish relationships. At thirty-five he was still unmarried.

Dunbar flipped open the slim file on Amy Teasdale. She had suffered almost continual renal problems from birth. Various treatments had been tried in a variety of hospitals while she waited for a suitable organ to become available, but her condition had deteriorated until, after a period of particularly severe illness, she was admitted to Medic Ecosse. The team there managed to stabilize her long enough for a suitable donor organ to be found.

Unfortunately the story had not had a happy ending. Amy’s body had rejected the organ almost immediately, despite the computerized match being good in terms of tissue compatibility. A copy of the Medic Ecosse comparator sheet was included. Cause of death was given as severe immune response to the presence of foreign tissue, despite satisfactory in vitro compatibility. As the compatibility rating of the donor organ was given as 84 per cent, Dunbar thought Staff Nurse Fairfax’s complaint that Amy had been given the wrong organ did not sound too convincing.

He turned to the file on Lisa Fairfax herself. In view of what had gone before, it was possible that the nurse’s claim might have stemmed from her having been deeply fond of young Amy Teasdale and correspondingly upset by her death — always an occupational hazard for staff in children’s wards. She obviously believed that the immunological reaction she had witnessed in her young charge had been caused by the child receiving an incompatible organ, but her reaction could have been inspired by grief and the inherent need to explain away an emotionally unacceptable happening.

Despite assurances from the hospital authorities that there had been no mix-up and that Amy had received an entirely compatible kidney, as shown by lab analysis, Lisa Fairfax had persisted in her claims and she and the hospital had parted company. It looked like a classic case of a nurse allowing herself to become too involved with her patient, thought Dunbar.

He closed the file. It seemed straightforward on paper, although the question of why Staff Nurse Fairfax had persisted with her allegations until Sci-Med became aware of them puzzled him. People did tend to make wild claims and accusations when they were deeply upset, but after a period they usually recovered and, in many cases, were embarrassed about things they had said under stress. Maybe he should arrange a meeting with her, to see if there was more to her than had come through in the report.

He looked to see if there was any more about her and found a one-page personnel file. It included her address and some background material, including the fact that she had worked for three years as a theatre nurse and for a further three specializing in transplant patient care. This made Dunbar think again. He had been ready to dismiss her as emotionally vulnerable, but perhaps he was wrong. You accumulated a lot of nursing experience in six years. Lisa Fairfax must have seen a lot of transplant patients come and go in that time. He decided that, in fairness, he would definitely have to arrange a meeting.

The file on Sheila Barnes’s complaint was skimpy. A young patient named Kenneth Lineham had, like Amy Teasdale, died after rejecting a transplanted kidney. The organ had been deemed highly compatible with his own tissue type but, again like Amy Teasdale, he had undergone immunological rejection of the organ after the operation. Sister Barnes, like Lisa, had maintained that there had been a mix-up somewhere along the line and he had been given the wrong organ. A preliminary investigation of her allegation failed to find any evidence of this and she had resigned in protest.

Dunbar could certainly understand why the Sci-Med computer had drawn attention to the situation. The two nurses had made almost identical claims about two different patients almost three years apart, and both were experienced transplant-unit nurses. But, it had to be said, there was a total lack of scientific evidence in both cases. The women’s assertions seemed to have been based on gut feeling and very little else.

Dunbar wondered if there had been any other cases of apparently severe immune rejection in patients receiving organs classed as perfectly compatible by lab testing. This was something he could check on the computer. He had access to the main Sci-Med computer through the IBM notebook he carried with him. All he needed was a convenient telephone line, and the hotel was equipped with telephone points for modem connection.

He logged on to the London computer through his access number and password and started asking questions about kidney-transplant records. There were plenty of them; kidney transplant had become an almost routine operation over the past few years. He had to narrow down the data available to that pertaining to unsuccessful transplants in the last two years. Asking the right questions was always the key to a successful computer search. Having access to all the data in the world was no use at all unless you knew exactly what to ask.

A lot of thought had gone into the systems design of the Sci-Med service. He further narrowed down the information to patients who had died within two days of their operation, as had Amy Teasdale and Kenneth Lineham. He then asked how many of them had been given kidneys with an 80 per cent compatible rating with regard to host tissue. The answer was none.

Dunbar stared unseeingly at the screen for a few moments. He was thinking about the result. Only two patients in the UK in the last three years had died within two days of their operation after receiving highly compatible organs, and both had been patients at Medic Ecosse. Coincidence? That couldn’t be ruled out, he supposed. Two wasn’t a large number, maybe statistically insignificant. Perhaps there were more cases just outside the 80 per cent compatibility figure. He asked the computer the same question with a less stringent figure on compatibility, reducing by first 5 then 10 per cent. The two Medic Ecosse patients were still the only ones. He then looked at cases in which the patient had died within the first month after transplant. There were ten, and without exception there had been other circumstances involved in their deaths. The two Medic Ecosse deaths remained out on their own. They were a puzzle.