Louise France, The Times
There are peak times when Dr Emer Sutherland and her team in the Emergency Department of King's College Hospital in South London can expect a stabbing victim. 4pm, just as local teenagers are coming out of school. And 9pm, when night-time closes in.
Often the teenage boys - for it is, despite all the headlines about the rise of girl gangs, mostly boys who are stabbed with knives - will be "walk-ins". "When I say walk-ins," explains the 42-yearold Sutherland, consultant in emergency medicine, "I mean that they'll come in with a loosely bandaged arm or a bleeding thigh." Sometimes they don't make it into the reception area. "We have teenagers, extremely badly injured, just left on the doorstep. His mates will have bundled him up into a car, dropped him off and then away they go. It's our job to go out with a trolley and scoop them up." Occasionally the injured will be just 11 or 12 years old.
When student doctors and nurses arrive for their first shift, Sutherland tells them: "Welcome to the cold hard reality."
Some nights she and her team will literally bring someone back to life. The blue lights of the ambulance will flash through the double doors and a body will be hurriedly wheeled into the Resuscitation Area. "Sometimes their hearts will have stopped for ten minutes. They are literally dead." The technical term is "lose output". There will be ten people on duty in the trauma team because stabbings usually come in flurries: one teenager will be injured and it's a case of counting down the hours until the revenge attack comes in. "The atmosphere is tense because we've all come to respect what a knife can do," says Sutherland.
For the second time in one evening, a blade is used. "We'll cut open their chests, from nipple to nipple, to try to get their hearts started again." Sometimes, because the patient is a teenager, young, strong and fit, with none of the health issues that come with middle age, they can get their hearts started again. These are the lucky ones.
Sutherland recalls vividly what she calls "the tragedies". She comes from middle-class Catholic Belfast, and she has the kind of lilting, sonorous accent that one instantly connects with that part of the world. It's somehow incongruous with her day-to-day work life - the harsh lighting, the unflattering scrubs, the make-do building which is always, somewhere, undergoing modernisation, the stories of boys dumped on doorsteps like bags of rubbish. She speaks in a whisper. The kind of voice a mother might ordinarily use to soothe a child who has had a bad dream.
"There was fighting in a park and knives had become involved. He had a stab wound in his chest and he died in the ambulance. He was 16. We opened his chest and tried to get him back. He was so young. So young-looking. Having to ask a mother to describe her son so that I don't tell a woman that the wrong child has died... And then having to say I am sorry but your son has been stabbed and he is dead... Awful. Absolutely awful. It never leaves you. It never leaves you.
"A young death from stabbing is so needless and so tragic. You feel it in the atmosphere as you walk in. Staff have the wind taken out of their sails completely."
She's had to tell a mother her son has died three times in the past 18 months. "And I'm not on every night," she says.
King's College Hospital, on Denmark Hill, Camberwell, sprawls beside one of the main arteries through South London. It is the major trauma centre for this part of the country, which means that its remit is vast - Brixton, Peckham, Camberwell, down through Lewisham and Croydon, as far as Dartford and Bromley. If an ordinary ambulance won't be quick enough, an air ambulance can drop patients off in nearby Ruskin Park. It's an area that historically has always had more than its fair share of poverty and violence and, despite the middle-class creep of basement conversions and artisan bakers, Montessori nurseries and double buggies, this is still the case.
A child born in Lambeth is likely to die eight years before their counterpart in the wealthier area of Kensington and Chelsea on the other side of the Thames. They are 50 per cent more likely to be born into a single parent family and have less than a 40 per cent chance of achieving five GCSEs grades A-C. There is a 20 per cent chance that they will get no qualifications at all.
According to Patrick Regan in his book Fighting Chance, problem drug use is five times higher in Lambeth, teenage conception four times as likely.
King's College Hospital is where Damilola Taylor was brought after he was injured with a broken bottle in November 2000. The tenyear-old schoolboy was dead before the ambulance could reach the doors. This is where five-year-old Thusha Kamaleswaran came when she was caught in the crossfire during a dispute between gang members in her uncle's grocery shop in Stockwell in March 2011. Her injuries left her paralysed.
The Emergency Department has its own policeman on duty. At any one time in the hospital there will be at least one patient with a police guard. According to Sutherland, on average three stabbings come in every day. In the past five years there has been an 89 per cent increase nationwide in the number of under-16s admitted to hospital with serious stab wounds. Recently, there's a trend for people being stabbed in the buttocks. "The perpetrator doesn't want to be up on a murder charge. But they do want to cause as much damage as possible." A bowel injury could mean the patient may have to have a colostomy bag, with the stigma that would entail.
Gun-related injuries used to be so rare that the staff talked about them. Not any longer. "Five years ago, you'd have been surprised to see someone who had been shot, but not so much now."
Unlike hospitals where there is a peak in admissions on Friday and Saturday nights due to drink-related incidents, here there is no let-up (although after the riots in August 2011, there was a lull for a while). The injured rarely show signs of intoxication or drug use, apart from, occasionally, skunk (a strong strain of marijuana). The violence will more often be the result of gang rivalries, fights about territory and control.
Seven years ago, Sutherland and colleague Tricia Fitzgerald, joint head of nursing for trauma, emergency and urgent care, began to notice a disheartening trend at their weekly departmental meeting. "We were seeing the same names coming back, again and again." They were known, according to one of the team, with the black humour which must be a prerequisite of working on the front line of emergency medicine, as "frequent flyers".
It was possible to trace an inexorable pattern. It might begin with a black eye as a result of a scuffle after school. The next time the same teenager would have injuries to his fists. A few months later he'd report a fractured finger, perhaps as a result of hitting someone, or punching a wall in anger. Then there would be injuries to the body - the imprint of boots, damage to internal organs. More signs of injuries to the head. A few months later, weapons-related injuries would appear. Umbrellas, bars, pieces of wood. The next time it would be more severe - a knife wound. More often than not, the victims would say they had "fallen on glass". "We have a lot of" - and Sutherland makes mock quotation marks with her fingers - "'fallen on glass'."
Often they need to stay overnight. "But many of them pick themselves up and take themselves home the following morning. Not even waiting to be signed out by the team. When they felt they could walk, they walked." No family member would turn up to help them.
Inevitably, or so it seemed to Sutherland and her colleagues, the knife injuries would get more serious and, ultimately, life-threatening. "We'd be literally trotting into theatre as they came in." Some of the young men seemed to have no fear. There was a view, perhaps due to medical dramas on television, or because they'd survived the Resus area before, that the doctors could perform miracles.
Sutherland looked at other hospitals with similar problems - London is home, according to the police, to at least 250 gangs - to see if they had any ideas about what could be done to break the cycle of violence. But everywhere seemed to be stuck in the same trap: save lives, wait for them to come back again.
It was from America's violent hotspots that they heard about a radical new approach. As a result of research that suggested that urban violence victims admitted to a US hospital trauma service had a 20 per cent chance of becoming the victims of homicide within 5 years, American doctors had begun to view youth violence as a chronic, recurrent disease. A patient injured by violence was seen to be in a high risk category for repeat violence, just as a person who had a heart attack was at a much higher risk for future heart problems.
But what they had realised was that the Emergency Department could provide a unique opportunity to intervene, psychologically as well as medically. Building on the notion that alcoholics often react positively to a moment of intervention, admission to hospital as a result of violent crime could offer a unique window. What if a trained youth worker could be embedded in the Emergency Department? It could provide, in a phrase that has now become the mantra in youth crime prevention in America, "a teachable moment".
This theory of a teachable moment rang true to Sutherland and the team. "The idea is that when they are faced with their own mortality for the first time - when the bravado evaporates - you can have a really important conversation with them about who they want to be and how you can support them to get there." But for the teachable moment to work, it is crucial that it is instigated not by the medical staff or the police - people who are deemed to be on the side of privileged authority - but by people who understand what life is really like on some of London's streets. Someone they could trust and could talk to, if necessary, in confidence.
They contacted a local project called Redthread that was already working with a GP practice in Gypsy Hill, South London. The director, John Poyton, the 38-year-old son of a lay vicar and a nurse, immediately understood the theory. "The young person is vulnerable, in pain and not in control of what is going on around them. Pain is a great catalyst to think through your life choices," he explains. "Whether it's self-imposed or not."
That phrase "self-imposed or not" is crucial to the thinking at King's College Hospital. Sutherland and team talk a lot about the "victim-perpetrator cycle". Or, as Sutherland says, "We can't be choosy about who comes through the door." Some days, when a teenager comes in injured, he will have been the victim of an altercation. On another, he will be the aggressor but he will have been injured during the incident (according to the police, a teenager is more likely to be injured with his own knife than by someone else's blade). Often, a teenager will begin as the victim - he'll be mugged, for instance. Poyton remembers seeing a boy who had been stabbed coming out of a newsagent's having bought a can of Coke on the way to school. "I don't think even he knew why he had been stabbed: to mug him for his loose change." He was admitted into hospital in his school uniform. Then it will happen again, a few months later. Over time, he'll start to believe that the only place that is safe is within the gang that keeps attacking him. Poyton describes a scenario where a teenager he knows got mixed up with a gang precisely because he was mugged.
"There was this young man who I saw in the community and at King's. He lived at home with his mum. His father had died.
"It all started when he was mugged by a gang who had beaten him up. He saw one of the gang members a week or so later and, unwisely, he confronted him and, without thinking about the repercussions, beat the crap out of him. Now he was at the mercy of the whole gang who wanted to protect their reputation. He ended up doing favours for the gang. The gang knew where he lived. He was coming along and telling me how they were making him climb out of this bedroom window and hide a box with a weapon in it in a wood in a park. He was being forced to become a runner for the gang otherwise they would do things to his house, to his family, to him."
Initially, the hospital found funding for Poyton to be at the hospital for ten hours a week. They set up a special room where young people, aged 13-19, could talk in private if necessary. (If they extended the age range to 23, the numbers of cases would double, says Poyton.) Now the Youth Violence Project has 4 staff on board who are available, within the Emergency Department or on the wards, for 20 hours a week, and there are plans to have a special area where victims of gang-related violent crime are treated separately. If youngsters check themselves out before they are seen by a youth worker, they'll be sent a text. If they don't want to come back into hospital, they'll arrange to meet them at a drop-in centre.
Poyton has a wry, calm, patient way about him that suits the work he does. He looks at his phone a lot, checking in case an emergency call comes in. What he's seen does not seem to have made him cynical. He clearly likes some of the teenagers he mentors, both at King's College Hospital and the drop-in centre that Redthread runs in Streatham. He describes young men "with a lot of weight on their shoulders". The symptoms, he says, are similar to post-traumatic stress.
"Really nervous, never going anywhere on their own, never walking the streets. Doing everything by getting lifts from friends or spending all sorts of money they don't have on taxis." He recalls one teenager who always wore layers of baggy clothes whenever they met, whatever the weather. It turned out that he always wore a bulletproof vest. "He lived his life in fear. Yet, at the same time, he was always smiley, appreciative; he'd always shake my hand." It was as though everything about him - his life, his state of mind - was split in two.
This is a group of people for whom streets mean territory. Sutherland recalls a teenager with deep lacerations across the palm of his hand. He was told to go to St Thomas' Hospital in Central London for specialist plastic surgery, but a few weeks later it was clear that he had not gone. "He told us, 'I can't go to that part of town.' You think this is London, the world is your oyster," explains Sutherland, "but there are kids who won't cross certain roads. Not even on the bus."
There is a window - "a chink", says Sutherland - when a youth worker from Redthread will sit with victims when they come in. If they're not severely injured they have a very small opportunity, maybe four hours or less. If they are admitted, they might talk to them the following day on the ward. They might be able to help with rehousing or legal issues. They might be able to suggest youth initiatives on their own estates. They might simply play the role of advocate and good listener. Often the boys are too young to properly understand what they have got into.
Poyton reports to the weekly departmental meeting, just like the rest of the emergency medical team. Underpinning the Youth Violence Project is the idea that, for as long as the teenager is in hospital, they are a victim and entitled to the support and respect of a victim. Sutherland describes her approach like this: "It is looking at these young people as vulnerable young people - the same way as you would look at a battered baby." If this kind of empathy sounds woefully soft, and a long way from David Cameron's rhetoric on gangs in the wake of the London riots of 2011, it is a philosophy that underpins much of the current research into the perpetrators of violent crime. The Home Office report Ending Gang and Youth Violence, launched by Home Secretary Theresa May in November 2011, includes a similar message, albeit less emotively put: "We need to change the life stories of young people who end up dead or wounded on our streets or are getting locked into a cycle of reoffending." The report promised to explore the potential in placing youth workers in Emergency Departments.
Rigorous assessment of the project at King's College Hospital is difficult. However, there seems to be evidence that the concept of the teachable moment has been a success in America. What most experts seem to agree on is the idea that this kind of intervention will ideally begin before injuries escalate. They need to reach 13 or 14-year-olds, before violent behaviour becomes a way of life. "No one joins a gang for the glamour and the excitement," says Sutherland. "They join a gang because they see it as a way out of a worse life." She describes boys born into oneparent families with low incomes, who are excluded from school or in and out of the care system. "What I hear is that the gang acts like a parent. The gang cares about them. The gang wants them. The gang gives them rules and boundaries for the first time. It is tragic that this is sometimes the only place where a young person can feel valued."
Recently teenage girls have become a focus for intervention. Not due to knife injuries, which are rare for girls, but for signs of chronic sexual exploitation. "It is a hidden harm because they don't have a stabbing wound; there is no blood on the floor," says Sutherland. She describes teenage girls in gangs who don't feel as though they can refuse sex, or if they do they will suffer real physical violence. Recently she heard from a girl who had received a text message from a gang member. Merely the receipt of the message meant that the girl had to have sex with the man who had sent it. You just have to, there is no way out, the girl explained. "Within her group of girls, that was the reality." She arrived in the Emergency Department asking for the morning-after pill.
Sutherland has developed a training package which teaches doctors and nurses to ask girls if they are being pressurised to have sex. Redthread plans to appoint a female youth worker to liaise.
Sutherland would like the Youth Violence Project extended so that there is someone available 24 hours a day, 7 days a week. For that, they need more funding. The problem is that this kind of project is difficult to assess, and the results may not be obvious for a long time. What counts as success? A teenage male who doesn't come back for one year? Two years? Never again? In Sutherland's mind it will take a generation to really see the benefits. "We do a good job to make sure as few as possible of them die. Now we need to give them better options to live," she says.
And with that she goes back to her office to pick up her phone. Her five-year-old was awake last night feeling ill, and she's worried his school might call. Another son, albeit a much luckier one, who needs her attention.
Hospitals across London, home to 250 gangs, werestuck in the same trap: save lives, wait for them to come back again
One stabbing victim was referred to St Thomas' for treatment. 'He told us, "I can't go to that part of town" '
A girl got a text from a gang member, so had to have sex with him. You just have to, she said, there is no way out