The neurosurgery department had a sitting room with red leather sofas beside the operating theaters. After a move to a new building, management steadily reduced its facilities, converting one theater to bariatric surgery. The space no longer felt like home. Marsh and his colleagues began locking the sitting room door while having lunch inside to prevent unwelcome intrusions.

One day, four unfamiliar doctors from another department forced open the locked sitting-room door and entered with sandwiches. When Marsh angrily objected that this was the neurosurgical office, one of the doctors replied that management had decreed all facilities would be shared. Upset, Marsh joined his registrar in theater and took over an unusually difficult operation. Distracted and angry, he damaged the nerve controlling the left side of the patient’s face. Seeing the patient’s paralyzed, disfigured face on later ward rounds filled him with deep shame. He and his colleagues were left undisturbed in the sitting room afterward, though Marsh believed other surgeons now disliked him.

Because of bed shortages, delays between operations had grown long despite government efficiency drives. While lying on the sofa waiting for his next case, a colleague remarked on the NHS culture-change mandate after the Stafford scandal. This remark prompted a flashback to 1976, when Marsh worked as a student nursing assistant on a “psycho-geriatric” ward of 26 men with profound dementia or degenerative brain disease. Many of the patients had undergone frontal lobotomies and were “zombie-like.” Their notes showed no follow-up treatment, although many had been in the hospital for decades. Occupational therapy consisted of leading the pajama-clad patients outside into the drought-parched grounds. One of the therapists used a catatonic, lobotomized patient named Sydney as a backrest while she sat and knitted. Sydney was renowned amongst the staff for his unusually large genitals. A Royal Commission on Psychiatric Care, established after insider abuse allegations at another hospital, made the staff suspicious of Marsh. One afternoon, the nursing officer sent him home early. He later learned that the Royal Commission had visited, and the nurses dressed all the patients in donated suits to impress the commissioners. The hospital still exists, but its grounds are now a golf course. 

Back in the neurosurgery sitting room, a colleague asked about Marsh’s reading matter—an incomprehensible book blending Buddhist meditation and quantum mechanics for treating obsessive-compulsive disorder (OCD). The colleague recalled that Marsh performed psychosurgery for OCD patients, making tiny lesions—a micro-lobotomy. Marsh remembered that one Californian patient wore three pairs of gloves to sign the consent form.

A nurse interrupted, revealing that a patient insisted his tumor was on the right side of the brain, contradicting the information on the consent form. Marsh explained the man had Gerstmann’s syndrome (left-right confusion) due to a left parietal tumor. Visiting the patient in the anesthetic room, Marsh told him that the tumor was definitely on the left, but he would operate on the right side of his brain if he preferred.

Forty minutes later, the nurse returned, confirming the patient was anesthetized. Marsh sent his junior to start the case. He often allowed juniors to open and close surgeries to give them valuable experience. However, it always made him anxious.

At the morning meeting, the on-call registrar presented the only overnight admission: a 40-year-old cyclist with a head injury. Another registrar revealed that the cyclist’s brain scan was performed at another hospital. He complained that, due to NHS confidentiality rules, the scan and the encryption code to view it arrived in two separate taxis. The scan showed catastrophic brain damage with both frontal lobes severely injured.

The registrar said she hoped the patient did not survive. Marsh asked a new trainee to identify the abnormalities; they discussed the depressed skull fracture and burst frontal lobe. Marsh argued that while surgery might keep the patient alive, he would be left profoundly disabled, without language capability, and with severe personality change. The registrar said a colleague had already decided to operate. Respecting protocol, Marsh remained silent. Though operating was often easier than having honest conversations with patients’ relatives about prognosis, he had become more willing to let patients die than survive with terrible brain damage. 

Afterward, he spoke with his neuroradiology colleague, and they agreed that neurosurgeons would be more selective if they saw the poor postoperative quality of life in some of their patients.

In his office, Marsh’s secretary, Gail, reminded him he was scheduled for Mandatory and Statutory Training that day. Marsh reluctantly sat through the three-hour session run by a lecturer with a background in catering. During a coffee break, he was told that a patient on the women’s ward was dying, and the family wanted to speak with him.

The patient, a woman in her forties with breast cancer, had a secondary brain tumor removed a week earlier but suffered a major postoperative stroke. Marsh found the patient’s husband and elderly mother at her bed in a crowded six-bed bay. Standing over them—there were no empty chairs—he explained that she was dying. Marsh asked the ward sister if the patient could be moved to a private room. She said they were critically short of beds but were trying, lamenting a decline in the hospital’s quality of care.

Back at the seminar, Marsh listened to a presentation on customer service principles and reflected on the absurdity of being taught empathy and composure after 30 years in neurosurgery. He signed the register and left early.

The next morning, a junior from the neurology ward asked Marsh to see a 59-year-old woman with Acute Disseminated Encephalomyelitis (ADEM) who had deteriorated, with a blown pupil and severe brain swelling. A decompressive craniectomy might save her life but leave her severely disabled. He agreed to the operation as a last resort and arranged for a colleague to perform it.

Later, he visited the theaters and found the anesthetic room unusually dark. Inside, a shroud-wrapped corpse lay on a trolley. Unsettled, he joined his colleague preparing for surgery, too embarrassed to ask directly whether someone had died on the table. Finally, he asked about the body. The team laughed: It was the cyclist from two nights earlier, who had become an organ donor after failing to survive surgery. The transplant team had harvested his heart, lungs, liver, and kidneys, but porters had not yet removed the remains.

Returning from a two-week trip to China to visit his daughter, Marsh found extensive paperwork awaiting him, including a letter from a doctor in Lincolnshire about Helen, a patient he had operated on three times over 10 years for a recurring ependymoma. Now terminal with severe headaches, her family clung to hope because another neurosurgeon had mentioned photodynamic therapy. Reviewing her latest scan, he saw extensive recurrence. He knew the therapy was worthless, and further surgery would offer only weeks of extra life, but he expected the family could not accept this. He had also grown to like Helen and admired her resilience during his years of treating her. Reluctantly, he asked his registrar to arrange her transfer.

The transfer became a bureaucratic nightmare, marked by conflicting reports and persistent bed shortages. Late at night, Marsh drove to the hospital and overrode protocol with the admissions nurse, insisting they accept the patient and telling her to blame him for any problems. Helen arrived in the middle of the night.

At the morning meeting, Marsh presented Helen’s case, explaining that families could become unrealistic with slowly progressive cancers. He recalled the parents of a dying child who sued him for refusing further surgery. His colleague, Francis, called him foolish for agreeing to operate, warning that if the bone flap became infected, he would have to remove it, leaving Helen to die slowly with “fungus cerebri”—a tumor growing outward through the skull defect. Marsh described this horrifying condition to the juniors, having seen it only once in Ukraine.

During surgery, Marsh found a tangle of tumor, dying brain, and blood vessels, and achieved almost nothing. While his registrar stitched the fragile scalp, he bitterly regretted agreeing to operate. The anesthetist reported that a manager had been angry about the admission without an available bed; Marsh snapped that clinical decisions were his responsibility, not management’s. His registrar remarked that the wound would not heal well.

Marsh broke the news to the family that the operation would make no useful difference. Helen’s brother thanked him, saying they understood she was dying but had wanted a little more time. Marsh softened, suggesting she might get a few extra months. 

The next morning’s meeting brought more grim cases. Afterward, a neurologist asked Marsh to see a 32-year-old woman whose scan showed a large, likely incurable malignant tumor. On the day ward, he explained the necessary treatment to the young mother and her husband, trying to balance “hope and reality” (140). He sent her home on steroids and scheduled surgery for Monday.

At the next meeting, Marsh challenged a younger trainee to explain how he would break bad news to a patient and their family. The trainee fumbled with euphemisms. Marsh pressed him to be more direct before admitting how difficult these conversations were.

Visiting Helen, the ward sister said the family had refused terminal care with effective painkillers as they would not accept that she was dying. The wound looked ready to “break down.” In Helen’s room, Marsh squatted beside her. She smiled and thanked him for operating again. He avoided looking at the dressing, told her they would get her home soon, and left.

Marsh reflects that death in his current practice has become sanitized and remote. It usually occurs in the intensive care unit, when ventilators are switched off, or when patients with fatal tumors die at home or in hospices. As a junior doctor, decades earlier, he was more intimately involved with death, regularly summoned at night to certify the deaths of elderly patients. As a casualty officer, he saw more violent deaths, including a man bleeding to death while looking into his eyes. Certifying the deaths of people brought in from the street, Marsh felt like he was assaulting them as he unbuttoned their clothes to use his stethoscope.

Driving out of London on a Friday afternoon before a holiday, admiring snow-outlined trees, he got a call about a patient, David H. The doctor said David had become drowsy but improved with steroids. Marsh recalled David’s 12-year battle with a low-grade astrocytoma that he had first operated on when David was in his early thirties—then a successful management consultant, a keen cyclist and runner, and married with young children. David had always insisted on knowing the truth. After three years, scans showed recurrence, and Marsh had to tell him the tumor would eventually kill him. Over the following years, he operated twice more; with radiotherapy and chemotherapy, David maintained a normal life until recently.

The doctor said David wanted him to review the latest scans, though another neurosurgeon was not optimistic. Marsh did not want to spoil his weekend by telling a patient he was dying. However, he knew that if he were dying, he would value such a visit. Reluctantly, he detoured to the hospital.

Marsh reviewed David’s scan and saw the tumor, now cancerous, burrowing deep into the brain. He told the sympathetic doctor that surgery would only prolong David’s death. In David’s darkened room, with his wife and two nurses present, Marsh knelt by the bed so David could see him. He explained that another operation would buy only a month or two and that he had usually regretted operating in similar situations. Forcing out the words, Marsh said that if David were family, he would not want him to have more treatment. He held David’s hand and told him it had been “an honour” to look after him. Unable to say goodbye, he wished David well and embraced his weeping wife before leaving.

Driving away in rush-hour traffic, Marsh furiously cursed other drivers, cried, shouted, and hit the steering wheel. He was ashamed not of failing to save David but of losing professional detachment in the face of David’s composure.

On a teaching trip to America, Marsh delivered a lecture titled “All My Worst Mistakes,” inspired by Daniel Kahneman’s book Thinking Fast and Slow (2011) on “the limits of human reasoning” (283). For months beforehand, he lay in bed each morning, painfully excavating suppressed errors from his career. The lecture met stunned silence.

Marsh recalled a case when his American trainee registrar showed him a scan of a 32-year-old paralyzed man. Rushing to his outpatient clinic, Marsh quickly concluded it was an inoperable tumor requiring a biopsy. The registrar performed the minor operation, but analysis revealed an infarct—a stroke—not a tumor. Embarrassed but not especially troubled, Marsh considered a stroke preferable to a malignant tumor.

Two years later, he received a letter from the patient’s father, sent via the complaints office, accusing him of causing his son’s death. Reviewing the notes, Marsh learned the man had died from a further stroke due to underlying vascular disease; the unnecessary biopsy was irrelevant.

After an exchange of letters, the father demanded a complaints meeting. A woman from complaints and improvements chaired the session while the elderly parents glared with hatred. Marsh tried to apologize while firmly explaining why the operation did not cause their son’s death. The manager interrupted, instructing Marsh to listen as the father poured out his grief. He later learned that the meeting had fallen on the second anniversary of the son’s death, just after the father had visited the grave.

Just before Christmas, the new chief executive of the hospital trust phoned to give advance warning of a New Year meeting about an unspecified complaint. Marsh spent Christmas brooding. The meeting was delayed for months. During that time, Marsh suffered a retinal detachment needing emergency surgery, fell downstairs and broke his leg, and then had another retinal tear.

Eventually summoned to meet the chief executive and director of surgery, Marsh assumed it concerned a complaint he had made two days earlier. During a norovirus outbreak, he had found a large DO NOT ENTER poster on ward doors. His colleague, Francis, tore it down. Marsh sent an angry email to the infection-control director, comparing the hospital to a “concentration camp.” The chief executive confronted him about the offensive email. Marsh apologized for the comparison, saying he should have said “prison” instead. Asked if he had removed the poster, he said no, protecting Francis. They also discussed the earlier complaints meeting. Marsh pointed out procedural failures, including scheduling the meeting on the anniversary of the dead patient’s death. During the exchange, the chief executive repeatedly corrected Marsh for saying “your Trust,” rather than “our Trust.” However, the chief executive acknowledged the error and admitted he could not do Marsh’s job. Marsh replied that he could not do the chief executive’s, grateful for the understanding. The author reflects on the immense pressures facing NHS chief executives, who average only four years in post.

After the meeting, Marsh emailed communications to suggest better wording for the poster, but received no reply. The chief executive left the trust weeks later for another troubled hospital; Marsh later heard he was on stress leave and felt unexpectedly sorry for him.