Key Clinical Team Table

The KCT was engaged by Hampshire Constabulary to screen 91 patient deaths and allocate those cases into the following categories: Category A (natural deaths), Category B (unclear deaths) or Category C (deaths unexplained by illness which “meant that the treatment had killed the patient and there was no explanation for that treatment” ), and Category 1 (optimal care), Category 2 (suboptimal care), Category 3 (negligent care) or Category 4 (where the care was intended to cause harm).

 When carrying out the screening process, the KCT first assessed each case individually and then convened to reach a group decision on the category for each case. Thereafter, Matthew Lohn reviewed most of the cases and provided a summary for Hampshire Constabulary. The table is comprised of the following information:

• Columns A and B: The name of the patient or an allocated patient letter in substitution, e.g. Patient A
  
• Columns C to J: The categorisation given by each expert for each patient, and the references for documents that contain the comments about that patient
  
• Columns K and L: The KCT collective categorisation of each patient and the references for documents that contain the collective comments about each patient
  
• Column M: Matthew Lohn’s summary of each case.
  

 Notes to accompany the table:

• Where the Panel has not received consent from the family of the patient, the patient’s name is substituted with a letter (in no particular order), and, where a summary was prepared by Matthew Lohn, this summary has been replaced with the words ‘No family consent’.
  
• Overall, the Panel found a poor audit trail for the KCT’s work generally. In this regard, it has not been possible for the Panel to accurately identify the categorisation in some of the cases. The Panel found a lack of clarity around the individual and group categorisations. The Panel also found that in some cases the expert noted more than one categorisation during the screening process and, therefore, it was not possible in every case to identify the allocated category.
  
• Where the Panel was able, with a reasonable degree of confidence, to identify an allocated categorisation for the patient, this is shown as a letter and number, e.g. A1.
  
• Where the Panel was able to identify the number but not the letter allocated to that patient, the words ‘No conclusive categorisation’ appear instead of the letter, e.g. ‘1 No conclusive categorisation’.
  
• Where the Panel was able to identify the letter but not the number allocated to that patient, the words ‘No conclusive categorisation’ appear instead of the number, e.g. ‘A No conclusive categorisation’.
  
• Where the Panel found more than one category had been noted by an expert, and the documents indicate uncertainty around the allocated categorisation, each category is shown on the table, e.g. A1 / A2.
  
• Where the Panel could not identify any categorisation from the documents, either because the audit trail was poor or the records were unclear, the words ‘No conclusive categorisation’ appear in the relevant box.
  
• Where the Panel has not seen any document, this is reflected in the relevant box with the words ‘The Panel has not seen any documents’.
  
• Where the records indicate that Matthew Lohn did not prepare a summary of the case, this is reflected in the relevant box with the words ‘The records indicate that Matthew Lohn did not produce a summary on Category 3 patients’.
  
• Patient O: The records indicate confusion in relation to this patient. Patient O appears twice on the list of patients and it is not clear from the records whether the experts had received the correct medical records or why this patient appeared twice on the list. The records indicate that two screenings of Patient O’s case were carried out without any conclusive categorisation being reached.    

To download the table, please click here.