Carol Welch

George Eliot Hospital NHS Trust 
College Street 
Nuneaton 
Warwickshire 
CV10 7DJ 

www.geh.nhs.uk 

6 March 2023 

PRIVATE & CONFIDENTIAL 

Ms L Lee 
Assistant Coroner for the Area of Warwickshire 
Coroner’s Office 
Warwickshire Justice Centre 
Newbold Terrace 
Leamington Spa 
CV32 4EL 

Dear Ms Lee 

RE: Regulation 28 Report - MRS CAROL ANN WELCH.   DoB: 20/03/1975  DoD: 
01/05/2022 

Thank you for your Regulation 28 report dated 11th January 2023 relating to the inquest of 
Mrs Carol Ann Welch.  I was sorry to read of you outstanding concerns at the conclusion of 
the inquest and hope the following information will provide you with further reassurance. 

Following receipt of your report, the Trust convened a working group to review the concerns 
raised  within  your  report  and  to  reappraise  the  findings  in  the  Root  Cause  Analysis  (RCA) 
presented during the coroner’s investigation.  For ease we have taken the liberty of providing 
an overview under relevant themes. 

Training and Assessment of Doctors Who Qualify Abroad (ref points:2 & 5 of Regulation 
28 report)  

Doctors who practice medicine in the United Kingdom (UK) need to hold a licence to practice 
along  with  a  suitable  type  of  registration  for  the  work  that  they  will  be  doing.    A  licence  to 
practice is provided by the General Medical Council (GMC) which allows them to carry out 
certain activities such as prescribing medicines and treating patients. 

           ‘Our vision is to EXCEL at patient care’ 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The GMC is an independent body with responsibility for regulating doctors in the UK and its 
legal purpose is to protect, promote and maintain the health and safety of the public by making 
sure doctors meet the stringent standards for good medical practice. 

Your concern was that the middle grade doctor in this case had trained overseas, and it was 
not clear to you how his familiarity with Royal College Guidance had been assessed. 

When the Trust receives an application from a doctor our People and Recruitment Department 
will  check  the  official GMC registration  to  ensure  the  doctor  is  appropriately registered  and 
holds the relevant qualifications and license to practice in the UK. The doctor in Mrs Welch’s 
case was registered with the GMC in April 2020.  In addition, this doctor became a member of 
the  Royal  College  of  Emergency  Medicine  before  they  started  working  at  this  Trust  in 
September 2020. Accordingly, the doctor will have been assessed as competent by the Royal 
College as part of their registration and accreditation process in exactly the same way a UK 
trained  doctor  would  be  assessed.  This  accreditation  includes  an  assessment  of  familiarity 
with relevant Royal College guidance. 

In short, the requirements for Royal College accreditation for overseas qualified doctors are 
identical to, and as robust as, those required of UK qualified doctors. 

Each junior and middle grade doctor within the Trust has an assigned Clinical Supervisor who 
is appropriately trained and responsible for overseeing the junior/middle grade doctors’ clinical 
work.    The  Clinical  Supervisors  at  the  Trust  are  always  at  a  consultant  level.  The  Clinical 
Supervisors  have monthly  meetings  where they discuss  each  doctor  to review  their  clinical 
work, ascertain how well they are doing and whether they require additional support or training 
in  certain  fields.    In  addition,  all  junior  and  middle  grade  doctors  also  have  appraisals 
undertaken  by  a  trained  Appraiser  on  an  annual  basis  where  their  performance  including 
training is monitored to ensure they are compliant.  

Shared Learning (ref points: 3, 4, 7 & 8 of Regulation 28 report) 

There are robust processes in place across the Trust including the Urgent and Emergency 
Care (UEC) Directorate to ensure staff awareness, participation, and dissemination of learning 
is completed to support the safe delivery of care for our patients.  

It  is  important  to  highlight  that  when  an  incident  is  reported  the  senior  leaders  within  the 
directorate are given oversight and supportive conversations take place with key staff involved 
in  the  care  to  understand  their  part  and  to  obtain  their  views  on  making  sustainable 
improvements.    This  may  entail,  but  is  not  exhaustive,  of  personal  reflection,  self-directed 
learning or creation or amendment to process or policy as an immediate action to learn from 
the events; this was the case regarding Mrs Welch.   

Any  incident  classified  as  having  resulted  in  moderate  or  above  harm  is  presented  at  the 
Trust’s  Review  of  Harm  Meeting  which  occurs  on  a  weekly  basis.    The  incident  is  also 
presented in detail at the preceding month’s directorate governance meeting, chaired by the 
clinical director and attended by all levels of medical and nursing staff and discussion ensues 
with attendees about the detail known of the events at that time. 

There are further opportunities for staff to contribute to collaborative and human factors driven 
conversations within our tabletop review exercises to determine how the incident occurred and 
what system driven actions need to be made to mitigate further reoccurrence.  This is followed 
by the opportunity for key staff to support with the content of the written report and any actions 
created.    There  is  always  senior  medical  and  directorate  leadership  support  oversight  and 
approval of the written reports. 

 
            
 
 
 
 
 
 
 
 
 
 
 
 Once a thorough review has taken place and the exact learning identified, the UEC Directorate 
has a plethora of means to ensure staff are aware of the learning.  The incident is discussed 
again and the report shared at the directorate governance meeting to ensure the outcomes 
from  the  review  are  discussed  and  to  offer  debate  and  prompt  further  opportunities  for 
sustainable improvements.  This is complimented by further meetings amongst our different 
work groups within the department (medical, nursing and administration) and these meetings 
are  another  chance  to  cascade  learning  and  reach  a  wider  forum.    There  are  daily 
departmental  safety  huddles  and  medical  and  nursing  handovers  that  allow  for  incidents, 
patient feedback and learning to be discussed and shared in a more practical forum. 

The  directorate  also  considers  other  ways  individuals  may  digest  information  and to  attract 
interest in learning they have a department messaging group, a monthly electronic newsletter 
and a highly visible display area deliberately placed outside the staff room to ensure maximum 
attention is captured from poster or other visual aids.  The content of the posters cover not 
just feedback from specific cases but also include information on the most common themes of 
incidents, complaints and risks to support staff learning. 

The directorate has a robust governance process in place to ensure that actions are monitored 
and completed.  This happens through oversight and support within the directorate incident 
management  group  which  links  into  our  governance  and  management  meetings  and  the 
Trust’s  Operational  Quality  and  Safety  Group  and  Finance  and  Performance  Executive 
meetings. 

Unfortunately,  it  is  not  possible  for  all members of  the  UEC  Directorate  to  attend meetings 
where  learning  from  incidents  are  shared  due  to  the  clinical  demands  of  the  department. 
However, minutes and learning are shared via email and through using the aforementioned 
methods so that all members of the team are informed even when they are unable to attend 
the meetings due to annual leave or other commitments. 

It is recognised that if an individual wishes to access reports or written material on learning in 
their own time that at the time of this incident these documents were kept within a restricted 
folder on our Trust server.  To ensure that meeting reports are accessible to all staff for the 
purpose of learning the directorate is exploring a shared drive on its server and a shared area 
on its staff intranet platform, so these are easily accessible as the documents do not hold any 
patient identifiable details. 

In Mrs Welch’s case, to support staff awareness of the incident a poster was created providing 
a summary, the findings and learning identified.  The poster was displayed in a visible location 
within  the  Emergency  Department  (ED)  and  was  shared  within  the  department  messaging 
platform which is accessed by staff of all professions.  To ensure wider dissemination the case 
was discussed at the consultant meeting and medical handover as well as the governance 
meeting  in  June  2022,  after the  incident  was  reported  and again  in  August  2022,  once  the 
investigation had been completed.  The case was also shared at the Trust’s Serious Incident 
Group on 1 September 2022.   

The aid memoire provided to the court was an example of key learning that was shared as 
part  of  a  comprehensive  induction  and  following  learning  from  Mrs  Welch’s  case.    The  aid 
memoire captured essential information and was not in order of priority.  In consideration of 
your comments regarding the aid memoire, this has been reviewed and revised to ensure all 
clinically essential information is at the top.   

Guidelines (ref points: 6 & 8 of Regulation 28 report) 

There  are  hundreds  of  guidelines  available  to  doctors  working  in  UEC and  as  part  of  their 
induction they are informed how and where they can access the guidelines through the Trust 
intranet.  It is recognised that the UEC directorate cover several specialties and each speciality 

 
            
 
 
 
 
 
 
 
 
 have Royal College Guidelines and NICE Guidelines applicable. Hyperlinks to both of these 
websites  are  easily  accessible  on  the  department’s  bespoke  intranet  page.  The  Trust  has 
proactively  considered  asking  every  clinician  to  sign  to  confirm  that  they  have  read  each 
guideline but at this time believe that due to the high volume of applicable guidelines it would 
be impractical to achieve and worse still it could turn into a tick box exercise. 

The  Trust  has,  however,  noted  that  the  middle  grade  doctor  in  question  did  not  follow  the 
appropriate guidance of referring to a consultant if a patient returns to the department within 
72 hours with the same clinical condition.  The Trust is currently working with its Information 
Technology Department to add an alert to the Clinical Portal used by UEC to flag/highlight if 
the patient reattends within 72 hours and mandate that the doctor should seek advice from a 
consultant  prior  to  discharging  the  patient  from the  department.    We  believe  this  additional 
safety measure would prevent future harm in this group of patients who are at higher risk.    

UEC are in the process of conducting an audit to review patients that have reattended within 
72 hours to see whether they were referred to a consultant prior to discharge.  The outcome 
of this review will be shared within UEC and will also be presented at the Trust Wide Audit 
Day. 

I  hope  this  information  demonstrates  that  we  have  thoroughly  reviewed  existing  processes 
and have implemented additional measures to prevent future harm.  

If I can be of further assistance, please do not hesitate to contact me. 

Yours sincerely 

Chief Executive Officer