‘Missed opportunities’ to act on concerns about children’s surgeon – report

Hospital bosses “missed” 32 opportunities to take action against an NHS surgeon who has been accused of botching children’s operations, a new review has found.

As a result, paediatric orthopaedic surgeon Kuldeep Stohr continued to work for years at Addenbrooke’s Hospital in Cambridge under increasing pressure which “resulted in prolonged risk to patients”, the investigation found.

Experts highlight how “actions could have been taken to reduce harm to patients”, but instead “deficiencies in Ms Stohr’s practice persisted for years”.

Complaints against her include allegations of botched hip surgeries and knee reconstructions.

The hospital trust has apologised for the impact on patients and families.

Concerns about Ms Stohr were first raised a decade ago, according to a new review which was commissioned by the Cambridge University Hospitals NHS Foundation Trust.

The review, conducted by independent investigations company Verita, highlights how a 2016 review raised concerns about her surgical technique and judgment, but it was “misunderstood” and opportunities to act on the findings were “missed”.

“The report identified shortcomings in Ms Stohr’s surgery and proposed remedial steps,” the authors said.

“The report was misunderstood, miscommunicated, and its findings reduced to a matter of interpersonal conflict rather than surgical concerns.

“As a result, deficiencies in Ms Stohr’s practice persisted for years as her caseload and patient complexity grew.

“Collectively, these failings resulted in prolonged risk to patients.”

The latest review highlights how a colleague of Ms Stohr raised formal concerns with hospital leaders in December 2015.

As a result, the hospital’s deputy medical director at the time commissioned an external review which highlighted “technical and judgment concerns” about Ms Stohr’s surgical work.

But the deputy medical director and his colleagues only “partially understood” the report and concluded that Ms Stohr’s clinical competence was not in question, Verita said.

“They appear to have interpreted (the) report as evidence that Ms Stohr could safely carry on practising,” the authors of the report wrote.

“The result was that she was not restricted from practising surgery or placed under closer supervision from then on.”

The majority of her colleagues knew nothing about the external review until early 2025.

Verita said the deputy medical director’s summary of the 2016 review’s findings was “inconsistent with its findings, advice, and recommendations” and “diluted the messages that needed to be sent to Ms Stohr about her practice”.

“The trust missed an opportunity in 2016 to address deficiencies in Ms Stohr’s clinical performance,” the authors of the new review said.

They said that following the review “nothing substantial was done by the trust to address any of Ms Stohr’s clinical practice shortcomings” and it “failed to learn” from the issues raised.

After 2016 Ms Stohr continued to operate on children “without effective managerial oversight”, the report adds.

She had a “disproportionately high surgical workload” and bosses seemed “satisfied with her contribution to reducing waiting lists”.

In 2015 and 2024, occupational health said she was suffering from work-related stress and unsustainable demands but no adjustments were made, Verita said.

There were no “red flags” raised about her practice and none of her fellow surgeons had concerns until 2024 when they assumed responsibilities for her patients when she went on a leave of absence.

“We found no one in the management of the paediatric orthopaedics service, or in the workforce directorate who held a complete picture of all the factors affecting Ms Stohr and, potentially, the quality and safety of her work,” the report adds.

Ms Stohr has not practised since she began a leave of absence in March 2024.

When colleagues took over her workload they raised concerns and another external review was commissioned which “confirmed issues with her operative technique and judgment in complex hip surgeries”.

The latest review, which does not focus on individual cases which are being examined in a separate investigation, concludes: “This investigation highlights a series of missed opportunities in how the trust addressed concerns about Ms Stohr’s clinical practice.

“Had these opportunities been recognised, appropriate actions could have been taken to reduce harm to patients.”

The trust formally excluded Ms Stohr from work in February 2025.

Roland Sinker, chief executive of Cambridge University Hospitals, said: “We are deeply sorry for the impact this has had on patients and families and are focused on supporting all of those affected.

“We accept the findings and recommendations made in Verita’s report in full.

“This should not have happened and today we are publishing an action plan which describes the changes we will make.

“While Verita’s investigation recognises that we have made progress, we are clear there is a lot more to do.

“Throughout this process, we have remained committed to supporting patients and families affected and will continue to do so as the separate external clinical review remains ongoing.

“Our services and the actions we now take will continue to be shaped by what our patients are telling us.

“Verita’s report makes for difficult reading, and we will learn from this. Now is a pivotal moment to change our hospitals for the better.”

Ed Marsden, founder of Verita, said: “This report highlights 32 missed opportunities to address concerns over a consultant’s practice in the paediatric orthopaedic department at Cambridge University Hospitals NHS Foundation Trust between 2012 and 2024.

“Our detailed report identified a range of avoidable issues including poor clinical supervision and communication, isolated practice in small specialities and strained professional relationships.”

One affected family has called for a public inquiry.

Lynn Harrison, whose daughter Tammy, 13, was operated on by Ms Stohr in April 2021, said: “I want a meeting with Wes Streeting urgently and I want him to order a fully independent inquiry into this scandal and why my daughter and all the other victims were tortured this way.”

Solicitor Elizabeth Maliakal, of Hudgell Solicitors, added: “It is simply not enough for the trust to announce an action plan and offer apology.

“The impact is so wide, and on such a large number of patients, we now need a Statutory Public Inquiry which can compel crucial witnesses to give evidence.”

Natalie Truman, a medical negligence group action lawyer at Irwin Mitchell, added: “The report makes for extremely worrying reading and vividly highlights how a catalogue of missed opportunities by the trust resulted in problems being allowed to manifest for many years.”

The family of one child who had two operations performed by Ms Stohr described how the anger is “hard to process”.

The mother of the boy, who has since died, described how her non-verbal son could not move after the second operation.

“All you want to do as a parent is to protect your children and you have to make difficult decisions sometimes, but I thought we were doing everything we could to make his life more comfortable”, said the mother, who is being represented by Osbornes Law and asked to remain anonymous.

“That anger is hard to process.”

Jodi Newton, a specialist medical negligence lawyer at Osbornes Law, added: “I hope that the report’s recommendations will be implemented in full and as a matter of urgency.”