The Background
Earlier this year, Cambridge University Hospitals Trust (“CUH”) commissioned an external clinical review into the practice of Ms Kuldeep Stohr, a trauma and orthopaedic consultant specialising in the treatment of children, following concerns about her surgical outcomes.
In parallel, the Trust Board initiated an independent investigation to determine whether there had been any missed opportunities to identify and address any concerns about her practice at an earlier stage. This investigation, led by the specialist investigations company Vertia, reviewed Ms Stohr’s clinical work between 2012 to 2014.
Crucially, Verita’s investigation did not include reviewing the clinical treatment of each individual patient, instead, the focus was an organisational oversight about what was known, and when, about Ms Stohr’s practice
Key Findings – What Were The Missed Opportunities?
The Verita Report finds that there were 32 identified missed opportunities for CUH to have intervened earlier.
Significantly, it was found that concerns were first raised almost a decade ago. In December 2015, a colleague of Ms Stohr at Addenbrooke’s Hospital raised formal concerns with hospital leaders and, as a result, the hospital’s deputy medical director commissioned an external review. This external review raised concerns about Ms Stohr’s technical and judgement issues, these findings, however, were ‘misunderstood’ and so not acted upon. Verita labelled this as a ‘pivotal missed opportunity’.
A further external review of Ms Stohr’s practice was not prompted until 2024, when her fellow surgeons assumed responsibilities for her patients when she went on a leave of absence. As a result of this, Ms Stohr has not returned to clinical practice since beginning her leave in March 2024.
The Verita report importantly found that the Trust lacked effective line-management, supervision, and clear oversight in the paediatric orthopaedics service, especially given the complexity of the work.
As demonstrated, the escalation of concerns were weak, the matters raised in 2015/2016 did not translate into immediate action or adequate supervision. As Vertia themselves note: ‘had these opportunities been recognised, appropriate actions could have been taken to reduce harm to patients’.
Next Steps for CUH
In response to Verita’s findings, CUH has pledged to accept the recommendations in full and has published an action plan structured around four programmes:
- Management and support for doctors
- Improving governance for safety and effectiveness of clinical services
- Effective oversight of clinical reviews
- Medical culture and tackling poor behaviours
The Trust has also stated that it will report progress against the action plan to ensure full accountability.
The Impact on Affected Patients and Families
The chief executive of CUH, Ronald Sinker, said the Trust was ‘deeply sorry’ for the impact on patients, claiming that Verita’s report makes for ‘difficult reading’.
For patients and families, the publication of this report is both a vindication of their concerns but also a cause for shock, frustration, and uncertainty.
Currently, wider reviews have been started into about 800 patient procedures; including 700 planned and 100 emergency operations involving Ms Stohr. The Trust has indicated that there’s a possibility that this review will be even extended further.
It therefore could be many years until the true scale and consequences of Ms Stohr’s shortcomings are determined, but what is certain is the fundamental failures of a system to act upon previous concerns, causing a lasting significant impact for the affected patients and families.
The Verita report can be accessed here: https://www.verita.net/wp-content/uploads/2025/10/FINAL-PUBLICATION-Report-into-Missed-Opportunities-to-avoid-harm-at-CUH-Ms-KS-paedorthopaedics-281025.pdf98.pdf
See our previous blog post on the suspension of Ms Stohr from CUH here: https://medicalandhealthcarelaw.co.uk/cambridge-paediatric-orthopaedic-surgeon-suspended/
If you or a loved one have been treated by Ms Kuldeep Stohr, or you have any concerns about the standard of care you have received from healthcare professionals, reach out to our clinical negligence team on 020 8891 6141.