Report Exposes Years of Missed Warnings on NHS Surgeon

Hospital leaders missed 32 opportunities to act over safety concerns about a paediatric orthopaedic surgeon accused of botching children’s operations, an independent review has found. 

The investigation said that failures by Cambridge University Hospitals NHS Foundation Trust allowed Kuldeep Stohr to continue operating at Addenbrooke’s Hospital for years, putting patients at prolonged risk.

Experts highlight how “actions could have been taken to reduce harm to patients”.

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

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

Longstanding Concerns Ignored

Concerns about Stohr were first raised a decade ago. 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 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 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 her surgical work.

But the deputy medical director and his colleagues only “partially understood” the report and concluded that 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.

Failure of Oversight

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, 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, according to Verita.

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.

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 Stohr from work in February 2025.

Apology and Action Plan

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.”