Cambridge University Hospitals NHS Foundation Trust have published a report dealing with concerns around the practice of a trauma and orthopaedic consultant, Ms Kuldeep Stohr, who specialised in treating children at Addenbrooke’s Hospital. A clinical review of around 800 patients is now underway. Ms Stohr has been suspended.
The issues raised are extremely concerning as multiple opportunities were missed to take action that potentially could have prevented harm to children.
The ‘Verita’ report details the findings of an independent investigation into whether there were opportunities to have earlier identified and addressed issues with Ms Stohr’s practice. The investigation did not examine individual patient care. A separate independent clinical review is now being carried out by a panel of expert clinicians, led by Andrew Kennedy KC, which is expected to conclude next year. The panel will examine the treatment of around 800 patients. This follows an initial review of complex hip surgery cases in recent years which found that nine children had received substandard care.
Concerns about Ms Stohr’s practice were raised as far back as 2015. An external clinical review was undertaken in 2016 by paediatric orthopaedic surgeon Mr Robert Hill after a senior colleague had raised concerns about Ms Stohr’s surgical practice. Mr Hill’s report identified shortcomings in Ms Stohr’s surgery, concluded that there was a need for technical improvements and made recommendations. However, the Verita investigation found that the Hill report was not adequately interpreted or communicated. The report states: ‘The two surgeons were led to believe that the principal problem was their poor relationship’. This seems to have distracted from the clinical shortcomings raised. The report does note that Ms Stohr ‘understood the findings of the Hill report and made her own efforts to improve her clinical practice. She did this without the help and support of the Trust.’
The Verita report in fact highlights that there were some 32 missed opportunities to address concerns over Ms Stohr’s practice between 2012 and 2024. The report concludes: ‘If these opportunities had been recognised at the time, appropriate actions could have been taken. Those actions would likely have reduced harm to paediatric orthopaedic patients.’
The Trust have apologised for the missed opportunities identified and the impact that this has had on patients and their families. According to the Trust, Pippa Heylings, MP for South Cambridgeshire, commented: ‘There has been harm done and that harm could have been avoided….. I will be holding the hospital to account on the delivery of the changes needed to ensure that nothing like this can be allowed to happen again.’ She went on to say that ‘the report makes clear that staff and senior consultants have not felt able to raise concerns about risk and harmful practice.’
The Trust say they are implementing an action plan which includes improving governance for the safety and effectiveness of clinical services and improving support for doctors. They also say that they are embedding an open and accountable medical culture. This is clearly key to preventing any similar incident in the future.
Orthopaedic legal claims
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