A devastating independent report has exposed a catalogue of missed warnings, management failures, and cultural problems at Cambridge University Hospitals NHS Foundation Trust (CUH), leading to avoidable harm for children under the care of a senior paediatric orthopaedic surgeon.
The 300-page Verita report, commissioned by CUH and published today, details how concerns about the clinical practice of Ms Kuldeep Stohr, a consultant paediatric orthopaedic surgeon, were repeatedly raised but not acted upon for nearly a decade.
The investigation found that “appropriate actions could have been taken” to reduce harm, but “deficiencies in Ms Stohr’s practice persisted for years as her caseload and patient complexity grew.”
Early warnings ignored
Ms Stohr joined CUH in 2012. By late 2015, her colleague, known as Consultant A, raised formal concerns about her surgical technique and decision-making. An external review by Mr Robert Hill, a senior paediatric orthopaedic surgeon, confirmed “technical and judgmental concerns about Ms Stohr’s surgical practice.”
But the Trust’s response was woefully inadequate.
The report states: “Deputy Medical Director A, and his colleagues only partially understood Mr Hill’s report and concluded that Ms Stohr’s clinical competence was not in question. They appear to have interpreted Mr Hill’s report as evidence that Ms Stohr could safely carry on practising. The result was that she was not restricted from practising surgery or placed under closer supervision from then on.”
The findings were not widely shared, and no plan was put in place to address the shortcomings identified.
“We found no evidence that anyone in management had set out a plan of activities she should undertake to improve her performance,” the report notes.
A culture of silence and missed opportunities
The investigation catalogues a series of “missed opportunities” including failures to act on warnings, poor communication, and a lack of managerial accountability.
The report is scathing about the Trust’s culture, stating: “Weak MDT structures, poor clinical governance, and lack of consultant oversight meant continuing clinical issues went undetected.
“The Trust failed to connect data with ‘soft signals’ of risk. That Ms Stohr’s difficulties remained unaddressed for so long exposes a serious gap in the Trust’s ability to identify and act on concerns about doctors’ practice.”
Consultant A, who first raised concerns, told investigators: “I am shocked, desperately saddened and very angry by the Trust’s seemingly wilful and deliberate mischaracterisation of the Hill Report in their August 2016 letter to me and their total inaction in relation to Ms Stohr’s surgical practice in 2016.
“Only now is it becoming clear that this missed opportunity and cover-up by the Trust has led to calamitous consequences for a currently unknown number of children.”
Harm to children
The full extent of harm is still being assessed, but the report confirms that “a number of Ms Stohr’s patients who had complex surgery for dysplastic hips over a two-year period had experienced significant harm. The reports found evidence of poor operative technique and issues with Ms Stohr’s decision making.”
In March 2024, Ms Stohr went on sick leave. When colleagues took over her caseload, they were “shocked to learn” of the problems. A second external review in late 2024 by Mr James Hunter confirmed the earlier findings. Ms Stohr was formally excluded from work in February 2025.
Systemic failures
The Verita report identifies deep-rooted problems in CUH’s governance and culture. It found that:
- There was “no real day-to-day oversight” of Ms Stohr’s clinical work.
- Management “took comfort from the fact that members of the department were no longer raising concerns and issues.”
- “Trust systems that generate hard data about patient safety issues had not indicated the incidence of any ‘red flag’ concerns about Ms Stohr’s clinical practice.”
- The report also highlights the damaging impact of poor relationships and lack of support, noting that “Ms Stohr was under-managed in the early years of her career at CUH” and that “management and clinical supervision appeared to be fragmented and remote.”
Families and staff let down
The Trust has now contacted all patients and families where harm has been identified, and a further external clinical review is underway. But for many, the damage is done.
A parent of a former patient told investigators: “I would say Kuldeep is an extraordinarily dedicated and conscientious doctor… but the one that she works in is high quality, high throughput, but highly specialised… you really need someone like this on your side.”
Yet the report makes clear that “the combination of these factors meant that any deficiencies in Ms Stohr’s practice persisted for the next seven/eight years during which, coincidentally, her patient population grew and presented with ever more complex conditions.”
A call for change
The Verita report makes 23 recommendations, including better induction and supervision for consultants, clearer accountability, improved governance, and a culture that encourages staff to speak up.
It concludes: “That Ms Stohr’s clinical difficulties went unaddressed for so long highlights a significant gap in the Trust’s capacity to identify and address concerns about doctors’ practice before things go wrong.”
As CUH embarks on a wide-ranging governance review, the eyes of Cambridgeshire—and the families affected—will be watching to see if real change follows.
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. With the backing of the whole CUH board, we will work tirelessly to deliver our action plan in full to build a safer and more effective organisation.”
Background
In April 2025, CUH confirmed that both an external clinical review and an independent investigation had commenced into the practice of Ms Kuldeep Stohr.
Both the review and investigation were commissioned by the Trust following an earlier external review, completed in January 2025, which found that the outcomes for some patients cared for by Ms Stohr were below standard.
Apart from the review published today an external clinical review led by Andrew Kennedy KC is now taking place. This is looking at the care of 698 patients who had planned surgery under Ms Stohr’s care while she worked at CUH.
