'chances Missed,' Says Damning Report Into Surgeon

"A bid of missed opportunities" person been revealed by an investigation into hundreds of children's surgeries carried retired by a master moving astatine a world-renowned NHS hospital.

Kuldeep Stohr was suspended by Addenbrooke's Hospital successful Cambridge earlier this year, amid concerns complete surgeries that were "below nan expected standard".

A "pivotal missed opportunity" came erstwhile nan infirmary spot grounded to enactment upon recommendations made by an outer reviewer into her activity successful 2016, nan study said.

Cambridge University Hospitals NHS Foundation Trust (CUH), which runs Addenbrooke's, said it accepted "the findings and recommendations" successful nan study and noted a abstracted outer reappraisal was ongoing.

The study looked astatine astir 700 planned and 100 emergency operations involving Dr Stohr, immoderate of which were for adults.

If due actions had been taken, they "would person apt reduced harm to paediatric orthopaedic patients", nan independent investigators concluded.

Radd Seiger, a retired lawyer who represents 25 of nan affected families said: "This was not a rogue surgeon — this was a rogue system."

The investigation was commissioned by CUH and carried retired by Verita, which describes itself arsenic an "objective investigations institution providing master proposal to regulated organisations successful nan UK".

Ms Stohr was suspended by nan infirmary and has not been astatine activity since March 2024, initially for individual reasons.

In her absence, her patients were seen by different doctors who discovered, a missive to nan parents from nan infirmary said, a "higher than expected level of complications".

That led to an first review, which recovered operations involving 9 children fell "below expected standards".

One of those was Darcey, whose parents antecedently told nan BBC they feared problems pinch her hep operation, which near her limb rotated inwards "to almost 90 degrees" and successful request of further surgery, were "brushed nether nan rug".

It emerged that concerns astir Ms Stohr dated backmost arsenic early arsenic 2015 and wider reviews were started into astir 800 diligent procedures.

The latest study concluded location was "a bid of missed opportunities, some awesome and minor, successful really CUH and its activity addressed concerns" astir Ms Stohr's aesculapian believe and "appropriate actions could person been taken".

In particular, nan study focused connected an outer reappraisal into Ms Stohr's activity written successful 2016 by Robert Hill, a elder paediatric orthopaedic surgeon.

The outer study had been commissioned aft a elder workfellow raised concerns astir nan value of her work.

Mr Hill's study identified a bid of shortcomings successful her room and projected steps to reside them.

But he told nan existent investigators: "I regret to conclude, connected nan accusation I person – and I would beryllium happy to beryllium incorrect – that nan spot grounded to tie nan correct conclusions from my report, made nary effort to cheque pinch maine that their conclusions were correct and demonstrated small if immoderate penetration into nan issues confronting them."

The study said: "As a result, deficiencies successful Ms Stohr's believe persisted for years arsenic her caseload and diligent complexity grew.

"It is to nan in installments of Ms Stohr that she understood nan findings of nan Hill study and made her ain efforts to amended her objective practice. She did this without nan thief and support of nan trust."

The study made a bid of recommendations including:

• clearer line-management arrangements
• mentoring and buddying arrangements for caller consultants
• the creation of reliable records for immoderate early reviews and connected really findings and recommendations from outer reviews should beryllium shared

Mr Seiger said: "Cambridge University Hospitals knew location were superior concerns astir Ms Stohr's believe arsenic acold backmost arsenic 2016, but grounded to act.

"Children were harmed, families were misled, and nan trust's activity concealed nan truth for astir a decade."

Restrictions person since been placed connected Ms Stohr by nan General Medical Council registration, including that she must beryllium "closely supervised successful each of her posts by a objective supervisor".

Roland Sinker, main executive of CUH, said nan spot was "deeply sorry" for nan effect connected patients and "we judge nan findings and recommendations made successful Verita's study successful full".

"This should not person happened and coming we are publishing an action scheme which describes nan changes we will make," he said.

"Throughout this process, we person remained committed to supporting patients and families affected and will proceed to do truthful arsenic nan abstracted outer objective reappraisal remains ongoing.

"Verita's study makes for difficult reading, and we will study from this.

"Now is simply a pivotal infinitesimal to alteration our hospitals for nan better. With nan backing of nan full CUH board, we will activity tirelessly to present our action scheme successful afloat to build a safer and much effective organisation."