Trust report warns of “32 missed opportunities” at Addenbrooke’s Hospital, regarding treatment provided by paediatric orthopaedic surgeon, Kuldeep Stohr
An independent review commissioned by Cambridge University Hospitals (CUH) has shed light on a number of missed opportunities within the paediatric orthopaedic service at Addenbrooke’s Hospital, regarding treatment provided by paediatric orthopaedic surgeon, Kuldeep Stohr – findings that raise important questions about patient safety and oversight.
According to the report, between 2012 and 2024 the Trust missed at least 32 opportunities to act on concerns about Ms. Stohr’s surgical practice. While the review does not focus on individual clinical errors, it identifies broader, systemic challenges in governance, communication, supervision and workplace culture that prevented timely action from being taken.
What was found?
- Early warnings – including a 2016 external clinical review – raised concerns about complex surgical cases. However, escalation and intervention were delayed
- Clinical supervision was limited: complex operations were often undertaken by a single consultant or with minimal senior oversight. The small size of the specialist team also made escalation more difficult
- Governance systems did not always respond effectively: concerns were raised but not consistently tracked or addressed in a timely way
- The report stresses that while there is no suggestion that every procedure was inappropriate, the combination of a high-risk workload, limited oversight and communication gaps created an environment where avoidable harm was possible.
Why this matters for patients and families
For patients and families affected by these findings, the report may understandably bring feelings of uncertainty or distress. It is reassuring, however, that CUH has publicly acknowledged the review’s conclusions, offered an apology, and committed to implementing a detailed improvement plan to strengthen governance and restore trust.
The Verita report provides a clearer route for families to ask questions and seek answers. It also offers a framework for legal professionals to explore not only individual issues of care but also the wider systemic factors that may have contributed to patient harm.
Our support and how we can help
If you or someone close to you received treatment under this service at CUH and you’re concerned about the standard of care provided, our experienced Medical Negligence team is here to help.
Patient safety depends on more than surgical skill – it relies on a culture of openness, accountability and proactive oversight. While the findings of this report are difficult to read, they represent an important step toward transparency and learning.
For additional insight into orthopaedic medical negligence matters, you may wish to read some of our related articles, on understanding orthopaedic injuries in medical negligence cases, common types of orthopaedic negligence claims, the claims process for orthopaedic medical negligence, and orthopaedic injuries in children. If you have any concerns, please contact us by email at enquiries@attwaters.co.uk, or call 0330 221 8855 to speak to one of our specialist solicitors.
