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A Cambridge hospital trust missed 32 opportunities to address concerns about a now suspended surgeon’s practice. A report has been published this week (October 29) following an independent investigation by Verita into what was known and when about the practice of Kuldeep Stohr, an orthopaedic surgeon who specialised in treating children.
Ms Stohr was suspended by Cambridge University Hospitals NHS Foundation Trust (CUH), which runs Addenbrooke’s Hospital, earlier this year after an external review found the outcomes for patients cared for by Ms Stohr were “below the standard” the Trust expected.
However, the independent report said there were a “series of missed opportunities” since concerns were first raised about Ms Stohr in 2015, that led to ‘deficiencies in her practice persisting for years’.
CUH has said it continues to offer its “sincere and unreserved apologies” to patients and their families affected. The Trust said it will now work with patients, families, and staff members to deliver the changes needed.
Ms Stohr joined CUH in 2012, with the independent report highlighting a missed opportunity at the very start, as it said the Trust “failed to equip her adequately for her first consultant appointment”.
It said: “The lack of clarity about her clinical governance and line management structure, combined with inadequate resource provision put her immediately under workload pressure without sufficient support.”
Concerns were first formally raised in 2015 about Ms Stohr’s surgical technique and decision-making. The report said the consultant who raised concerns said they had begun to “fear that Ms Stohr’s practice was leading to poor surgical outcomes causing harm to children”.
An external review was conducted at this time, which confirmed “technical and judgemental concerns about Ms Stohr’s surgical practice”. The report said advice and recommendations were made that offered “a package of practicable steps” to help the Trust and Ms Stohr to make improvements.
However, the report said a deputy medical director and their colleagues “only partially understood” the external review report and concluded that Ms Stohr’s clinical competence was not in question. This meant Ms Stohr was not restricted from practising surgery, or placed under closer supervision.
However, the report did say that it was “to the credit of Ms Stohr” that she had understood the findings and “made her own efforts to improve her clinical practice”, but that she did this “without the help and support of the Trust”.
The report said the Trust missed an opportunity at this point in 2016 to “address deficiencies in Ms Stohr’s clinical performance”, as it said “nothing substantial was done by the Trust to address any of Ms Stohr’s clinical practice shortcomings”.
Ms Stohr’s workload grows as ‘deficiencies persist’
Following this, the report said Ms Stohr’s surgical workload grew and that she showed a “willingness to volunteer to take on extra responsibilities”. The report said the impact of this “disproportionately high surgical workload” on her was “less obvious to management”, who the report said “seemed satisfied with her contribution to reducing waiting lists”.
However, the report said occupational referrals in 2015 and 2024 cited “work-related stress and unsustainable demands on her”, but no adjustments were made to her workload or supervision. The report said: “Numerous opportunities were missed to consider whether Ms Stohr’s workload was sustainable, and to assess whether the workload presented a risk to the quality and safety of her practice.”
The report said deficiencies in Ms Stohr’s practice “persisted” for seven to eight years, during which her patient population grew and presented with ever more complex conditions. The report went on to explain that most staff members who worked closely with Ms Stohr were unaware that concerns had been raised about her in 2015.
It went on to say that in 2024 when further concerns about her practice came to light staff were “shocked to learn” that a report from eight years earlier had highlighted similar issues, but had not been widely shared or acted upon. The report said there had been a “series of missed opportunities” that if identified appropriate action could then have been taken to “reduce harm to patients”.
It added that the fact Ms Stohr’s “clinical difficulties went unaddressed for so long”, highlighted a “significant gap” between the Trust’s capacity to identify and address concerns about doctors’ practice before things went wrong.
It said: “The investigation concludes that while the Trust acted correctly in commissioning an external review, the pivotal missed opportunity was the Trust’s failure to interpret and act on the 2016 Hill report. The report identified shortcomings in Ms Stohr’s surgery and proposed remedial steps.
“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 report said Verita had made 23 recommendations to the Trust to act on, including that the induction process for new consultants should be reviewed to ensure that appropriate mentoring is in place.
The Trust has also been recommended to ensure that “reliable records” are available for any further investigations or reviews, and that more comprehensive written records should be kept on meetings and conversations with people involved in patient safety issues.
The report also recommended that the outcomes and recommendations of an external review should be shared with a senior clinician in the speciality “for the purpose of understanding the findings, conclusions, and recommendations”.
CUH apologises and accepts findings of missed opportunities
CUH said it has put together an action plan in response to the findings of the independent investigation. The Trust apologised for the missed opportunities identified in the report and the impact this had on patients and families affected. CUH said it accepts all of the recommendations made by Verita and said its action plan sets out how it will meet each of these.
It said these actions will result in “better management and support to doctors; more effective clinical governance; a reformed approach to commissioning and acting on external reviews; and a more open and collaborative medical culture”.
Roland Sinker, chief executive of CUH, 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.”
Ed Marsden, founder of Verita, said he was pleased CUH had agreed with and accepted the assessment of the missed opportunities and would be taking on board the series of recommendations made.
He said: “This report highlights 32 missed opportunities to address concerns over a consultant’s practice in the paediatric orthopaedic department at CUH between 2012 and 2024.
“Our detailed report identified a range of avoidable issues including poor clinical supervision and communication, isolated practice in small specialities and strained professional relationships. We are pleased that CUH has agreed with and accepted our assessment of missed opportunities and recommendations in full.
“Throughout our investigation, the Trust has been open and transparent in sharing information with us and acted in good faith. We would like to thank everyone who contributed their time and insight to this investigation.”
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