An independent investigation into potential missed opportunities for identification and avoidance of possible harm to paediatric orthopaedic patients at Cambridge University Hospitals NHS Foundation Trust (October 2025)

Summary

Verita conducted this independent investigation commissioned by Cambridge University Hospitals NHS Foundation Trust (CUH) into potential missed opportunities to identify and avoid harm to paediatric orthopaedic patients under the care of Ms Kuldeep Stohr, Consultant Paediatric Orthopaedic Surgeon.

Concerns were raised in 2024 about patient outcomes and aspects of Ms Stohr’s decision-making. An external review confirmed issues with her operative technique and judgment in complex hip surgeries. Ms Stohr has not practised since she began a leave of absence in March 2024. The Trust formally excluded her from work in February 2025.

This report sets out to show what was known about Ms Stohr’s practice, when it was known, and whether earlier intervention could have prevented harm.

Content

Summary of recommendations

1. The Trust should consider implementing a more organised approach to the initial job and role planning process for new consultants. This should include clear identification of the consultant’s line management arrangements, and the responsibility for their clinical supervision.
2. The workplace induction process for new consultants should be reviewed to ensure that appropriate mentoring and/or buddying arrangements are in place to enable consultants joining the Trust to have a resource to assist them to integrate quickly to their role and their division.
3. Line managers should intervene with clinicians more promptly to address and resolve relationship problems where they might adversely affect patient safety (especially in small specialties). Line managers should consider whether informal approaches to resolve any problems, such as encouraging colleagues to talk through issues are needed. Support may also be considered for more explicit conflict resolution or mediation if problems persist.
4. The Chief Medical Officer’s team should develop written guidance on the commissioning of external reviews to ensure they are properly specified, that their findings and recommendations are actioned, and that appropriate monitoring arrangements are established to track progress with any improvement plans. This guidance should be developed in collaboration with line management. The agreed guidance should be set out in a standard operating procedure (SOP).
5. To ensure that reliable records are available in any further investigation or review, we recommend that the Trust should maintain more comprehensive written records or file notes of meetings and important conversations with people involved in patient safety issues and their investigation.
6. In evaluating reports produced by external reviewers we recommend that the commissioner, or the manager responsible for interpreting the report, should always speak with the reviewer to test understanding of the findings and any recommendations flowing from the report.
7. Outcomes, findings and recommendations from an external review should be shared with a senior clinician in the specialty for the purpose of understanding the findings, conclusions, and recommendations.
8. The Chief Medical Officer (CMO) should develop a protocol for ensuring that the handover from their office of an external report for action is managed in concert with the specialty or divisional manager.
9. We recommend that a named individual should be held responsible for ensuring that actions are taken consequent upon a review. That individual should be responsible for ensuring any improvement plan for a clinician whose practice has been reviewed is properly resourced and enabled by the Trust.
10. The Chief Medical Officer’s office and the named individual should agree what monitoring and reporting mechanisms are needed to track progress, and to ensure key steps and outcomes are accurately recorded.
11. We recommend the CMO’s office, and the named individual should sign off and record the closure of any actions arising from the review.
12. The CMO’s team should ensure that the findings and conclusions of any external review are shared with the management team involved and that an appropriate plan is developed and implemented that sets out the actions to be taken and by whom.
13. The CMO’s team should satisfy itself in the commissioning and delivery of an external review that any information and/ or findings are recorded in the appropriate Trust data streams and risk registers. Any completed review should be assessed by the CMO’s team to identify any need to exercise the Trust’s duty of candour.
14. We recommend that the Chief Medical Officer and the Chief People Officer should produce guidance that clearly sets out the respective roles of appraisers and line managers in the management of consultants. This guidance should also clarify who is responsible for clinical supervision of consultants and how that supervision should operate.
15. To improve the confidence that the Trust has in the competence of its surgeons we recommend that the Chief Medical Officer should consider developing appropriate mechanisms to ensure surgical practice is routinely observed by qualified colleagues.
16. The Trust should consider whether to develop a more formal mechanism to share outputs from appraisals with line management. Any concerns about a clinician’s practice, or factors that might affect it, need to be routed, with the clinician’s agreement, into the management of the Trust so that they can be considered and acted upon.
17. While the personal and medical content of Occupational Health referrals and reports are private to the individual, the Trust should assure itself that appropriate arrangements are in place for line management to understand whether any reasonable adjustments need to be made to support the individual to maintain good health and performance.
18. Line managers should be encouraged to be proactive in identifying and correcting excessive workload for their team members. Managers should be alert to the possible effect that staff carrying excessive workloads may have on patient safety and quality of care.
19. We recommend that the Trust should develop a more consistent approach to the establishment and management of MDTs. The aim should be to standardise, where appropriate, those common elements that apply to MDTs across the Trust. Such an approach could be set out in a Standard Operating Procedure (SOP).
20. The Trust should consider an audit of all existing MDTs to consider their effectiveness in enabling the consistent delivery of safe care. Such an audit should consider; clarity of the MDT’s aims; team working; use of data and information for decision-making, and regularity/inclusiveness of meetings.
21. The CMO and the Chief People Officer should establish an implementation working group to ensure that changes to clinical governance structures, processes and practice are embedded effectively across the Trust. The group should include corporate management, and staff from a ‘deep slice’ of the organisation to ensure representation from all the key groups responsible for patient safety.
22. The Trust should establish a structured process for supporting clinicians whose participation in MDT meetings is affected by health or interpersonal difficulties. The aim 291 should be to ensure that safe, collaborative clinical practice is maintained. This process should comprise early discussion of reasons for withdrawal; assessment of any risk to clinician or patients; mitigation of such risk; alternative mechanisms for peer review and monitoring of safe practice.
23. The CMO’s team should ensure that the Trust has the necessary procedures in place to meet the expectations of the IHPN Medical Practitioners Assurance Framework.