Report finds ‘missed opportunities’ into Addenbrooke’s surgeon

A “series of missed opportunities” has been found in a surgeon's review that is investigating hundreds of operations involving children carried out at an NHS hospital.

Earlier this year, Kuldeep Store was suspended from his job at Addenbrooke's Hospital in Cambridge over concerns about operations that were “below the expected standard”.

A “critical missed opportunity” occurred when the hospital trust failed to implement an external reviewer's recommendations regarding her performance in 2016, the report said.

Cambridge University Hospitals NHS Foundation Trust (CUH), which runs Addenbrooke's, said it accepted the report's “findings and recommendations” and noted that a separate external review was currently underway.

If appropriate action were taken, it would “likely reduce harm to pediatric orthopedic patients,” the independent researchers concluded.

Rudd Zeiger, a retired lawyer representing 25 affected families, said: “This was not a rogue surgeon – it was a fraudulent system.”

The investigation was commissioned by CUH and carried out by Verita, which describes itself as “an objective investigations company providing expert advice to regulated entities in the UK.”

The current separate review is looking at about 700 planned and 100 emergency operations involving Ms Stohr, some of which were for adults.

Ms. Stohr was suspended from her job at the hospital and has not worked since March 2024, initially for personal reasons.

In her absence, her patients were seen by other doctors who found, as a letter to parents from the hospital said, “a higher than expected rate of complications.”

This led to an initial review which found operations involving nine children were “below expected standards”.

One of them was Darcey, whose parents previously told the BBC they feared problems with hip surgery which caused her leg to turn inwards. “almost 90 degrees” and those in need of further surgery were “swept under the rug.”

It emerged that concerns about Ms Stohr date back to 2015 and wider reviews of around 800 patient procedures were launched.

The latest report concluded that there were “a number of missed opportunities, both major and minor, in the way CUH and its management dealt with issues” about Ms Stohr's medical practice and “appropriate action could have been taken”.

In particular, the report focuses on an external review of Ms Store's work written in 2016 by Robert Hill, a senior pediatric orthopedic surgeon.

The external report was commissioned after a senior colleague raised concerns about the quality of her work.

Mr Hill's report identified a number of shortcomings in its operation and suggested steps to address them.

But he told current investigators: “I regret to note, based on the information available to me – and I would be happy to be wrong – that the trust failed to draw correct conclusions from my report, made no effort to check with me about the correctness of their conclusions, and demonstrated virtually no understanding of the issues facing them.”

The report said: “As a result, deficiencies in Ms. Stohr’s practice persisted for years as her caseload and patient complexity grew.

“It is to Ms. Stohr’s credit that she understood the findings of the Hill report and made her own efforts to improve her clinical practice. She did this without the help or support of the trust.”

The report makes a number of recommendations, including:

• clearer line management mechanisms
• mentoring and mentoring arrangements for new consultants
• creating reliable records for any future reviews and how the findings and recommendations of external reviews should be shared.

Mr Seiger said: “Cambridge University Hospitals was aware of serious concerns about Ms Store's practices as early as 2016 but took no action.

“Children were harmed, families were misled, and the foundation’s leadership concealed the truth for nearly a decade.”

Ms Stohr has since been subject to restrictions when registering with the General Medical Council, including that she must be “closely supervised in all her positions by a clinical supervisor”.

Roland Sinker, chief executive of CUH, said the trust “deeply regrets” the impact on patients and “we fully accept the findings and recommendations made in the Verita report.”

“This should not have happened, and today we publication of an action plan which describes the changes we will make,” he said.

“Throughout this process, we have remained committed to supporting affected patients and families and will continue to do so as a separate external clinical expertise remains ongoing.

“The Verita report is difficult to read and we will learn from it.

“Now is the critical time to change our hospitals for the better. With the support of the entire CUH board, we will work tirelessly to fully implement our action plan and build a safer, more efficient organization.”

The Care Quality Commission is considering whether regulatory action should be taken in this case.