Unanswered questions after hundreds of patients harmed

Hundreds of orthopaedic patients - mostly children - were harmed at a major hospital. Some will never fully recover. What do we know and what questions remain unanswered?

In early 2025 surgeon Kuldeep Stohr was suspended by Addenbrooke's Hospital in Cambridge - the East of England's major trauma centre - amid concerns over surgeries that were "below the expected standard".

Two separate reviews began and it was an update on one of those that was mistakenly released then removed from the hospital trust's board papers that revealed the true scale of the damage.

It stated of the 924 patients reviewed so far, 209 "experienced harm", the majority of whom were children when they had elective surgery. Forty-seven were classed as severe, with one being fatal.

Stohr was appointed by Addenbrooke's to her first consultant position in 2012, having previously done fellowships at Great Ormond Street Hospital, the Royal National Orthopaedic Hospital, and in New Zealand.

In 2024 she was away from work for personal reasons, and in her absence, her patients were seen by other doctors.

According to a letter to the parents from the hospital, those clinicians discovered a "higher than expected level of complications" and an initial review began.

Nine children's operations were below expected standards. They included Darcey, from Somersham in Cambridgeshire, who in 2022, had a procedure linked to her dislocating hips.

Her parents said after surgery "without support" her leg "would inwardly rotate almost to 90 degrees" and she needed another operation.

Two separate reviews were launched, one by investigations company Verita into possible missed opportunities and the other a clinical review led by Andrew Kennedy KC.

In October 2025, Verita found there were a "series of missed opportunities both major and minor, in how [the hospital trust] and its leadership addressed concerns".

Reviewers said Stohr's arrival at the trust was "disorganised", that she "quickly inherited a large workload" and had "fragmented and remote" clinical supervision.

"We believe that Stohr was under-managed in the early years of her career at [the trust]," they found.

Concerns were raised in 2015 by a consultant who had a "difficult relationship" with Stohr and who had a "history of raising clinical concerns about colleagues and about other matters".

The consultant told reviewers they "came across cases that troubled me", adding: "I began to fear that Stohr's practice was leading to poor surgical outcomes causing harm to children."

Verita's report said Stohr "went on practising unaware of any concerns about her practice until May 2016".

That year, Robert Hill conducted an external review which identified a series of shortcomings in her surgery and proposed steps to address them.

But he told the Verita investigation: "I regret to conclude, on the information I have – and I would be happy to be wrong – that the trust failed to draw the correct conclusions from my report, made no effort to check with me that their conclusions were correct and demonstrated little if any insight into the issues confronting 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 the credit of Ms Stohr 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 and support of the trust."

The Kennedy review is made up of 10 senior consultants working at NHS trusts around the country and is expected to conclude in November.

The deleted update said 994 patients had "now had an initial clinical review" - and 93% of cases were fully completed.

Some families involved in the review went to the trust's board meeting on Wednesday, where chief executive Nicola Ayton apologised to them for both any harm they came to while under the care of Addenbrooke's - but also that the information was put in the public domain when it should not have been.

The trust has promised to share the final report in full with patients and families first before publishing it.

Elizabeth Maliakal, from Hudgell Solicitors, which is representing several families, said she expected the final report to be "damning".

Lynn's 13-year-old daughter Tammy was among the first to receive findings from an independent investigation last year.

She said: "One or two can be classed as a mistake, but this amount – no. It's ridiculous, especially where parents like me have had to see their children go through additional surgery."

Natasha, whose daughter, Neave was operated on by Stohr, said the Verita report had focused more on protecting the hospital's reputation than answering questions or holding anyone accountable.

She has called for a public inquiry.

Then chief executive Roland Sinker said in the wake of the Verita investigation he would not resign as the trust was implementing new plans that "will put patients at the heart of how we deliver services in future".

Two months later he stepped down to take up a new role at Cambridge University.

In the most recent statement, his replacement Ayton said: "We are deeply sorry to the patients and families who came to harm or experienced care below the standards they should expect.

"This should never have happened and we are making changes so that something like this could not happen again."

Stohr has previously said she was co-operating with investigations and: "I always strive to provide the highest standards of care to all my patients."

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