Kuldeep Stohr Investigation: Lessons from Addenbrooke’s Hospital

By Chris Gresswell-Green

Published October 29, 2025In: Clinical Negligence

A newly published independent report has revealed “a series of missed opportunities” in the monitoring and management of orthopaedic surgeon Kuldeep Stohr, whose work at Cambridge’s world-renowned Addenbrooke’s Hospital has been linked to harm suffered by dozens of children.

As medical negligence solicitors , we regularly see the lasting impact of hospital systems that fail to act on early warning signs. This case is a powerful reminder of why effective oversight and leadership accountability are essential for patient safety.

What the external review by senior paediatric orthopaedic surgeon Robert Hill found

Concerns about Ms Stohr’s surgical outcomes date back almost a decade. In 2016, an external review by senior paediatric orthopaedic surgeon Robert Hill highlighted serious shortcomings in her surgical practice and set out clear recommendations for improvement.

However, those recommendations were never fully implemented. Despite ongoing concerns, Ms Stohr continued operating for several years. It was only after her suspension in 2024 that the full extent of the problem began to emerge.

An independent investigation by Verita, commissioned by Cambridge University Hospitals NHS Foundation Trust (CUH), examined around 800 operations performed by Ms Stohr. The report found that if earlier concerns had been acted upon, harm to children “would likely have been reduced.”

This was not a sudden failure. It was the result of years of inaction and missed opportunities to protect patients.

Missed warnings and years of inaction

The report found major and minor failings in how CUH leadership handled concerns.
Had the Trust followed up on the 2016 recommendations, which included clearer line-management arrangements, mentoring for new consultants, and proper record-keeping, it is likely that harm could have been reduced or prevented altogether.

Even more troubling is the observation that Ms Stohr herself made efforts to improve, but “without the help and support of the trust.” This raises serious questions about how well NHS organisations support clinicians under scrutiny, and whether the culture prioritises protection of patients or protection of reputation.

CUH has since apologised and published an action plan promising to “build a safer and more effective organisation.” But for many families, that acknowledgment comes far too late.

The legal perspective on surgical negligence

From a legal standpoint, this case highlights the importance of clear clinical governance, early escalation, and transparent reporting. When independent reviews identify risks, those findings must lead to action, not delay.

In our work with families affected by medical negligence and surgical errors, we see the same themes repeated:

Concerns raised but not investigated
Leadership reluctant to challenge colleagues
Families left uninformed until years later

These failures are not just procedural. They breach the fundamental duty of care owed to patients. Legal action can provide answers, accountability and drive the change needed to prevent future harm.

Medical negligence solicitor and director, Chris Gresswell-Green comments: "Yet again, we see a report which highlights multiple missed opportunities to prevent injury and harm to people caused by medical negligence and by hospital officials’ inability to see the warning signs and act accordingly.

"It is deeply worrying to hear that concerns about Ms Stohr were raised as far back as 2016 in a report which looked into the work she was doing. How many patients have suffered harm since then which could have been prevented? All of them have the right to ask the Trust – why?

"Sadly, we see this pattern occurring in Trusts across the NHS. Concerns are raised but are either swept under the carpet or are not dealt with effectively when they need ot be. The upshot is always the same – innocent patients’ lives affected and sometimes changed forever. It’s simply unacceptable.

"Hundreds of people may have been affected because of the failure to act and to protect the most important priority of all – patient safety."

How hospital culture must change to protect patients

CUH’s Chief Executive, Roland Sinker, has acknowledged that Verita’s report makes “difficult reading” and has promised change. The Trust has committed to improving line management, mentoring for new consultants and clearer record-keeping.

But real change depends on culture, not policy alone. NHS leaders must ensure that staff feel safe to raise concerns, that investigations are transparent, and that learning is embedded, not delayed.

Every hospital owes its patients not only competent care, but also an environment where safety, honesty and accountability come first. That is how trust is rebuilt.

We help families affected by surgical errors and medical negligence

At Switalskis, our medical negligence solicitors have extensive experience supporting families affected by paediatric surgical negligence. We understand how devastating it is when something goes wrong during a child’s care and how vital it is that those families get clear answers and accountability. Our specialist team has acted in cases involving delayed diagnosis, errors during surgery, and failures in post-operative care.

We work sensitively with families to help them rebuild their lives after such traumatic experiences, ensuring that children receive the support, rehabilitation, and compensation they need for the best possible future.