Earlier this year, the Trust initiated an external clinical review into the practice of Ms Kuldeep Stohr, a trauma and orthopaedic consultant who specialises in treating children. Alongside that, the CUH Trust Board commissioned an independent investigation into missed opportunities to have identified and addressed any concerns arising from her practice sooner.
Today we are publishing the independent Verita report into missed opportunities, which can be found below.
Alongside the report, here is our action plan in response to the findings of the investigation.
We continue to offer our sincere and unreserved apologies to the patients and families affected. We will now work with patients, families and colleagues to deliver the changes needed.
Non-urgent advice: Roland Sinker, Chief Executive of Cambridge University Hospitals, 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.”
Click here for the Verita report and CUH action plan
Background
The Verita report and external clinical review were commissioned by the Trust following an earlier external review, completed in January 2025, which found that the outcomes for some patients cared for by Ms Stohr were below the standard we expect — and that our patients and their families should expect from us.
As a precaution, we restricted Ms Stohr’s clinical practice in 2024 while that first review took place. After the initial review was completed, she was suspended.
Verita scope
The independent investigation, led by a specialist investigations company called Verita, looked into what was known when about the practice of Ms Stohr and whether there were opportunities to have identified and addressed these issues sooner.
We know that concerns were raised as early as 2015 and were the subject of an external clinical review in 2016. As part of their work, we asked Verita to investigate whether that review was acted upon appropriately and, if not, why.
The terms of reference for the investigation can be found here.
The scope of the Verita investigation was not to examine the clinical care and treatment of individual patients of Ms Stohr - this is the subject of the separate independent clinical review being led by Andrew Kennedy KC and a panel of experts, which will conclude in 2026.
More details about this review can be found here.
Verita’s report
Verita’s report highlights a series of missed opportunities in how the Trust addressed concerns about Ms Stohr’s clinical practice. Had these opportunities been recognised, appropriate actions could have been taken to address issues sooner.
Ed Marsden, Founder of Verita said: “This report highlights 32 missed opportunities to address concerns over a consultant’s practice in the paediatric orthopaedic department at Cambridge University Hospitals NHS Foundation Trust 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.”
Action plan in response to findings
We are sorry for the missed opportunities identified in this report and the impact on the patients and families affected. This should not have happened and we accept Verita's findings and recommendations in full.
Our action plan sets out the changes we will make to ensure an incident like this cannot happen again.
The plan is structured in four programmes of work, aligned to the recommendations in the report:
- Management and support for doctors
- Improving governance for the safety and effectiveness of clinical services
- Effective oversight of clinical reviews
- Medical culture and tackling poor behaviours
Each programme of work outlines actions we have already taken in 2025, followed by changes we will deliver within three, six and twelve months respectively. We will report our progress against these to ensure full accountability and transparency.
Cambridge MP Daniel Zeichner said: "Concerns raised by patients should always be taken seriously. My sympathies lie with the patients and families who have been affected. I am reassured that Cambridge University Hospitals Foundation Trust are engaging with the Verita Investigation to ensure that the appropriate steps are taken going forward."
Support to patients and families
We recognise the impact this incident, the publication of the Verita report and the ongoing clinical reviews are having on the affected patients and their families. It should not have happened and we are deeply sorry for the harm and distress caused.
If you need support please contact the Patient and Family Liaison team:
Phone: 07719 407 210
Email: cuh.familyliaison@nhs.net