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Update on our action plan: six-month milestones

20 May 2026 6 min read

In October 2025, we published Verita’s independent investigation report into what was known when about the practice of Ms Stohr and whether there were opportunities to have identified and addressed these issues sooner.

Update on our action plan: Learning, Accountability and Change | Sue Broster, Chief Medical Officer

Link: https://www.youtube.com/watch?v=JFK6t0rAPvc

Video transcript

Sue Broster, Chief Medical Officer, Cambridge University Hospitals NHS Foundation Trust

I'd like to start by apologising to all patients and families impacted by the clinical review and the investigation that is ongoing. We know this continues to have an impact, and we are committed to supporting you.

I want to update you on the progress we have made to improve our services and deliver the action plan we published in response to the Verita report.

Our Trauma and Orthopaedics teams are continuing to make changes based on what patients and families have told us and what we have learned from the clinical reviews.

For example, we have responded to patient feedback and reviewed how children's pain is managed after surgery. Using these findings, we are improving how pain is assessed, monitored and treated.

After surgery, teams now review scans and X-rays together to check that operations have met the standards we would expect. We are also recording discussions between specialists more clearly so that decisions are documented and easier to follow.

We have started a review to improve care for children with additional needs, including how different teams work more closely together. All of this is helping us improve safety, experience and outcomes for patients.

Alongside these changes in Trauma and Orthopaedics, we are making improvements across our hospitals in six key areas to address all of the recommendations in the Verita report:

  • Better support, oversight and accountability for doctors
  • Stronger leadership and clearer responsibility for patient safety
  • Using data to identify and reduce variation in care
  • Improving how clinical teams work together
  • Focusing on higher-risk specialist services
  • Improving culture and how concerns are addressed

Over the past few months, we have made important changes to improve patient safety and care across CUH.

For example, we have strengthened the support and supervision available to doctors, providing clearer oversight of important clinical decisions and complex cases.

We are also using data more effectively to track outcomes, identify differences in care and spot problems earlier. At the same time, we are helping clinical teams work more closely together and improving how higher-risk and specialist services are reviewed and assessed.

Importantly, we are continuing to build a more open culture where staff feel able to raise concerns, and where those concerns are listened to and acted upon promptly.

If you would like to read more about these actions, please visit our website.

I also wanted to provide an update on the ongoing external clinical review chaired by Andrew Kennedy KC.

The majority of patients and families within the scope of the review have now received the outcome of their individual reviews.

If you are still awaiting the outcome of your review, please be assured that you have not been missed or forgotten. Once the review of your case has been completed, we will contact you to explain the outcome and discuss whether any follow-up care is needed.

The clinical review will be completed in the autumn, and we will publish the findings later this year.

We know this continues to affect many patients and families, and we want to make sure you have the support you need.

We have a dedicated Patient and Family Liaison Team that is here to support you and answer any questions you may have.

You can contact the team by phone or text between 9.00am and 4.00pm, Monday to Friday, or by email using the details shown on screen.

We know we still have more work to do to improve care, strengthen culture and rebuild trust. We are committed to making lasting improvements for patients.

Thank you for watching.

To accompany this, we published our action plan ‘Learning, accountability and change’, which details how we will address the recommendations identified within the report and implement the necessary improvements across our Trust.

We apologise unreservedly to the patients and families affected by this incident. Through our action plan, we are committed to delivering Verita’s recommendations in full. We recognise that this is a critical first step in regaining the trust of our patients.

As part of our commitment to transparency and accountability, we are publishing this six-month update on the progress we have made against the commitments in the plan. We have continued to make positive progress and have delivered the further 13 commitments we aimed to complete by May 2026.

Below, we set out what we have delivered and, importantly, what these changes mean for patients and families.

Better support, oversight and accountability for doctors

What we have delivered

We are strengthening how doctors are supported, managed and reviewed. This includes improving how workloads are understood, introducing clearer guidance for managers, strengthening appraisal processes, and providing a more structured induction programme for new consultants.

What this means for patients and families

Doctors will receive more consistent support, supervision and feedback throughout their careers at CUH. This will help us identify concerns earlier, support safe clinical practice and provide more consistent, high-quality care for patients.

Stronger leadership and clearer responsibility for patient safety

What we have delivered

We have strengthened how senior clinical leaders and the Trust Board oversee quality and safety. This includes leadership development and clearer ways of working between senior medical leaders and clinical teams.

What this means for patients and families

Patient care is being monitored more closely across the Trust, so problems are spotted and dealt with faster, and it’s clear who is responsible for making improvements.

Using data to identify and reduce variation in care

What we have delivered

We have reviewed Trust-level data on patient outcomes to identify where there may be opportunities to improve our services.

What this means for patients and families

We will be better able to identify differences and take action to ensure all patients receive consistently safe, high-quality care.

Improving how clinical teams work together

What we have delivered

We have introduced clearer standards for how multidisciplinary teams (MDTs) work together across the Trust.

What this means for patients and families

Care will be better coordinated, with the right specialists involved in decisions, leading to safer and more consistent treatment.

Focusing on higher-risk and specialist services

What we have delivered

We have reviewed services that provide highly specialised or complex care, to identify any areas where governance or safety arrangements need strengthening. We have also developed a Trust-wide plan to strengthen quality and safety, based on a review by NHS England.

What this means for patients and families

We are paying closer attention to more complex areas of care to make sure all our services are safe, consistent and well-coordinated for patients and families.

Improving culture and how concerns are addressed

What we have delivered

We have taken forward actions to improve culture across the hospital, including promoting a more open and respectful environment and applying a “just and learning” approach to address concerns earlier and more fairly.

What this means for patients and families

Staff are better supported to speak up and address issues quickly. This will help to prevent problems from happening and improve the safety and quality of care for patients.

The final actions set out in the ‘Learning, accountability and change’ action plan are due for completion in October 2026.

Improvements to patient care

We want to share the below update on the steps we are also taking to improve patient safety and care across the hospital and within individual services.

Trauma and Orthopaedics

Our children’s and adults’ Trauma and Orthopaedics teams are continuing to make improvements to the care patients and families receive.

These improvements are based on what patients and families have told us, as well as learning from independent clinical reviews.

  • A detailed review has been carried out looking at how children’s pain is managed after orthopaedic surgery. Learning from this review is being used to improve how pain is assessed, monitored and treated.
  • The Trust is also introducing wider real-time monitoring of pain management across paediatric services so that any issues can be identified and addressed more quickly.
  • A review is underway to improve care for children with neurodisabilities, helping orthopaedic, neurology and community paediatric teams work more closely together and improve coordination of care.
  • The Pavlik harness information leaflet has been updated following feedback from families.
  • We are putting in place the recommendations from the MDT (multi-disciplinary team) review, including a new system to clearly record discussions between different healthcare professionals in each patient’s record.

Our commitment

We know there is more to do. Improving care, rebuilding trust and making sure changes are fully embedded across the organisation will take time and continued effort.

We are committed to listening to patients and families, learning from feedback, and making lasting improvements to the quality and safety of the care we provide.

Patient Advisory Board (PAB)

Catherine Kimberley, Chair of the Patient Advisory Board, has shared an update as part of this work.

The Board meets every month, with meetings held either in person or online.

The next meeting will take place on:

  • Wednesday 10 June – 10am-11.30am (online)

If you are interested in joining the Patient Advisory Board (PAB) or have any questions, please contact:
cuh.familyliaison@nhs.net

We remain committed to supporting the Patient Advisory Board and hearing from patients and families.

Find out more about the Patient Advisory Board and how to join.

Listening event for children and young people (NYAS)

If you are a parent of a child under 16 who is involved in this review, you will have received an invitation to a listening event for children and young people supported by the National Youth Advocacy Service (NYAS).

NYAS are offering two short online information sessions:

  • Tuesday 2 June, 6:00–6:30pm
  • Wednesday 3 June, 2:00–2:30pm

Following these sessions, an in-person listening event will be held on:

  • Saturday 13 June
  • 10:00am to 2:00pm
  • Meadows Community Centre, Cambridge

This interactive event will use creative activities such as play and graffiti-style art to help children and young people share their thoughts, feelings and experiences.

Families can register with NYAS using the details provided in their invitation.

Oversight of the improvements we are making

To make sure the delivery of our action plan has oversight from our partners, we report progress to the dedicated Oversight Board, which includes representatives from NHS England, the Care Quality Commission, Healthwatch, GMC and the Integrated Care Board alongside CUH Executive and Non-Executive Directors. We will continue to do this as we progress.

Ongoing support for patients and families

We recognise the impact the incident, the publication of the Verita report and the ongoing clinical reviews may have on affected patients and families. Our dedicated Patient and Family Liaison team remains on hand to support you and answer any questions you might have:

Psychological support provided by the Cambridgeshire and Peterborough NHS Foundation Trust is available for patients and families should you need it. If you would like an appointment, please email paediatricOrthopaedicreferrals@cpft.nhs.uk or contact the Patient and Family Liaison team who can help.

This document was correct at the time of printing - 05-07-2026 14:24