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Update on our action plan: nine-month milestones

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.

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.

While there were no specific commitments to deliver between the six and nine month milestones, we have continued to make progress to improve our organisation.

Better support, oversight and accountability for doctors

What we have delivered

Managers now have better oversight of the planned activity of doctors thanks to the introduction of a new digital job planning tool.

The system allows us to identify when staff may be working significantly more or less than planned or are carrying out activities that differ from their agreed job plan.

What this means for patients and families

We can identify issues earlier, target support where needed or intervene when workloads or activities need to be addressed. The system, used alongside regular appraisals and feedback, helps us to better support doctors and maintain safe, high-quality care for patients.

Improving how clinicians lead and work together

What we have delivered

We have introduced a development programme for consultants who have joined the Trust within the last two years. Delivered in partnership with The King’s Fund, it helps new consultants strengthen the way that they lead and build supportive relationships across specialties.

As more groups of doctors complete the programme, we will develop a formal peer support and alumni network to ensure established consultants can support newly-appointed consultants.

What this means for patients and families

Improving leadership and mentorship across our consultant workforce will help to better support newly-recruited consultants and ensure learning is better shared across specialities – meaning we can deliver high-quality care, more consistently. 

Using data to improve patient outcomes

What we have delivered

We have carried out our first Trust-wide review of patient outcomes using national NHS data, which showed many areas of good performance while also highlighting some areas where we need to do further work. This is the start of a programme to regularly use both local and national data to improve oversight of the performance of our services and our surgeons.

What this means for patients and families

Strengthening routine access to, and use of, both national and local data about patient outcomes will give us better oversight of performance, support clinicians to make decisions about patient care, and mean we can monitor quality and patient outcomes more proactively.

Adopting revised standards to improve patient safety

What we have delivered

We have continued to implement the revised National Safety Standards for Invasive Procedures (NatSSIPs 2) across our services.

The revised standards are designed to help reduce misunderstandings and errors and improve the way teams work together.

What this means for patients and families

Their introduction will support safer care and reduce the number of patient safety issues related to invasive procedures.

Improving culture and how concerns are addressed

What we have delivered

Earlier this year, we commissioned independent experts to conduct a listening exercise with our doctors to understand more about their experience of raising concerns. We published the final report on our website and shared it with all of our staff. We are now using insights from that report, alongside other quantitative and qualitative data like the annual staff survey, to create a consistently healthy medical culture.

What this means for patients and families

Improving our culture will lead to greater openness and transparency and ensure staff are better supported to listen to and act upon concerns sooner.

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

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.

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.

An update from the Patient Advisory Board

Here is an update from Catherine Kimberley, a parent of a young person involved in the review and Chair of the Patient Advisory Board (PAB):

Over the last few months, parents and families of those children and young people affected by the review continue to attend our monthly PAB meetings which rotate between online and in person.

Those of us attending the meetings are able to raise any issues which are then shared at the hospital’s Oversight Board by the Chair so that any action can be taken. Issues such as access to follow-up care, support with equipment and advice on next steps following review outcomes are just some of the issues raised to date.

By listening to parents of children and young people affected by the ongoing review, we are able to influence meaningful change. Our advocacy has improved clinical pathways for those who require follow-up care, ensuring their cases continue to be prioritised.

A number of parents have asked for the final Andrew Kennedy KC review to be provided in an accessible format so that findings can be clearly understood. As we near the end of the clinical review, a separate meeting will be held for patients, parents and carers to discuss how they would like the external report to be presented - please contact me by email if you would like to be involved at catherine.kimberley@nhs.net.

If you are a patient, parent, carer or family member affected by the clinical review into cases and want to join the Patient Advisory Board, please email cuh.familyliaison.nhs.net.

The upcoming PAB meetings will be held on:

  • 26 August, online from 6-7:30pm
  • 26 September, in person from 10-11:30am

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.