In 2024, concerns were raised about the practice of Ms Kuldeep Stohr and the treatment of individual patients. Alongside an independent clinical review into patient harm, Cambridge University Hospitals NHS Foundation Trust commissioned Verita to carry out a separate independent investigation.
The investigation was to consider whether the Trust had missed opportunities to identify and address concerns about Ms Stohr sooner, and whether earlier intervention could have prevented harm. The results of the Verita investigation have now been released.
The investigation reviewed Ms Stohr’s care between 2012 to 2024 and highlights a series of missed opportunities in addressing concerns about Ms Stohr’s clinical practice, concluding that had they been recognised, appropriate actions could have been taken to reduce harm to patients.
The investigation notes that the pivotal missed opportunity was an external report carried out in 2016 after concerns were raised about Ms Stohr’s practice in 2015. The investigation found that the Trust failed to interpret and act on the findings of the external report and although the 2016 report had identified shortcomings in the standard of Ms Stohr’s surgeries, Verita’s 2025 investigation has concluded that the report findings were misunderstood and miscommunicated, resulting in the continuance of these failings and prolonged risk to patients.
The investigation considers that “weak MDT structures, poor clinical governance, and lack of consultant oversight meant continuing clinical issues went undetected”, making 23 recommendations for the Trust to act upon.
It is reassuring to read that the Trust’s Board are willing to accept the investigation findings and recommendations in full and have chosen to publish the entire report in the spirit of openness, transparency, and change. However, we recognise that this acknowledgment will bring little comfort to the many patients and families who have suffered as a result of the serious failings identified.
What matters now is meaningful action and ensuring that the lessons from this investigation are fully implemented so that the Trust can begin to address what was clearly a wider systemic failure and prevent others from experiencing similar harm in the future.
At Tees, we remain committed to representing those affected and ensuring their concerns are heard and addressed on an individual basis, as patient needs are bespoke. Please call us on 0800 013 1165 to discuss.
