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Calls were today made for an independent probe into how an NHS hospital missed chances to stop a surgeon accused of botching operations on children. A review found there were 32 opportunities to take action against paediatric orthopaedic surgeon Kuldeep Stohr, who is accused of bungling children's operations - but bosses failed to act. As a result she continued to work for years at Addenbrooke's Hospital in Cambridge under increasing pressure which "resulted in prolonged risk to patients", the investigation found. Experts today highlighted how "actions could have been taken to reduce harm to patients", but instead "deficiencies in Ms Stohr's practice persisted for years". Complaints against her include allegations of botched hip surgeries and knee reconstructions. The hospital trust has apologised for the impact on patients and families. Today Lynn Harrison demanded an independent probe after her daughter Tammy, 13, was operated on by Ms Stohr in April 2021. Tammy, who has cerebral palsy, has had problems with her hip joints throughout her life, causing her legs to face inwards towards her body. Ms Harrison described how Tammy was left in "considerable pain" after a procedure to stabilise her hip joint and improve mobility. Cambridge University Hospitals NHS Foundation Trust (CUH) has said the cases of almost 800 patients of Ms Stohr are being reviewed. Tammy's case was one of the first to be looked at. Lawyers said the review noted there had been "technical problems" with her surgery. A separate investigation published today did not focus on individual cases but examined whether any steps could have been taken to act earlier to protect patients. It identified 32 missed opportunities between 2012 and 2024. "I don't know how to feel. This is all overwhelming for Tammy and I, we want the full truth to come out and we want everyone responsible for harming Tammy to be held to account," Ms Harrison said. "I'm not interested in apologies. I want to know why this was allowed to happen to my daughter, and I want justice for her. This report does not give us any of that. "I want a meeting with Wes Streeting urgently and I want him to order a fully independent inquiry into this scandal and why my daughter and all the other victims were tortured this way." Concerns about Ms Stohr were first raised a decade ago, according to the review, conducted by independent investigations company Verita. It highlighted how a 2016 probe raised concerns about her surgical technique and judgment, but it was "misunderstood" and opportunities to act on the findings were "missed". "The report identified shortcomings in Ms Stohr's surgery and proposed remedial steps," the authors said. "The report was misunderstood, miscommunicated, and its findings reduced to a matter of interpersonal conflict rather than surgical concerns. As a result, deficiencies in Ms Stohr's practice persisted for years as her caseload and patient complexity grew. Collectively, these failings resulted in prolonged risk to patients." The latest review revealed a colleague of Ms Stohr raised formal concerns with hospital leaders in December 2015. As a result, the hospital's deputy medical director at the time commissioned an external review which highlighted "technical and judgment concerns" about Ms Stohr's surgical work. But the deputy medical director and his colleagues only "partially understood" the report and concluded that Ms Stohr's clinical competence was not in question, Verita said. "They appear to have interpreted (the) report as evidence that Ms Stohr could safely carry on practising," the authors of the report wrote. "The result was that she was not restricted from practising surgery or placed under closer supervision from then on." The majority of her colleagues knew nothing about the external review until early 2025. Verita said the deputy medical director's summary of the 2016 review's findings was "inconsistent with its findings, advice, and recommendations" and "diluted the messages that needed to be sent to Ms Stohr about her practice". "The trust missed an opportunity in 2016 to address deficiencies in Ms Stohr's clinical performance," the authors of the new review said. They said that following the review "nothing substantial was done by the trust to address any of Ms Stohr's clinical practice shortcomings" and it "failed to learn" from the issues raised. After 2016 Ms Stohr continued to operate on children "without effective managerial oversight", the report adds. She had a "disproportionately high surgical workload" and bosses seemed "satisfied with her contribution to reducing waiting lists". In 2015 and 2024, occupational health said she was suffering from work-related stress and unsustainable demands but no adjustments were made, Verita said. There were no "red flags" raised about her practice and none of her fellow surgeons had concerns until 2024 when they assumed responsibilities for her patients when she went on a leave of absence. "We found no one in the management of the paediatric orthopaedics service, or in the workforce directorate who held a complete picture of all the factors affecting Ms Stohr and, potentially, the quality and safety of her work," the report adds. Ms Stohr has not practised since she began a leave of absence in March 2024. The trust formally excluded Ms Stohr from work in February 2025. When colleagues took over her workload they raised concerns and another external review was commissioned which "confirmed issues with her operative technique and judgment in complex hip surgeries". 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." Solicitor Elizabeth Maliakal, of Hudgell Solicitors, which represents a number of patients and families affected, including Ms Harrison, said: "The impact is so wide, and on such a large number of patients, we now need a Statutory Public Inquiry which can compel crucial witnesses to give evidence. "It is simply not enough for the Trust to announce an action plan and offer an apology. People need to be placed under scrutiny and held accountable. A message needs to be sent out across the NHS that this will not be tolerated. From the clients we've managed to speak to since receiving this report last night, there seems to be a clear feeling of anger and betrayal, and that is understandable." Another family, represented by Osbornes Law, has called for a "complete culture shift" in the NHS. The family, who asked to remain anonymous, said the "anger is hard to process" in the wake of the report. Their son, who has since died, was operated on twice by Ms Stohr. Lawyers representing the family said that when his case was reviewed, evidence was found that "severe physical harm was caused". His mother said: "All you want to do as a parent is to protect your children and you have to make difficult decisions sometimes, but I thought we were doing everything we could to make his life more comfortable. "That anger is hard to process. He was the light of our lives - the most incredible, smiley, resilient, brave young boy - and we'll never know what potential was lost. Those 'what if' questions are horrible, they never leave you." Jodi Newton, a specialist medical negligence lawyer at Osbornes Law, said: "The findings of the report provide a damning verdict of the lack of visibility, broken systems, and absence of communication by those in leadership at the Trust in 2016. "It makes clear that this was not the fault of one person, but the result of systemic failings that allowed her to continue, unchecked, for several years while patients, mostly vulnerable children, suffered at the hands of a surgeon who repeatedly practised in a way which was substandard and, regrettably, caused them avoidable harm. "I hope that the report's recommendations will be implemented in full and as a matter of urgency. Those seeking justice for their loved ones will also want accountability from those responsible, and the unambiguous acknowledgement, without excuses, that the majority of the harm and trauma caused could have been avoided."
