The case will now be investigated further by Cambridgeshire’s Coroner Court
The case of a boy who died less than two months after a now-suspended Cambridge surgeon operated on him has been referred to a coroner, as a review found “evidence that fatal physical harm was caused”.
Jack Moate, aged nine, was operated on by Kuldeep Stohr, an orthopaedic consultant who specialised in children, at Addenbrooke’s Hospital in Cambridge on September 28, 2015.
Jack, who had several complex medical needs and limited mobility, spent almost eight hours in surgery for an operation on his hips.
He died on November 21, 2015, with his mother saying he was “in agony” and his care has since been reviewed as part of a wider exercise. A letter from Cambridge University Hospitals NHS Foundation Trust (CUH) to Jack’s mother, Elizabeth Moate, seen by the Press Association, says that an independent clinical expert who reviewed Jack’s care found “there was evidence that fatal physical harm was caused”.
The letter, dated February 2 of this year, said: “In the NHS, fatal harm means at the time of reporting, the patient, in this case Jack, has died and the incident may have contributed to the death.”
It added: “We have reported Jack’s case to the coroner”, who would be in contact with Ms Moate “to discuss next steps”. The expert also found that “the care provided was not in line with the standards we expect”.
Dr Sue Broster, chief medical officer at CUH, said in a statement: “On behalf of the trust, I offer my unreserved apologies for the failings in Jack’s care.” Jack’s case was examined as part of a broader external clinical review commissioned by the trust last year into Ms Stohr’s practice following concerns about care that was “below the expected standard”.
Last March, the trust said that the care of “almost 700 patients who have undergone planned surgical procedures” would be reviewed. Concerns were raised as early as 2015 and were the subject of an external clinical review in 2016.
A separate independent review, which reported back last year, highlighted how the 2016 review raised concerns about Ms Stohr’s surgical technique and judgment but it was “misunderstood” and opportunities to act on the findings were “missed”.
Jack’s mother, who lives in Cambridgeshire, said her son had epilepsy and was largely wheelchair bound, although he could sit independently and unaided on the floor without any back support, and was able to stand in a standing frame and use a walking machine.
He had regular physiotherapy, which sometimes caused pain, but he mainly coped well with his many life-limiting conditions. He was also able to understand commands and communicate using facial expressions and noises.
Ms Moate said she was concerned about him undergoing surgery due to his complex conditions and as he was highly susceptible to infections. Jack suffered “significant blood loss” in a procedure which ultimately left his right hip wrongly aligned and his left hip unstable and unhealed. Ms Moate added: “I’ll never be able to forgive the hospital for what happened.
“They sent my boy home and he died in agony. I said I didn’t want him to have surgeries on both hips at the same time.
“I’d have much rather him had one operation at a time. I felt pressured into signing the consent form.”
She said she wanted “answers and justice for Jack”.
His cause of death was recorded at the time as deep vein thrombosis, cerebral palsy alongside epilepsy.
Solicitor Elizabeth Maliakal, of Hudgell Solicitors, who represents Ms Moate, said Jack’s death “pre-dates all investigations and reviews carried out into Ms Stohr’s practice”.
“Had it been properly and fully investigated at the time, action to address her shortcomings could have been taken then, and we may well not be where we are now, with more than 700 cases being reviewed,” she said.
She has called for a statutory inquiry. Ms Maliakal added: “There is a wider pressing hospital patient safety issue to be addressed around the management and governance of specialist surgeons. We want a meeting with (Health Secretary) Wes Streeting as a matter of urgency.”
Dr Broster said: “Our thoughts remain with his family, and we are doing everything we can to support them at this extremely difficult time.
“We have passed all details of his care at the trust to the coroner to investigate the cause of Jack’s death and will continue to provide full assistance to them.
“The external retrospective clinical review, led by Andrew Kennedy KC, into the cases of patients who received care by Kuldeep Stohr remains ongoing and we continue to focus on supporting all patients and families affected.
“We will publish a summary of the review findings once all cases have been reviewed and discussed with those affected, and remain committed to implementing improvements to our services to ensure that cases like Jack’s cannot happen again.”
Ms Stohr was removed from clinical practice in 2024 and subsequently suspended. She remains suspended.
The clinical review process is anticipated to reach completion this summer, with the trust scheduled to release its findings and any recommendations.
