Jack Moate was operated on by Kuldeep Stohr at Addenbrooke's Hospital in Cambridge on September 28, 2015, and died on November 21, 2015, less than two months after the procedure. An independent clinical expert reviewed Jack Moate's care and found evidence that fatal physical harm was caused, and the expert also determined that the care provided was not in line with the standards expected. According to Cambridge University Hospitals NHS Foundation Trust, fatal harm in the NHS means the patient has died and the incident may have contributed to the death. The specific surgical errors or actions by Kuldeep Stohr that contributed to Jack Moate's death have not been publicly detailed, and the current status of the coroner's investigation into his death remains unclear.
Kuldeep Stohr is a now-suspended orthopaedic consultant who specializes in children. Jack Moate had many complex medical needs and limited mobility, and spent almost eight hours in surgery for the operation on his hips. The disciplinary actions taken against Kuldeep Stohr, and whether she is still suspended, have not been confirmed by authorities.
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.
The Cambridge University Hospitals NHS Foundation Trust reported Jack Moate's case to the coroner. Dr Sue Broster, chief medical officer at Cambridge University Hospitals NHS Foundation Trust, offered unreserved apologies for the failings in Jack's care on behalf of the trust.
Jack Moate's case was reviewed as part of a wider external clinical review commissioned by CUH last year into the practice of Kuldeep Stohr amid concerns about care that was below the expected standard. CUH said last March that the care of almost 700 patients who have undergone planned surgical procedures would be reviewed. Concerns about Kuldeep Stohr's practice were raised as early as 2015 and were the subject of an external clinical review in 2016. The outcomes of the wider review of almost 700 patients, and how many other cases involved harm, have not been disclosed.
On behalf of the trust, I offer my unreserved apologies for the failings in Jack’s care.
A separate independent review, which reported back last year, highlighted how the 2016 review raised concerns about Kuldeep Stohr's surgical technique and judgment but it was misunderstood and opportunities to act on the findings were missed. The steps Cambridge University Hospitals NHS Foundation Trust has taken to address the systemic failures identified in the reviews are not fully known.
Jack Moate's mother, Elizabeth Moate, said he was in agony after the operation.