The death of a nine-year-old boy weeks after he was operated on by surgeon who has since been suspended has been referred to a coroner.
Jack Moate had surgery by Kuldeep Stohr, an orthopaedic consultant who specialises in children, at Addenbrooke’s Hospital in Cambridge in September 2015, but a review has found « evidence that fatal physical harm was caused ».
Jack died almost eight weeks later, with his mother saying her son was « in agony » and his care has since been reviewed as part of a wider exercise.
Dr Sue Broster, from Cambridge University Hospitals NHS Foundation Trust (CUH) , said in a statement: « On behalf of the trust, I offer my unreserved apologies for the failings in Jack’s care. »
Jack, who had many complex medical needs and limited mobility, spent almost eight hours having surgery on his hips.
A letter from CUH to Jack’s mother, Elizabeth Moate, seen by the Press Association, states an independent clinical expert who reviewed Jack’s care found « there was evidence that fatal physical harm was caused ».
The letter, written in February, 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 also said it had reported Jack’s case to the coroner who would be in contact with his family.
Jack’s case was looked at as part of a wider external clinical review involving almost 700 patients.
It was commissioned by the trust last year into the practice of Stohr amid concerns about care « below the expected standard ».
Concerns were raised as early as 2015 and examined in an external clinical review in 2016.
A separate independent review, published last year, highlighted how the 2016 review raised concerns about Stohr’s surgical technique and judgement 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 needed to use a wheelchair, although he could sit independently and unaided on the floor and was able to use a standing frame and walking machine.
Moate said she was concerned about the surgery due to his complex conditions and as he was highly susceptible to infections – and now wanted « answers and justice for Jack ».
The youngster suffered « significant blood loss » in a procedure which ultimately left his right hip wrongly aligned and his left hip unstable and unhealed.
Moate said: « 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 he had one operation at a time.
« I felt pressured into signing the consent form. »
Jack’s cause of death was recorded at the time as deep vein thrombosis, cerebral palsy alongside epilepsy.
Solicitor Elizabeth Maliakal, of Hudgell Solicitors, who represents Moate, said Jack’s death « pre-dates all investigations and reviews carried out into Ms Stohr’s practice ».
She has called for a statutory inquiry and said she wanted to meet Health Secretary Wes Streeting to discuss hospital patient safety issues.
Broster, CUH’s chief medical officer, said it was supporting Jack’s family and an external retrospective clinical review was ongoing.
« 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, » she said.
« 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 cases like Jack’s cannot happen again. »
Stohr was removed from clinical practice in 2024 and subsequently suspended.
She remains suspended.
It is expected that the clinical review process will conclude this summer, with the trust set to publish findings and any recommendations.
The BBC has approached her solicitor for a statement about the development.
Stohr has previously said: « I always strive to provide the highest standards of care to all my patients.
« I am cooperating fully with the trust investigation, and it would not be appropriate to comment further at this time. »
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