“A series of missed opportunities” have been revealed by a review of a surgeon who is being investigated over hundreds of surgeries involving children carried at an NHS hospital.

Kuldeep Stohr was suspended by Addenbrooke’s Hospital in Cambridge earlier this year, amid concerns over surgeries that were “below the expected standard”.

A “pivotal missed opportunity” came when the hospital trust failed to act upon recommendations made by an external reviewer into her work in 2016, the report said.

Cambridge University Hospitals NHS Foundation Trust (CUH), which runs Addenbrooke’s, said it accepted “the findings and recommendations” in the report and noted a separate external review was ongoing.

If appropriate actions had been taken, they “would have likely reduced harm to paediatric orthopaedic patients”, the independent investigators concluded.

Radd Seiger, a retired lawyer who represents 25 of the affected families said: “This was not a rogue surgeon — this was a rogue system.”

The investigation was commissioned by CUH and carried out by Verita, which describes itself as an “objective investigations company providing expert advice to regulated organisations in the UK”.

An ongoing, separate review, is looking at about 700 planned and 100 emergency operations involving Ms Stohr, some of which were for adults.

Ms Stohr was suspended by the hospital and has not been at work since March 2024, initially for personal reasons.

In her absence, her patients were seen by other doctors who discovered, a letter to the parents from the hospital said, a “higher than expected level of complications”.

That led to an initial review, which found operations involving nine children fell “below expected standards”.

One of those was Darcey, whose parents previously told the BBC they feared problems with her hip operation, which left her leg rotated inwards “to almost 90 degrees” and in need of further surgery, were “brushed under the rug”.

It emerged that concerns about Ms Stohr dated back as early as 2015 and wider reviews were started into about 800 patient procedures.

The latest report concluded there was “a series of missed opportunities, both major and minor, in how CUH and its leadership addressed concerns” about Ms Stohr’s medical practice and “appropriate actions could have been taken”.

In particular, the report focused on an external review into Ms Stohr’s work written in 2016 by Robert Hill, a senior paediatric orthopaedic surgeon.

The external report had been commissioned after a senior colleague raised concerns about the quality of her work.

Mr Hill’s report identified a series of shortcomings in her surgery and proposed steps to address them.

But he told the current investigators: “I regret to conclude, on the information I have – and I would be happy to be wrong – that the trust failed to draw the correct conclusions from my report, made no effort to check with me that their conclusions were correct and demonstrated little if any insight into the issues confronting them.”

The report said: “As a result, deficiencies in Ms Stohr’s practice persisted for years as her caseload and patient complexity grew.

“It is to the credit of Ms Stohr that she understood the findings of the Hill report and made her own efforts to improve her clinical practice. She did this without the help and support of the trust.”

The report made a series of recommendations including:

• clearer line-management arrangements
• mentoring and buddying arrangements for new consultants
• the creation of reliable records for any future reviews and on how findings and recommendations from external reviews should be shared

Mr Seiger said: “Cambridge University Hospitals knew there were serious concerns about Ms Stohr’s practice as far back as 2016, but failed to act.

“Children were harmed, families were misled, and the trust’s leadership concealed the truth for nearly a decade.”

Restrictions have since been placed on Ms Stohr by the General Medical Council registration, including that she must be “closely supervised in all of her posts by a clinical supervisor”.

Roland Sinker, chief executive of CUH, said the trust was “deeply sorry” for the impact on patients and “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,” he said.

“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.

“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. With the backing of the whole CUH board, we will work tirelessly to deliver our action plan in full to build a safer and more effective organisation.”

The Care Quality Commission has been considering whether to take regulatory action in this case.