A mother has shared the distressing story of her nine-year-old son’s painful death following a surgical procedure at an NHS hospital. Jack Moate underwent surgery performed by orthopaedic consultant Kuldeep Stohr at Addenbrooke’s Hospital in Cambridge on September 28, 2015. Tragically, Jack passed away less than two months later due to complications arising from the operation, including significant blood loss, misalignment of his right hip, and instability in his left hip.
Following a review of Ms. Stohr’s practices that revealed evidence of fatal harm, Jack’s case has been referred to a coroner almost a decade after his untimely death. Despite having multiple complex medical needs and limited mobility, Jack had been recommended for the surgery to address his hip issues. His cause of death was initially attributed to deep vein thrombosis, cerebral palsy, and epilepsy.
A letter from the Cambridge University Hospitals NHS Foundation Trust to Jack’s mother acknowledged the evidence of fatal harm in his case, prompting the coroner’s involvement. The independent clinical expert who assessed Jack’s care found that the provided treatment did not meet expected standards.
The review of Jack’s case was part of a broader investigation initiated by the trust into Ms. Stohr’s practices due to concerns about substandard care. The trust committed to reviewing the care of nearly 700 patients who underwent planned surgeries, following earlier reviews in 2015 and 2016 that highlighted issues with surgical techniques and decision-making.
Despite being wheelchair-bound and coping with various medical challenges, Jack was able to communicate effectively through facial expressions and sounds. His mother expressed regret over the decision to proceed with the surgery on both hips simultaneously, feeling pressured to consent to the procedure.
Elizabeth Maliakal, representing Jack’s mother, emphasized the need for a thorough inquiry into the circumstances surrounding Jack’s death, citing missed opportunities to address Ms. Stohr’s deficiencies earlier. The solicitor called for urgent action to address broader patient safety concerns regarding the oversight of specialist surgeons in hospitals.
Acknowledging the failures in Jack’s care, Dr. Sue Broster, the chief medical officer at CUH, issued a formal apology and assured support for the family during this challenging period. The trust has cooperated with the coroner’s investigation into Jack’s case and pledged to implement improvements based on the clinical review findings.
Ms. Stohr was removed from clinical practice in 2024 and remains suspended pending the completion of the ongoing clinical review process. The trust aims to release the review outcomes and any recommendations by the end of the summer.
