NHS Surgeon's Suspension After Boy's Death Reveals Systemic Failures
A nine-year-old boy who died less than two months after undergoing surgery by an NHS surgeon now suspended was subjected to fatal physical harm, according to a damning review. Jack Moate, who had complex medical needs, passed away on November 21, 2015, following an operation at Addenbrooke's Hospital in Cambridge.
Surgery and Subsequent Tragedy
Jack Moate was operated on by Kuldeep Stohr, an orthopaedic consultant specialising in children, on September 28, 2015. The procedure, which lasted almost eight hours, aimed to address issues with his hips. Jack's mother, Elizabeth Moate, has stated that her son was in agony after the surgery and that she felt pressured into signing the consent form.
An independent clinical expert reviewed Jack's care and concluded that there was evidence of fatal physical harm. In NHS terminology, this means the incident may have contributed to the patient's death. The case has now been referred to the coroner for further investigation.
Systemic Oversights and Delayed Action
Concerns about Ms Stohr's surgical practice were raised as early as 2015, leading to an external clinical review in 2016. However, a separate investigation reported last year highlighted that the 2016 review's findings were misunderstood, and opportunities to act were missed. This allowed Ms Stohr to continue operating unimpeded for years.
Her shortcomings only came to light in 2024 after she took sick leave, prompting two colleagues to review her caseload and raise alarms. As a result, Ms Stohr was removed from clinical practice and remains suspended. A wider review of approximately 700 patients who underwent planned surgical procedures under her care is currently underway.
Mother's Anguish and Call for Justice
Elizabeth Moate, Jack's mother, expressed profound grief and frustration. She recalled her initial concerns about the surgery due to Jack's susceptibility to infections and complex conditions. The operation resulted in significant blood loss, misaligned hips, and instability.
I'll never be able to forgive the hospital for what happened. They sent my boy home and he died in agony, Ms Moate said. She emphasised feeling pressured to consent to simultaneous hip surgeries, preferring a staggered approach. Her solicitor, Elizabeth Maliakal, has called for a statutory inquiry, arguing that earlier investigation could have prevented further cases.
Hospital Response and Ongoing Reviews
Dr Sue Broster, chief medical officer at Cambridge University Hospitals NHS Foundation Trust, offered an unreserved apology for the failings in Jack's care. The trust is cooperating fully with the coroner and supporting affected families.
The external retrospective clinical review, led by Andrew Kennedy KC, is ongoing and expected to conclude this summer. The trust has committed to publishing findings and implementing improvements to prevent similar tragedies. Jack's cause of death was initially recorded as deep vein thrombosis, cerebral palsy, and epilepsy, but the review suggests surgical complications played a role.
