Maria Repanos of Hudgell Solicitors, representing Amy and her mother, said: “The findings of the review into Amy’s case are deeply concerning and highlight extremely serious shortcomings.

“A wide-scale public health matter of such gravity requires the full public scrutiny at a statutory inquiry.”

A DOH spokesperson said: “Our sympathies are with Amy and all families affected by this deeply distressing situation”

They said the Verita report, external had already made “several recommendations”, adding: “We expect the trust to deliver every recommendation and provide strong support for families. Independent bodies will oversee this to ensure lessons are learned and that this can never happen again.”

The DOH said a further independent clinical review should report next year and that NHS England was reviewing governance around high-complexity, low-volume orthopaedic and spinal surgery services.

Ms Stohr, through her lawyers, did not respond to the BBC’s questions about Amy’s case, but had 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.”

CUH said patients and families concerned about their care could call a freephone helpline on 0808 175 6331.