“Cambridge University Hospitals NHS Foundation Trust and Ashford and St”

The coroner’s concerns

Cambridge University Hospitals NHS Foundation Trust and Ashford and St. Peter’s and Royal Surrey NHS Foundation Trusts The failure by Royal Surrey County Hospital and Addenbrookes Hospital to; a. record in Indy’s medical record and then implement a clear plan concerning the follow up of the vascular lesion findings from the ultrasound undertaken at Royal Surrey County Hospital in May 2021, b. the adequacy of the notes recorded by clinicians from Royal Surrey County Hospital and Addenbrookes Hospital concerning their telephone communications relating to Indy’s presentation at Royal Surrey County Hospital in May 2021. The effect of these failures contributed to the subsequent confusion and misunderstanding relating to the scan undertaken at Addenbrookes in June 2021 and which focused solely on the transplanted kidney. Cambridge University Hospitals NHS Foundation Trust a. The management of electronic patient clinical records at Addenbrookes Hospital. Clinical practice in June 2021 led to a failure by the treating clinician to have regard to an important note made by another clinician concerning the 27th May 2021 telephone communication with a Royal Surrey County Hospital clinician. b. How patient information was provided, both in terms of the level of detail and manner of provision as part of the handover of Indy’s care and treatment between Addenbrookes Hospital and Ipswich Hospital. The full patient record was not handed over and a summary letter provided which omitted important information that was available within the Addenbrookes Hospital records. NHS England a. Lack of access to a patient’s full clinical record in circumstances where multiple NHS Trusts are involved in the care and treatment of patients, including the sharing of information such as scan results. b. The ability of NHS Ambulance Services to identify the location of patients within high density residential locations. This includes the effectiveness of call handler scripts used by NHS Ambulance Services, whether this be NHS Pathways or MPDS to provide precise locations and whether the incorporation of systems such as ‘what three words’ may afford greater accuracy. East of England Ambulance Service NHS Trust (EEAST) a. The persistent delays in relation to EEAST meeting target response timings across all categories of calls. In Indy’s case his call was categorised as a category 2 call with a target of an 8-minute response. In fact, an ambulance was not dispatched until 53 minutes after the call, some three times the target response time. The evidence before the Court is that such delays are chronic, with few effective measures capable of addressing the problem. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: The Family of Indy Storm Mason-Kidd. East Suffolk and North East Essex NHS Foundation Trust. I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Darren STEWART OBE HM Area Coroner for Suffolk

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0352

Added to Minute Book

7 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0