The hospital says it is ‘committed to learning from this case.’
A man died after “confusion” between hospitals meant that the wrong kidney was scanned. A prevention of future deaths report found “chronic” delays and hospital mix ups led to “missed” opportunities to effectively treat Indy Mason-Kidd, prior to his death.
Indy, who is remembered by his family as the “kindest, caring and most gentle man”, died at Ipswich Hospital aged 24, due to either a ruptured arteriovenous fistula or pseudoaneurysm in the lower pole of his left kidney, arising from a biopsy procedure performed in June 2019.
Area Coroner for Suffolk Darren Stewert OBE raised concerns about the planning and management of Indy’s care and treatment, including the poor communication between Addenbrooke’s Hospital in Cambridge and Royal Surrey County Hospital in Surrey.
“Several concerns have national implications”, Coroner Stewert said. The report concerns Addenbrooke’s Hospital, Royal Surrey County Hospital, NHS England and East of England Ambulance Service NHS Trust (EEAST). 24-year-old Indy had suffered from Immunoglobulin A nephropathy and associated hypersensitive heart disease which resulted in him receiving a renal transplant in May 2020.
Indy, who had undergone several biopsy procedures prior to his transplant, had one that resulted in an injury to his native left kidney that subsequently developed into a vascular lesion. An ultrasound scan taken at the Royal Surrey County Hospital in May 2021 identified a vascular lesion in the left native kidney.
The coroner said there was a “missed opportunity to effectively treat his condition as no follow up was taken” at the hospital. Indy underwent a further scan at Addenbrooke’s Hospital in June 2021.
The scan did not identify any abnormality because it did not include the native kidneys – which were the ones of concern. The prevention of future death report reads: “The effect of these failures contributed to the subsequent confusion and misunderstanding relating to the scan undertaken at Addenbrooke’s in June 2021 and which focused solely on the transplanted kidney.”
He was then transferred to Ipswich Hospital for medical care. Although a treatment summary was provided at the time by the other hospitals, no mention was made about the vascular lesions identified in the original scan.
Coroner Stewert deemed this represented a “further missed opportunity to effectively deal with the vascular lesions identified through further investigation and treatment”. Indy became unwell and attended Ipswich Hospital’s accident and emergency department on October 20, 2023. At about 1.50am the following day, Indy suffered a catastrophic internal bleeding and collapsed. Attempts were made to resuscitate him but he was pronounced dead just before 3am.
Coroner Stewert has raised a “failure“ by Royal Surrey County Hospital and Addenbrooke’s Hospital to implement and record a plan regarding the follow up of the vascular lesions and the adequacy of its recorded notes by both hospitals.
The Coroner also raised concerns about the management of electronic patient clinical records at Addenbrookes Hospital and how patient information was provided between the Cambridge and Ipswich hospitals. The report adds: “The full patient record was not handed over and a summary letter provided which omitted important information that was available within the Addenbrooke’s Hospital records.”
NHS England has been advised of concerns regarding the lack of access to patient’s full clinical records in circumstances where multiple NHS Trusts are involved and the ambulance services’ ability to identify the location of patients within high density locations. East of England Ambulance Service (EEAST) has also been scrutinised for its “persistent delays” in meeting response timings.
Indy’s emergency phone call was deemed a category two call with an eight-minute target response. However, an ambulance was not dispatched until 53-minutes after the call. The report states: “The evidence before the court is that such delays are chronic, with few effective measures capable of addressing the problem.”
A Cambridge University Hospitals Trust spokesperson said: “We extend our sincere condolences to the family of Indy Mason-Kidd. Patient safety is our highest priority, and we are committed to learning from this case.
“We have carefully reviewed the findings in the Prevention of Future Deaths report and have taken steps to strengthen our systems and processes. Many of the issues identified involve care delivered across multiple organisations, and we will continue to work closely with our NHS partners to improve communication, information sharing and continuity of care for patients.”
An East of England Ambulance Service spokesperson said: “Our thoughts are with Indy Mason-Kidd’s family and loved ones. The Coroner’s report highlights concerns about the ambulance response on the night Indy became seriously unwell.
“At that time, our response times were being significantly affected by pressures across the wider healthcare system, including delays handing over patients at busy emergency departments, which reduced ambulance availability in the community. We recognise the impact this had on patients waiting for our help.
“Improving response times remains a key priority. We continue to work closely with NHS partners to reduce hospital handover delays and improve ambulance availability so that we can reach patients more quickly when they need us most.”
In a response to the concerns, Medical Director at Royal Surrey NHS Foundation Trust Dr Bill Jewsbury, said: “I would like to extend my sincere condolences to Indy’s family and loved ones.
“We have carefully considered the coroner’s findings and recognise the important lessons arising from this case. In response, we have taken steps to strengthen our processes for documentation and information sharing with partner organisations.”
According to NHS England, CUH was assessed as meeting the Programme’s core Electronic Patient Record (EPR) standards against Digital Capability Framework (DCF). However, Ashford and St Peter’s Hospitals NHS Foundation Trust and Royal Surrey County Hospital NHS Foundation Trust were assessed against the DCF and identified as not fully meeting the Programme’s core EPR standards.
Consequently, funding was secured through the Frontline Digitisation (FD) Programme to support further optimisation and enhancement of the EPR environment. In a response to one of the concerns, NHS England said: “Ambulance services should maintain robust processes and technology to accurately identify and locate patients, including within high-density residential settings, ensuring that crews can access patients safely and without avoidable delay.”
All reports to prevent future deaths are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. NHS England said this “ensures that key learnings and insights around events, such as the sad death of Indy, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action”.
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