Coroner calls for change after Ipswich student's death

Indy Mason-Kidd was living in Ipswich and studying at the University of Suffolk at the time of his sudden death in 2023.

The 24-year-old had a kidney transplant in 2020 and underwent biopsies in the intervening years, his inquest was told in June.

In 2021, Mr Mason-Kidd attended A&E in Surrey while visiting family and a vascular lesion was found on his “native” kidney.

However, Addenrbooke’s Hospital, under whose care he remained, mistakenly thought the lesion was on Mr Mason-Kidd’s transplanted kidney.

When their own scan did not identify the lesion, they cancelled the CT scan recommended by Surrey.

(Image: PA)

Indy Mason-Kidd was a photography student at the University of Suffolk. (Image: Family of Indy Mason-Kidd)

Two years went by, until Mr Mason-Kidd called 999 in October 2023 saying he was light-headed and concerned his body was rejecting his transplanted kidney.

An ambulance was delayed getting him to hospital, arriving after 53 minutes, three times the target of 18 minutes.

Mr Mason-Kidd died hours arriving at Ipswich Hospital. His cause of death was given as either an arteriovenous fistula or a pseudoaneurysm in his kidney, which would have led to extensive bleeding before cardiac arrest.

Indy Mason-Kidd's family described him as a man of 'incredible determination and grit'. (Image: Family of Indy Mason-Kidd)

The presiding coroner Darren Stewart OBE has written to the chief executives of Cambridge University Hospital, Ashford Hospital and St Peter’s Hospitals in Surrey, the chief of NHS England and the head of the East of England Ambulance Service.

In his report, Mr Stewart criticised poor record-keeping and communications between the hospitals, and the severely delayed ambulance arrival.

“The evidence before the court is that such delays are chronic, with few effective measures capable of addressing the problem,” Mr Stewart wrote.

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."

A Cambridge University Hospital 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.”

Bill Jewsbury, Medical Director at Royal Surrey NHS Foundation Trust 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.”