Indy Mason-Kidd
6 Jul 2026 · Coroner Darren Stewart · Suffolk
The coroner's concerns
1. failure to record vascular lesion findings and implement follow-up plan
“The failure by Royal Surrey County Hospital and Addenbrookes Hospital to; a. record in [the deceased]'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”
2. confusion and misunderstanding about scan focus
“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”
3. failure to consider important note in electronic records
“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”
4. inadequate patient information handover
“How patient information was provided, both in terms of the level of detail and manner of provision as part of the handover of [the deceased]'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”
5. lack of full clinical record access across trusts
“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”
6. inability to locate patients in dense residential areas
“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”
7. persistent ambulance response delays
“The persistent delays in relation to EEAST meeting target response timings across all categories of calls. In [the deceased]'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”