Indy Mason-Kidd

Dear Mr Stewart, Re: Regulation 28 Report to Prevent Future Deaths – Indy Storm Mason Kidd who died on 21st October 2023. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6th July 2026 concerning the death of Indy Storm Mason-Kidd on 21st October 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Indy’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Indy’s care have been listened to and reflected upon. Your Report raises the following concerns:
1. Issues with NHS trusts being able to access records from other NHS trusts involved with the care of a patient and access information such as scan results.
2. The ability of ambulance services to identify the precise location of a patient more accurately through the use of location identifier systems.
1. Accessibility of patient records by other NHS Trusts NHS England recognises that limited information-sharing between care settings can contribute to less effective continuity of care, particularly when patients are receiving care from a number of different Hospital trusts in England. NHS England (Frontline Digitalisation) has reviewed the electronic patient record (EPR) position relating to East Suffolk and North East Essex NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Ashford and St Peter's Hospitals NHS Foundation Trust and Royal Surrey County Hospital NHS Foundation Trusts. This is outlined below. East Suffolk and North East Essex NHS Foundation Trust As part of the Frontline Digitisation (FD) Programme, the Trust was assessed against the Digital Capability Framework (DCF) and identified as not meeting the Programme’s core Electronic Patient Record (EPR) standards at that time. Through the FD

[Page 2] Programme, the Trust secured funding to support the implementation of the Epic EPR system, which went live in October 2025. This implementation consolidated a number of legacy systems into a single integrated platform across Ipswich Hospital, Colchester Hospital and five community hospitals. Cambridge University Hospitals NHS Foundation Trust (including Addenbrooke’s Hospital) As part of the FD Programme, the Trust was assessed as meeting the Programme’s core EPR standards against the DCF. The Trust self-funded the implementation of its Epic EPR system, which was deployed in 2014. The Trust received funding through the Global Digital Exemplar (GDE) Programme, the predecessor to the Frontline Digitalisation Programme, to support ongoing optimisation of its digital capabilities. Subsequently, the Trust achieved a high level of digital maturity and was awarded HIMSS EMRAM Stage 7 accreditation in October 2020. Ashford and St Peter’s Hospitals NHS Foundation Trust and Royal Surrey County Hospital NHS Foundation Trust Ashford and St Peter’s Hospitals NHS Foundation Trust and Royal Surrey County Hospital NHS Foundation Trust use the Oracle Health Millennium (formerly Cerner Millennium) EPR system, implemented through the Surrey Safe Care Programme in May 2022. As part of the FD Programme, both organisations were assessed against the DCF and identified as not fully meeting the Programme’s core EPR standards. Consequently, funding was secured through the FD Programme to support further optimisation and enhancement of the EPR environment. It should be noted that The National Care Record Service (NCRS) National Care Records Service - NHS England Digital provides access to a patients’ Summary Care Records (SCR). The SCR is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines. It is important to remember that information in the SCR is sourced from the patient’s GP record only. If information was not passed to the patient’s GP, it cannot form a part of the patient’s SCR. Furthermore, the structure of the SCR message with regards to ‘Additional Information’ is that it is intended to include a clinical code, associated text and an associated date. The structure of the SCR message is not intended to include the full detail of an ultrasound scan report (which commonly will be 2 or 3 paragraphs in length). Whenever a GP record is updated, the changes are synchronised to SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient's direct care but do not need access to the patient's full record. As such, the SCR is intended to provide a summary of the patient’s GP record, including key information most likely to be of benefit to patients during an unscheduled care encounter.

[Page 3] Further information regarding SCR is available here: Summary Care Record - NHS Digital As a minimum, the SCR contains important information about:
• current medication
• allergies and details of any previous reactions to medicines
• the name, address, date of birth and NHS number of the patient In addition, details of long-term conditions, significant medical history, or specific communications needs, is now included by default for patients with an SCR, unless they have previously told the NHS that they did not want this information to be shared;
• Additional Information in the SCR (Additional Information in SCR - NHS England Digital) includes the active problems and significant past problems as recorded by their registered GP practice.
• significant medical history (past and present)
• reason for medication
• anticipatory care information (such as information about the management of long-term conditions)
• end of life care information (from the national dataset)
• immunisations Radiology images (Xray’s, ultrasound examinations, MRIs and CT scan can be shared between hospitals and we have been provided with further information from the Picture Archive Communication System (PACS) project team. The three trusts that were involved in the care of Indy were Ashford and St Peters Hospitals NHS Trust, Royal Surrey County Hospital NHS Trust and Cambridge University Hospitals NHS Trust. Of these organisations, Ashford and Royal Surrey are within the same Imaging Network (Frimley Surrey and Sussex, within the South East NHS Region) and one would expect them to regularly share images and reports as part of normal patient workflow. They have the same PACS vendor (Sectra) and technically they have been in a position to undertake Cross Site sharing of images and reports and Cross Site reporting since August 2025. It is not clear from the information available whether this took place or not in the care of this patient. Indy was also treated at Addenbrookes Hospital which is a site within the Cambridge University Hospitals NHS Trust and is geographically remote from the trusts within the Frimley Surrey and Sussex Imaging Network. It is possible that there is an existing referral pathway for certain patients and conditions. However, because these trusts are not in the same Imaging Network and therefore would not be routinely expecting to collaborate on patient care (specifically working towards Cross Site Reporting) another mechanism would be required in order to share the records of a patient. In the

[Page 4] early days of electronic records this would include the use of portable media such as a DVD and more recently during the last 15 or so years the use of the Image Exchange Portal (IEP) Sectra Image Exchange Portal | Sectra Medical, may be used to facilitate transfer of images. Further investigation would be required to establish if IEP was used to transfer any images or reports between these hospital trusts. The National Imaging Registry (NIR) National Imaging Registry (NIR) - NHS England Digital is a strategic digital service developed as part of NHS England’s Diagnostics Digital Capability (DDC) Programme. It provides a standards-based national infrastructure that enables interoperable access to diagnostic imaging and reports across NHS and approved independent sector organisations. NIR enables and supports healthcare providers and clinical systems in accessing prior imaging, supporting safer clinical decision-making, reducing unnecessary repeat scans, and improving coordination of care across pathways and organisations. When the NIR is fully deployed this will enable the sharing of imaging scans and results using the Application Platform National Imaging Registry API - NHS England Digital NHS England and DHSC have published Fit for the Future: 10 Year Health Plan for England, which sets out the government’s plan for healthcare in England over the next decade. The Plan includes a commitment to give patients ‘a single, secure and authoritative account of their data – a single patient record’ to support more coordinated, personalised and predictive care. We note you have directed your Report to the trusts involved who would be better placed to comment on the specific content and details of the medical records held in each trust. NHS England is unable to comment with regards to the specific details of the content of the hospital medical records.
2. Ambulance ability to identify the patient’s precise location 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. The specific technologies and operational processes used to support patient location, including ‘What3Words’, are determined locally by individual ambulance services. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. 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.

[Page 5] Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear HM Coroner, Re: Regulation 28 Report to Prevent Future Deaths- Mr Indy Storm Mason-Kidd who died on 21 October 2023 Thank you for your Report to Prevent Future Deaths dated 06 July 2026 concerning the death of Mr Indy Storm Mason-Kidd on 21 October 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Indy’s parents and family. Cambridge University Hospitals NHS Foundation Trust (‘the Trust’) are keen to assure the family and the Coroner that the concerns raised about Indy’s care have been listened to and reflected upon. We have considered your concerns and set out our formal response to each matter using your numbering as follows. Matters of Concern Failure to 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; I understand that the discussion between the two Trusts was recorded within the ‘Telephone Encounter’ section of Indy’s medical records. It is recorded that there was agreement between the two Trusts that there was agreement that a CT scan would be arranged locally, however there appears to have been a miscommunication as to the Trust responsible for following this up. The above has been relayed to clinicians responsible for taking phone calls from referring hospitals and the importance of confirming responsibilities in communication. Visit ou r website

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[Page 2] 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; Please see above. 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. At the time of Indy’s care, clinicians using Epic could access information through a number of different views and encounter records. I understand that the clinician who reviewed Indy on 22 June 2021 accessed a specific patient encounter and, as a result, did not identify the earlier telephone encounter documenting the discussion with Royal Surrey County Hospital. Since that time, the Trust has introduced and reinforced a number of measures to improve the visibility of clinically significant information:
1. Reinforcement of use of the Problem List Clinicians have been reminded of the importance of using the Epic Problem List to record significant issues and agreed management plans. The Problem List is one of the most visible sections of the electronic patient record and appears when a patient chart is opened. The importance of reviewing all relevant entries within the patient record before outpatient appointments has also been reinforced within the team.
2. Redesign of outpatient summary reports In 2025, the Trust redesigned its outpatient summary reports so that clinicians are presented with a consolidated view of previous notes from the relevant specialty when opening a patient record. Following consideration of the issues identified in this case, the summary view has now been expanded to include telephone encounter notes from the same specialty across all patient encounters. This means that, were the same circumstances to arise today, the relevant telephone encounter would be visible within the clinician's summary view.
3. Introduction of an outpatient note summary tool The Trust is progressing implementation of an AI-supported outpatient note-summary tool. This tool will provide clinicians with a summary of relevant clinical information from the preceding three years, including telephone consultation notes, helping to improve the visibility of important historical information. Testing has been completed and further customisation is being undertaken before implementation.

[Page 3]
4. Ongoing digital training and professional development The Trust is introducing an annual Digital Continuing Professional Development requirement for staff. This will support clinicians in maintaining knowledge of digital systems and their optimal use, with compliance reviewed through the appraisal process. 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 I understand that because the clinician reviewing Indy on 22 June 2021 did not identify the earlier telephone encounter, the subsequent correspondence to Ipswich Hospital did not include reference to the discussion that had taken place with Royal Surrey County Hospital in May 2021. Had that information been identified, it would have been included within the clinical correspondence sent to Ipswich Hospital. The Trust recognises the importance of ensuring that significant clinical information is readily identifiable and therefore incorporated into correspondence shared with other organisations. The improvements outlined above, particularly the enhanced outpatient summary view, inclusion of telephone encounter notes within specialty summaries, reinforcement of Problem List usage, and development of the outpatient note-summary tool, are intended to improve clinicians' access to relevant historical information when reviewing patients and preparing clinical correspondence. While NHS organisations continue to operate different electronic record systems, the Trust believes these changes significantly reduce the risk of important historical information not being identified and subsequently communicated to receiving organisations. Our teams have reflected deeply on Indy’s experience and the findings of the Coroner as evidence by the changes and improvements set out above. We hope that these actions will assure the Court that we are committed to ongoing learning and improvement from this tragic case. If I can assist further with these matters, please do not hesitate to contact me.

[Page 1] REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance publication policy PDF. THIS RESPONSE IS BEING SENT TO: HM Area Coroner, Darren Stewart OBE for the Coroner Area Suffolk in response REPORT TO PREVENT FUTURE DEATH REGULATION 28 investigation into the death of Indy Storm Mason-Kidd, and an inquest that concluded on 19 June 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, (Chief Executive, East of England Ambulance Service NHS Trust) provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE 25 August 2026
3. The MATTERS OF CONCERN were identified in the report are as follows: East of England Ambulance Service NHS Trust (EEAST) The persistent delays in relation to EEAST meeting target response timings 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.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here. If you feel that the response should not have been sent to you, please state this]. Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The persistent delays in relation to EEAST meeting target response

[Page 2] 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.
1. The court was previously provided with the EEAST Action Plan Feb 2025-26 (Appendix A) and this response should be read in conjunction with this action plan to demonstrate the progress made to date.
2. EEAST Action Plan April 2026-27 is the latest action plan EEAST is working towards in respect of managing delays and will be reviewed in early 2027 to establish what further action is required.
3. For clarity, Category 2 coded calls are for patients whose condition is potentially serious and require rapid assessment, urgent on scene intervention or urgent transport to hospital. We aim to respond to nine out of ten patients with the appropriate emergency resource within 40 minutes and with an average time of 18 minutes. A&E Operations
4. Operational Productivity is measured and monitored by EEAST both internally and externally. It is managed through the Productivity forums, local performance cells, the Trust Performance Board and the Change Portfolio Board. Reports on compliance are also shared with the Trust Board sub-committees and through external meetings.
- Improve Category 1 mean performance to a 7 minute response time
5. EEAST remains focused on prioritising emergency responses for the most critically unwell patients. Performance against the Category 1 (C1) mean response time has improved with April 2026 recording an average of 8 minutes 4 seconds. This represents a 5-second improvement in March 2026 and a 41-second improvement compared with February
2026. This continues to be a key priority and is subject to regular oversight.
- Improve Category 2 mean performance response times to 31 minutes and 15 seconds
6. operational activity. Performance has shown improvement, with the average C2 response time in April recorded at 27 minutes 21 seconds. This reflects an improvement of nearly one minute compared with March 2026, and a more substantial improvement of almost ten minutes when compared with February 2026. This continues to be a key priority and is

[Page 3] subject to regular oversight.
- Reduce the number of patients conveyed to hospital to 62%
7. Performance against this measure remains consistent with expected operational practice, reflecting a greater emphasis on thorough on-scene assessment and the appropriate use of alternative care pathways. The overall conveyance rate for April 2026 achieved the 62% target, at
59.36%.
- Reduce the average on scene time for patients that are not conveyed to hospital to 70 minutes
8. For non-conveyed patients, the average on-scene time in April 2026 was recorded at 1 hour 8 minutes 6 seconds, continuing to remain within target.
- Reduce the average on scene times for patients that are conveyed to hospital to 42 minutes
9. For conveyed patients, the average on-scene time remained consistent with previous months but continued to exceed the target, which in April 2026 was recorded at 44 minutes 45 seconds.
- Aim to achieve an arrival to handover at A&E time of 30 minutes
10. Average Arrival to Handover (A2H) time showed improvement in April 2026, meeting the target at 29 minutes 58 seconds.
- Aim to achieve a handover to clear time of 15 minutes
11. Handover to Clear performance remained within the 15-minute target for April 2026, recorded at 12 minutes 10 seconds which is consistent with previous months.
- Reduce the out of service shift hours to less than 6%
12. EEAST continues to report Out of Service (OOS) performance using both measures that include and exclude cohorting. Cohorting is an operational approach whereby a double-crewed ambulance awaiting handover at a hospital assumes responsibility for an additional patient. This enables the other ambulance crew to become available more

[Page 4] quickly and respond to further 999 calls, thereby improving resource utilisation and operational capacity.
13. This approach recognises that cohorting is a system-level intervention distinction between internal performance and wider system pressures. Overall, OOS performance improved to 4.91% in April 2026, achieving the 6% target. When cohorting is excluded, OOS performance further improves to 4.14%. Telephone triage via Clinical Assessment Service (CAS)
14. The Unscheduled Care Co-ordination Hubs (UCCH) have all been successfully implemented across EEAST, these allow clinicians to access alternative pathways or clinical support other than attendance at an Emergency Department. EEAST monitor the Hear and Treat metric on a monthly basis, which is showing an increasing trajectory.
15. Calls are now passed via technology links to our 111 providers in 5 out of the 6 areas of the region.
16. In terms of the number of Category 2 calls receiving a clinical call back, this was 62,000 over the last year. EEAST has recently implemented a larger nationally approved code set of C2 calls that can be navigated, which means a further clinical assessment before the correct pathway is confirmed.
17. The number of calls being passed to other healthcare providers via Access to the Stack has also been increasing with an acceptance rate increase compared to last year.
18. There is an improving trend of Hear & Treat across the region and EEAST is managing more patients than ever in this manner, circa 1000 patients more each week compared to last year.
19. The number of Clinical Assessment Service clinicians has increased and the current establishment is 112 WTE work force effective of the anticipated148 WTE in post. The addition of these clinicians to the team will continue to support the work outlined above. Community Response
20. EEAST has continued to increase our ongoing recruitment of volunteers within the community response and blue light collaboration portfolio. This includes the development of the Emergency Responder scheme with our Basics partners in Norfolk and Beds and Herts, our Emergency Responder partnership with St John in Norfolk along with the increased development of our fire service relationships across the region to

[Page 5] develop the response model. Our Community First Responder recruitment has continued and will continue to support the development of the existing CFR groups, the locality cars with appropriate plans for sustainability of volunteers. The hours provided by the Community Response and Blue light teams has continued to consistently deliver a level of hours around 20,000 per month. Urgent Care EEAST has twelve teams of Advanced Clinical Paramedics and Advanced Paramedics across the Trust targeted to suitable low acuity calls with the aim of safe and effective admission avoidance. They're coordinated by the EOC-based Urgent Care Desk (UCD). Patient Safety
21. EEAST are committed to engage with system partners to effectively review delay incidents across the region. The patient safety team reporting system, Datix.
22. Any delay which is deemed to have harmed a patient will be discussed at Those meeting the moderate, severe or fatal harm are reviewed by the patient safety team, this includes a Duty of Candour (DOC) call with the patient or family involved and ensures our statutory obligations in terms of Duty of Candour are completed in full.
23. Throughout the 2025/26 financial year, the Head of Patient Safety and patient safety lead from the Suffolk and North East Essex Integrated Care Board (SNEE ICB this wa at the time) conducted a trial to improve the review of system delays. With delays being multifactorial, our aim was to better include the acute hospitals or community services involved in the delay to ensure we were not reviewing incidents in isolation.
24. Due to ICB reconfiguration the reviews of delays that are deemed to have caused harm to patients are now reported directly to the acute hospitals involved, this is completed by the EEAST patient safety team. Patients and families are made aware of the report we make to the acute hospitals so that they are aware the acute hospital trust may well be in contact directly with them during their external review processes.
25. number of delays discussed at the IRP regardless of the harm decision made by IRP, this is to demonstrate that delays are not an issue during months we do not report any delays that have caused moderate or above harm. This continues to be monitored with the current lead Norfolk and Suffolk ICB.

[Page 6] Summary
26. Category 2 performance remains heavily influenced by system-wide demand, with pressures across the urgent and emergency care pathway having a direct effect on operational delivery. Recognising this, we have developed more comprehensive and resilient seasonal plans for both winter and summer, designed to improve demand management, enhance system responsiveness and maintain the positive trajectory of performance improvements achieved at the start of the financial year.
5. DETAILS OF FURTHER ACTION PROPOSED Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. HM Coroner also identified a further concern during the inquest, which was addressed to NHS England: 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 In order to assist with this, EEAST is writing to all university campuses in the region to provide advice to students on how to call 999 and, specifically, the best method of providing their location and address.
6. SIGNATURE

[Page 1] REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance with the Chief Coroner’s publication policy PDF. THIS RESPONSE IS BEING SENT TO: HM Area Coroner, Darren Stewart OBE for the Coroner Area Suffolk in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Indy Storm MASON-KIDD, and an inquest that concluded on 19 June 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Medical Director – Royal Surrey NHS Foundation Trust provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE 21.08.2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows:
a. The failure of a clear plan to be recorded in Indy’s notes at either the Royal Surrey County Hospital or Addenbrookes Hospital concerning the follow up of the vascular lesion findings from the ultrasound undertaken at RSCH in May 2021;
b. Adequacy of the notes recorded by both concerning their telephone communications and subsequent plan concerning the care and treatment of Indy;
c. The practice at Addenbrookes Hospital in managing electronic patient clinical records and the failure of to have regard to the important telephone note made by concerning the 27th May 21 telephone communication with
d. Handover between Addenbrookes Hospital and Ipswich Hospital, the extent of the information provided and how it is provided;
e. Lack of access to patient records where multiple trusts involved in the care and treatment of patients are involved, including the sharing of information such as scan results;
f. The ability for EEAST and ambulance services more widely to identify the location of students or others within high density residential locations
g. The delays that were experienced and which are a common occurrence,

[Page 2] in relation to EEAST response to category 2 calls.
4. DETAILS OF ACTION TAKEN, I have reminded all clinicians at the Royal Surrey County Hospital to clearly record any conversation that they have with clinicians at another organisation in the medical record. I have also reminded them that if it is expected that the patients care be continued at another organisation and there are relevant findings from clinical investigations undertaken at the Royal Surrey that this should be included within the discharge summary, provided to the patient and their General Practitioner, including any expectations around follow up and who that follow up should be managed by. If this follow up should be with another secondary care provider, Addenbrookes Hospital in this case, a formal letter should be sent to that organisation transferring the care of the patient and documenting any relevant investigation findings and expected follow up.
5. DETAILS OF FURTHER ACTION PROPOSED
6. SIGNATURE