Indy Mason-Kidd

DATE OF REPORT 06 July 2026

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

On 05 August 2024 I commenced an investigation into the death of Indy Storm MASON-KIDD aged 24. The investigation concluded at the end of the inquest on 19 June 2026. The conclusion of the inquest was that: Narrative Conclusion – Indy Storm MASON-KIDD is remembered by his Family as the kindest, caring and most gentle man. A person with incredible determination and grit, someone who experienced and tolerated great physical and mental pain yet maintained a positive outlook on life. It is clear that Indy was a significantly positive force touching a great many people during his relatively short life and which was cut so tragically short. Indy suffered from Immunoglobin A nephropathy and associated hypertensive heart disease which resulted in him receiving a renal transplant in May 2020. Indy had previously undergone several biopsy procedures prior to his transplant, the last of which was performed on 24th June 2019. During this biopsy Indy sustained an injury to his native left kidney that subsequently developed into a vascular lesion. On the 27th May 2021 Indy presented to the Royal Surrey County Hospital complaining of headache and was diagnosed with accelerated hypertension which was treated.  An ultrasound scan taken at this time identified a vascular lesion to the lower pole of the left native kidney. There was a missed opportunity to effectively treat this condition as no follow up action was taken in relation to this finding at Royal Surrey County Hospital, the treating clinician being under the mistaken impression that this would be followed up at Addenbrookes Hospital where Indy was under the care of the Renal Department. Indy subsequently underwent a further ultrasound scan of his transplanted kidney on the 22nd June 2021 at the Renal Department at Addenbrookes Hospital. The scan did not identify any abnormality because it did not include the native kidneys. An entry in Indy’s patient clinical records recording a telephone consultation between a consultant at Addenbrookes Hospital and the Royal Surrey County Hospital and which referred to the ultrasound findings from a scan undertaken at Royal Surrey County Hospital in May 2021, was not considered by the treating clinician and did not inform Indy’s ongoing care and treatment.  As a consequence, there was a further missed opportunity to effectively treat the vascular lesion due to the fact that no investigation was carried out at Addenbrookes Hospital concerning the ultrasound findings reported by Royal Surrey County Hospital including consideration of undertaking a CT scan. In June 2022 Indy was transferred to East Suffolk and North Essex NHS Foundation Trust (Ipswich Hospital) for ongoing care and treatment.  A summary of the care and treatment provided and the plan for Indy’s ongoing care and treatment was handed over at the time. No mention was made, or records provided which referred to the vascular lesions identified by the Royal Surrey County Hospital ultrasound scan in May 2021, or the plan for further investigation of this recorded in the telephone note recorded in the Addenbrookes Hospital patient records for Indy. The fact that this important information was not included as part of the handover between hospitals represented a further missed opportunity to effectively deal with the vascular lesion through further investigation and treatment. On the evening of the 20th October 2023 Indy suffered a period of haematuria and general unwellness. He presented to Ipswich Hospital Accident and Emergency Department where he was triaged and placed in a cubicle awaiting further assessment. At around 0150 hours on the morning of the 21st October 2023 he suffered a catastrophic internal bleed and collapsed. An emergency alarm was sounded and extensive attempts were made to resuscitate him. Sadly these were unsuccessful and he died at 0258 hours on the 21st October 2023. Indy Storm MASON-KIDD died due to either a ruptured arteriovenous fistula or pseudoaneurysm in the lower pole of his left kidney which is a recognised but rare complication arising from a biopsy procedure performed on 24th June 2019. The medical cause of death was confirmed as: 1a Retroperitoneal Haematoma 1b Ruptured Arteriovenous Fistula or Pseudoaneurysm in the Lower Pole of the Left Kidney 2 Renal Transplant for IgA Nephropathy, Hypertensive Heart Disease