Following an Inquest opened on 10 December 2018 and an Inquest Hearing on 22 August 2019 the following was found: Name of the deceased: Euan David Brinley ELLIS Medical Cause of death: 1a) Haemopericardium b) Ruptured Aneurysm of Ascending Thoracic Aorta

The deceased; together with his close and extended family; live with Marfan's Syndrome He therefore had a cardiac vulnerability: He had missed a number of scheduled cardiac appointments. He was admitted to an Emergency Department with a history of chest pains on 19 November 2017_ A clinical decision was made not to carry out further tests but to refer him to a primary carer; namely his General Practitioner; for a future appointment It appears the Emergency Department had limited access to the deceased"s Health Records. On the balance of probability the clinical decision maker would have been better informed had the decision maker had such access to all Medical Records. The deceased attended his General Practitioner on 20 November 2017 . That Doctor referred the deceased for a non urgent Echocardiogram: That Doctor appeared to have limited information about the deceased's cardiac vulnerability: The deceased suffered a fatal Haemopericardium at home on 23 November 2017 .

In my opinion action should be taken to prevent future deaths and believe you the power to take such action. request that you review the steps taken to in place the recommendations referred to by which; for ease of reference, are attached to the letter accompanying this Report: Kindly report the steps taken SO far Kindly provide an update in six month's time as to the expected completion date of the recommendations