Euan David Brinley ELLIS · Prevention of Future Deaths report

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
c) Marfan’s Syndrome

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.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
At the Inquest the Coroner received evidence from ████████ who referred to a multi disciplinary investigation which contained recommendations. The Coroner is concerned to be assured that the recommendations are being followed.