There will be no Fatal Accident Inquiry into the death of a new mother who is thought to have become lost while in hospital before suffering a brain haemorrhage four days after giving birth.
Amanda Cox’s family said new “basic, common sense measures” had come three years too late for her.
In December 2018, Mrs Cox gave birth to her son weighing only 3lb 7oz after she developed pre-eclampsia, a serious blood pressure condition that affects some women in the latter stages of pregnancy.
Mrs Cox had been transferred to the Royal Infirmary of Edinburgh (RIE) in December 2018.
On December 10, the 34-year-old dressed in pyjamas and slippers and visited her baby in the Neonatal Unit.
“We are so sorry that Mrs Cox died in our care and extend our sincere condolences to her family.”NHS Lothian
It is thought that on her way back to her ward she became disorientated. She was reported missing at about 5pm.
Police Scotland issued a missing person appeal with CCTV images asking the public to help find Mrs Cox.
The new mum had been missing for seven hours before she was found unresponsive in a stairwell at the other end of the hospital at around 10pm.
She was pronounced dead shortly after, with police treating her death as unexplained.
Later that month, her cause of death was revealed on her death certificate as an “intracranial haemorrhage” when she was in the “plant room on 3rd level” of the RIE at 11.08pm.
NHS Lothian initiated a Serious Adverse Event (SAE) Investigation. It made a series of recommendations that resulted in “significant changes” being made both clinical and in terms of the hospital’s facilities.
A statement issued by Marina Urie, a senior lawyer with Thompsons Solicitors, on behalf of Mrs Cox’s husband, Michael, and her family, said: “The publication today by NHS Lothian of their new safety measures comes three years too late for Amanda.
“Had these basic, common sense measures been in place then Amanda would not have lost her life in the tragic circumstances she did.
“Amanda was a beautiful, caring person and a wonderful wife. She had just become a mother to our son. She did not deserve such a catalogue of errors in her care from NHS Lothian.
“The statement today from the health board barely mentions her and is very cold and unfeeling. We just hope that because of Amanda’s tragic death no other family has to go through the horror that our family has.”
The decision not to hold a Fatal Accident Inquiry (FAI) has follows what the Crown Office and Procurator Fiscal Service (COPFS) described as a “thorough and independent investigation” by the Scottish Fatalities Investigation Unit.
The decision was made following discussions with Mrs Cox’s family.
Katrina Parkes, head of the Scottish Fatalities Investigation Unit of COPFS, said: “The decision not to hold a FAI has been taken in consultation with Amanda Cox’s family, who have suffered a terrible loss, and I would like to thank them for their patience and co-operation.
“NHS Lothian have provided assurance that significant changes have been made since Amanda’s death and I sincerely hope the lessons learned will help prevent similar deaths in the future.”
NHS Lothian’s medical director said Mrs Cox’s death was “a deeply tragic occurrence” and that the health board had conducted a thorough investigation to help prevent a similar tragedy happening again.
Dr Tracey Gillies said: “We are so sorry that she died in our care.
“The recommendations about the physical area were implemented immediately and clinical recommendations have also been shared with obstetric and neurology services across Scotland to help develop national guidance.
“Following the review, a robust action plan was put in place to improve maternity patient pathways, upgrade signage and wayfinding and extend CCTV surveillance throughout the Royal Infirmary of Edinburgh.”
In its public statement, NHS Lothian published details of the review, the changes made and the learning points for general practice across Scotland.
The NHS Lothian review found that Mrs Cox left the neonatal unit by going through a fire door by mistake.
Fire door signage has now been made clearer, while signage within the neonatal unit itself has also been improved, to make it clearer which way to go out of the unit in order to get back to the post-natal ward.
There are plans to install 60 more CCTV cameras across the hospital, with a focus on covering stairwells, corridors and fire doors.
The COPFS said Crown Counsel were satisfied the reasons for Mrs Cox’s death had been established, lessons learned and, as a result, an FAI would not be in the public interest.
A statement from NHS Lothian said: “We are so sorry that Mrs Cox died in our care and extend our sincere condolences to her family.”