The tragic death of a new mother who was lost in a hospital could have been avoided if “basic, sensible action” had been taken, her family said.
Amanda Cox, 34, was found unresponsive five hours after she disappeared from a maternity ward at Edinburgh Royal Infirmary in December 2018.
Following an inquest into her death, NHS Lothian said it had improved signs and CCTV coverage.
Her husband criticized the health department for an “error catalogue”.
It came as the Crown Office confirmed Ms Cox’s death would not be the subject of a fatal accident investigation.
- ‘Lost’ new mother dies in hospital
Ms Cox, who was from Peebles in the Scottish Borders, became disoriented after visiting her newborn son in the neonatal unit.
The alarm was raised when she failed to return to the maternity ward.
She was found in a stairwell at the far end of the hospital after accidentally exiting the neonatal ward through a fire door. She died a short time later.
At the time of her death, it was reported that she had suffered from headaches since before her son was born.
Following an investigation into serious adverse events, NHS Lothian said it had taken a number of actions including:
- Development of national guidelines for the treatment of headaches in pregnancy
- Better continuity of care for women with complex pregnancies
- Voice-activated signs installed on stairways that are not open to the public
- Improved signage between neonatal and postpartum wards
- 60 more CCTV cameras installed, focusing on stairwells, corridors and fire doors.
- Fire shields have been improved
- Review of missing persons and search logs.
dr NHS Lothian Medical Director Tracey Gillies also apologized for Ms Cox dying in her care.
“Ms Cox’s death was a deeply tragic event and our sincere condolences go out to her family,” she added.
However, Ms Cox’s family, including her husband Michael, said the release of the new safety measures was “three years late”.
“Had these basic, sensible actions been taken, Amanda would not have lost her life in the tragic circumstances that she did,” the family said in a statement released by Marina Urie of Thompson’s Solicitors.
“Amanda was a beautiful, caring person and a wonderful wife. She had just become the mother of our son. She didn’t deserve such a catalog of failures in her NHS Lothian care.
“Today’s statement from the health department barely mentions her and is very cold and callous.
“We just hope that because of Amanda’s tragic death, no other family has to go through the horror that our family is going through.”
Meanwhile, the Crown Office said an inquiry into Ms Cox’s accidental death was not in the public interest.
It said the purpose of an FAI was to determine the cause of death and what lessons could be learned to minimize the risk of future deaths in similar circumstances.
Crown Counsel is pleased that the reasons for her death have been established and lessons learned, they added.
Katrina Parkes, head of COPFS’ Scottish fatalities investigation unit, said: “The decision not to carry out an investigation into fatal accidents was taken in consultation with the family of Amanda Cox, who has suffered a terrible loss, and I would like to thank them for their patience and cooperation.
“NHS Lothian has provided assurance that significant changes have been made since Amanda’s death and I sincerely hope that the knowledge gained will help prevent similar deaths in the future.”
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