No fatal accident inquiry into death of new mother who ‘got lost in hospital’

NHS Lothian carried out a Sudden Adverse Event Review (SAER) and has implemented changes mainly relating to the physical environment at RIE as the mother is believed to have become disorientated when she left the neonatal unit to make her way back to her ward.

The Crown Office said Crown Counsel are satisfied the reasons for Mrs Cox’s death have been established, lessons have been learned and that, as a result, a fatal accident inquiry (FAI) would not be in the public interest.

The family of Ms Cox said she did not deserve such a “catalogue of errors” in her care and hope no other family has to go through what they did.

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.”

Mrs Cox was reported missing at about 5pm on December 10 and was found collapsed at about 10pm, police said at the time.

The NHS Lothian review found that the patient 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.

NHS Lothian has also shared clinical information to help develop national guidance on the management of headache in pregnancy and the development of national pathways for the management of women with complex, obstetric care needs.

Dr Tracey Gillies, medical director at NHS Lothian, said: “The death of Mrs Cox was a deeply tragic occurrence and our sincere condolences remain with her family. We are so sorry that she died in our care.

“NHS Lothian conducted a thorough investigation to help prevent a similar tragedy happening again. 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.”

Katrina Parkes, head of the Scottish Fatalities Investigation Unit of the Crown Office and Procurator Fiscal Service, said: “The decision not to hold a Fatal Accident Inquiry 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.”