THE death of a new mother believed to have got lost in a hospital could have been avoided if “basic, common sense measures” had been in place, her family have said.

Amanda Cox, 34, was found unresponsive in a stairwell at the Royal Infirmary of Edinburgh in December 2018.

Following a serious adverse event (SAE) investigation into her death, NHS Lothian says it has improved signage and has plans to install around 60 more CCTV cameras across the site.

The Crown Office has now announced that a fatal accident inquiry will not be held into the death of Ms Cox, of Peebles.

It said that an inquiry would not be in the public interest as the reasons for Ms Cox’s death have been established and “lessons have been learned”.

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A statement from Marina Urie, of Thompsons Solicitors, speaking on behalf of Ms Cox’s husband Michael and 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."

“We are so sorry that she died in our care”

Ms Cox is believed to have become disorientated when leaving to return to the maternity ward after visiting her newborn child in the neonatal unit.

She was found unresponsive in a stairwell at the other end of the hospital and later died.

NHS Lothian’s review found that Ms Cox had left the neonatal unit by going through a fire door by mistake.

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 has 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.”