Amanda Cox death: no FAI into tragic mum who was missing for seven hours in Edinburgh Royal Infirmary

There will be no fatal accident inquiry into the death of a new mother who was missing for seven hours at Edinburgh’s Royal Infirmary before being found dying in a little-used stairwell, the Crown Office has announced.
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Amanda Cox, 34, is thought to have got lost on her way back to the maternity ward after going to visit her premature baby son Murray in the hospital’s neonatal unit.

She was discovered slumped unconscious and barely alive in a disused third-level plant room at the Infirmary on December 10, 2018.

Amanda Cox was missing for seven hours before being found.Amanda Cox was missing for seven hours before being found.
Amanda Cox was missing for seven hours before being found.
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Despite emergency treatment, doctors were unable to save her. She died of a brain haemorrhage, her death certificate confirmed.

She was said to have been suffering headaches even before the birth and was reportedly due to see a specialist.

The Crown Office said the decision not to hold an FAI had been taken with the agreement of Ms Cox's family and took account of the review and improvements carried out by NHS Lothian following her death.

The Crown Office statement said: “The purpose of a Fatal Accident Inquiry is to determine the cause of death and to establish what lessons can be learned to minimise the risk of future deaths in similar circumstances.

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“Crown Counsel are satisfied the reasons for Amanda’s death have been established, lessons have been learned and, as a result, an FAI would not be in the public interest.”

Ms Cox, from Peebles, had been transferred to the Infirmary from Borders General Hospital along with four-day-old Murray, who was born weighing only 3lb 7 ounces, for specialist care.

Staff launched a search for her after she was reported missing, wearing only her pyjama bottoms, a T-shirt and slippers, and she was found seven hours later following a review of CCTV footage.

Katrina Parkes, head of the Crown Offices’s Scottish Fatalities Investigation Unit, 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.

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“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.”

In a separate statement, NHS Lothian said since Ms Cox’s death it had upgraded signage and wayfinding and extended CCTV surveillance throughout the Infirmary.

And it said it had also shared clinical information to help develop national guidance on the management of headache in pregnancy and 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.

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"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.”

Ms Cox’s family said she did not deserve such a “catalogue of errors” in her care and hoped no other family would have to go through what they did.

Marina Urie, a senior lawyer with Thompsons Solicitors, speaking 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.

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“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.”

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