The family of a new mum who collapsed and died after she went missing in hospital hours after giving birth to her premature son say "basic and common sense measures", would've prevented her death.
Amanda Cox, 34, died on December 10, 2018, after she was found unresponsive in a stairwell at the Royal Infirmary of Edinburgh (RIE) after a five hour police hunt.
Mrs Cox from Peebles in the Scottish Borders, had just given birth to her son Murray when she is thought to have become disoriented after leaving the Neonatal Unit and exiting via a fire door.
The 34-year-old's family have since slammed NHS Lothian for a ‘catalogue of errors’ in her care.
After calls for a fatal accident inquiry into her death the Crown Office announced one will not be held.
A statement from Mrs Cox's husband Michael, and her family, issued by their solicitors 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."
Following the mum's death NHS Lothian carried out a Sudden Adverse Event Review (SAER) and has implemented changes mainly relating to the physical environment at RIE as the Mrs Cox is believed to have become disorientated when she left the neonatal unit to make her way back to her ward.
The Crown Office said it was 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.
Mrs Cox was reported missing at around 5pm on December 10 and was found collapsed at about 10pm, police said at the time.
The NHS Lothian review stated the fire door signage has now been made clearer, while signage within the unit itself has been improved to make it clearer which way to go to get back to the post-natal ward.
They also mentioned there are plans to install 60 more CCTV cameras across the hospital, with a focus on covering stairwells, corridors and fire doors.
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."