Sophia died at the Royal Hospital for Children at the Queen Elizabeth University Hospital Campus, Glasgow on 11 April 2017.
In her determination, Sheriff Joanna McDonald made formal findings that an active blood stream infection caused by methicillin sensitive Staphylococcus aureus producing Panton-Valentine Leucocidin (PVL-MSSA) materially contributed to Sophia’s death.
However, she found that there were no precautions which could reasonably have been taken, that may have prevented Sophia’s death.
The PVL-MSSA infection was not related to the built hospital environment and was not associated with the new build hospital at Queen Elizabeth University Hospital campus, Glasgow.
PVL-MSSA is a rare strain of Staphylococcus aureus, which is both virulent and aggressive. Vulnerable patients, such as extremely ill neonates like Sophia, are particularly at risk from serious harm or death.
The Sheriff made a recommendation for weekly screenings for Staphylococcus aureus colonisation, in babies being treated in neonatal intensive care and for NHS Greater Glasgow and Clyde to review their existing protocol.
The Sheriff also made a recommendation for Public Health Scotland to share risk, diagnosis and treatment information on PVL-MSSA infections, with other neonatal clinical teams throughout Scotland.
Following a detailed investigation by the Procurator Fiscal, the Lord Advocate decided that it was in the public interest to hold a discretionary Fatal Accident Inquiry to look at the full circumstances surrounding Sophia's death.
The Procurator Fiscal, who acts in the public interest, provided comprehensive information to the Inquiry and led evidence on the facts and circumstances of Sophia’s death.
Following the publication of the determination, Procurator Fiscal Andy Shanks, who leads on fatalities investigations for COPFS said:
“Sophia Smith’s mother, father and their family have my deepest sympathy for all they have endured.
“The Sheriff’s determination, which makes recommendations for NHS Greater Glasgow and Clyde and Public Health Scotland, is extensive and detailed.
“The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal, who ensured that the full facts and circumstances of Sophia’s death were presented in evidence. "
As the independent death investigation authority for Scotland, the Crown Office and Procurator Fiscal Service has a duty to investigate all sudden, suspicious, unexplained, and unexpected deaths, as well as deaths which have occurred in circumstances that give rise to serious public concern.
More information on our role in the investigation of deaths can be found at Our role in investigating deaths | COPFS
For more information on Fatal Accident Inquiries see the Crown’s guide.