A baby died at the Royal London Hospital's special care unit after a medical emergency went unnoticed because a monitoring alarm was set too low to be heard, a coroner has found. Ismaeel Islam, who was under six months old, died on March 7, 2025.
Coroner Mary Hassell stated that on November 3, 2024, Ismaeel suffered a desaturation and respiratory arrest. This critical event went unnoticed for approximately 30 minutes because the alarm's volume had been reduced to a level that was "too low to be usefully audible." The coroner determined that this undetected medical emergency was the cause of the infant's death.
In response to the incident, Hassell issued a Prevention of Future Deaths report to Masimo UK, the manufacturer of the monitoring alarms used at the hospital. The company has 56 days to provide a response. During an inquest at North London Coroner's Court, Hassell noted that the nurse attending to Ismaeel, who had health complications related to Down's syndrome, growth restriction, and prematurity, was also caring for another infant and Ismaeel was not within her line of sight.
The coroner acknowledged that Barts Health NHS Trust, which operates the hospital, has implemented measures to enhance alarm audibility and improve lines of sight to infant cots within the unit. However, she expressed concern that the alarms' volume could still be set low enough to be inaudible and warned of a risk of future deaths if no further action was taken. Hassell has called for baby monitors to have their volume locked at a maximum setting or be defaulted to maximum volume. "If Ismaeel's deterioration had been recognised immediately and treated appropriately, his life would have been saved," the coroner stated in her report.