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A coroner has expressed serious concerns following the death of an infant whose medical emergency was not detected in time due to a hospital monitor alarm being set too quietly. The child, Ismaeel Islam, who was under six months old, passed away at the Royal London Hospital’s special care baby unit on March 7, 2025.
According to Coroner Mary Hassell, Ismaeel experienced a significant drop in oxygen saturation and subsequent respiratory arrest on November 3, 2024. However, this critical event went unnoticed for approximately 30 minutes because the alarm volume had been adjusted to a level described as “too low to be usefully audible.” The coroner concluded that this failure to promptly recognize and respond to the emergency directly contributed to Ismaeel’s death.
During the inquest held at North London Coroner’s Court, it was revealed that the nurse responsible for Ismaeel’s care was attending to another infant and did not have a clear line of sight to him. Ismaeel had underlying health conditions including those related to Down’s syndrome, growth restriction, and prematurity. While Barts Health NHS Trust, which manages the hospital, has since implemented enhancements designed to improve alarm audibility and visibility of cots, concerns remain about the possibility of alarm volumes being set too low in the future.
In response to these findings, Coroner Hassell has issued a Prevention of Future Deaths report to Masimo UK, the manufacturer of the alarms used at the hospital. The company is required to reply within 56 days. She further recommended that baby monitors should be locked at or set to maximum volume to prevent similar incidents. “If Ismaeel’s deterioration had been recognised immediately and treated appropriately, his life would have been saved,” the coroner stated in her report
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