A coroner has expressed concerns following the death of a baby at the Royal London Hospital, where a medical emergency went unnoticed due to a monitor alarm being set too low.
Ismaeel Islam, who was under six months old, died on 7 March 2025. The coroner, Mary Hassell, found that Ismaeel suffered a desaturation and respiratory arrest on 3 November 2024, which was not detected for approximately 30 minutes because the alarm's volume was "too low to be usefully audible".
This medical emergency was found to have led to his death. The coroner has issued a Prevention of Future Deaths report to Masimo UK, the manufacturer of the monitoring alarms used at the hospital, which has 56 days to respond.
The nurse caring for Ismaeel, who had health problems linked to Down's syndrome, growth restriction, and prematurity, was attending to another baby and he was not in her line of sight at the time. While Barts Health NHS Trust, which runs the hospital, has since introduced measures to improve alarm audibility and lines of sight, the coroner raised concerns that alarms could still be set too low, posing a risk of future deaths.
The coroner has called for baby monitors to be locked at a maximum volume or set to maximum, stating that if Ismaeel's deterioration had been recognised and treated immediately, his life would have been saved.