Baby died after hospital monitor alarm set too low

A baby died following a medical emergency that went unnoticed because a hospital monitor alarm was set too low to be heard, a coroner has found. Ismaeel Islam, who was under six months old, died at the Royal London Hospital's special care baby unit on 7 March 2025. The emergency occurred on 3 November 2024.

Alarm volume issue

Coroner Mary Hassell stated that Ismaeel suffered a desaturation and respiratory arrest on 3 November 2024. This event went unrecognised for approximately 30 minutes because the alarm's volume had been reduced to a level "too low to be usefully audible". The coroner determined that this delay in recognition and treatment led to the infant's death.

The inquest at North London Coroner's Court heard that the nurse attending to Ismaeel, who had health issues including Down's syndrome, growth restriction, and prematurity, was occupied with another baby at the time. Ismaeel was not within her line of sight during the critical period.

Safety concerns and actions

Coroner 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 respond to the report. The coroner acknowledged that Barts Health NHS Trust, which operates the Royal London Hospital, has since implemented measures to enhance alarm audibility and improve visibility of cots on the unit.

Despite these improvements, the coroner expressed concern that alarms could still be set at a volume insufficient to be heard. She warned of a risk of future deaths if further action was not taken. In her report, Hassell stated, "If Ismaeel's deterioration had been recognised immediately and treated appropriately, his life would have been saved."

The coroner has called for baby monitors to be locked at a maximum volume or set to their highest setting to prevent similar incidents.