Hospital Monitor Alarm Too Low, Baby Died

A tragic incident at the Royal London Hospital's special care baby unit has led to a coroner's critical report. Ismaeel Islam, an infant under six months old, died on March 7, 2025, following a medical emergency on November 3, 2024. This emergency, a desaturation and respiratory arrest, went undetected for about 30 minutes because the monitoring alarm's volume was set "too low to be usefully audible."

Coroner Mary Hassell determined this undetected medical event was the cause of Ismaeel's death. The nurse attending to Ismaeel, who had health issues related to Down's syndrome, growth restriction, and prematurity, was caring for another infant at the time, and Ismaeel was not visible.

The coroner has issued a Prevention of Future Deaths report to Masimo UK, the alarm manufacturer, urging action. While Barts Health NHS Trust has improved alarm audibility and lines of sight, Hassell stressed the risk of future deaths if alarms can be set too low, recommending they be locked at maximum volume.