Ismaeel Islam, aged under six months, died at the Royal London Hospital's special care baby unit on 7 March 2025, following a medical emergency that went undetected for approximately 30 minutes because a monitoring device's alarm was configured at insufficient volume to be heard effectively.
A coroner has issued a formal Prevention of Future Deaths report after concluding that the boy's life could have been saved had his deterioration been identified and treated promptly. Coroner Mary Hassell, who conducted an inquest at North London Coroner's Court, found that Ismaeel suffered a desaturation and respiratory arrest on 3 November 2024, an event that remained unnoticed due to the alarm being "too low to be usefully audible".
How did the emergency go unnoticed?
The nurse assigned to Ismaeel's care was attending to another infant at the time of his medical crisis and could not see his cot from her position. The combination of the low alarm volume and the child's location outside the caregiver's direct line of sight meant that critical warning signs of his deterioration were missed during the crucial 30-minute window.
Hassell stated in her findings:
"If Ismaeel's deterioration had been recognised immediately and treated appropriately, his life would have been saved."
What underlying health conditions did Ismaeel have?
Ismaeel had multiple medical vulnerabilities stemming from Down's syndrome, intrauterine growth restriction, and complications related to prematurity. These pre-existing conditions placed him at elevated risk and made prompt clinical recognition of acute changes even more critical.
What action has the hospital trust taken?
Barts Health NHS Trust, which operates the Royal London Hospital, has already implemented improvements to address the systemic failures identified. The trust introduced measures designed to enhance the audibility of alarms and improve sightlines to cots within the special care baby unit. However, Hassell emphasised that these local changes, while positive, do not fully resolve the underlying risk.
What are the coroner's formal recommendations?
The coroner has called for baby monitors to be locked at maximum volume or configured to default to maximum volume settings. According to the official Prevention of Future Deaths report, Barts Health NHS Trust had already requested that the manufacturer implement such changes, but no decision had been reached at the time the report was issued on 20 August 2026.
Hassell raised concerns that alarms could continue to be set at volumes too low to be heard and warned of a risk of future deaths unless action was taken by the device manufacturer.
What is the manufacturer's response?
Masimo UK, the alarm manufacturer, expressed its "deepest sympathies" to Ismaeel's family and confirmed it is investigating the incident. A spokesperson for the company stated that patient safety is its "highest priority" and that it takes "all events involving patient harm very seriously".
"Masimo was recently informed of this incident and, upon notification, immediately initiated an investigation in accordance with our established quality management procedures. While the investigation is ongoing, Masimo can confirm that all alarms on our monitoring devices meet UK regulatory standards."
The coroner's report indicates that the trust had asked the manufacturer to lock the alarm volume or make maximum the default setting, but the company had not yet made a decision on this request when the report was finalised.
What happens next?
Masimo UK has 56 days from the coroner's report to formally respond to the Prevention of Future Deaths recommendations. The company's response will determine whether it commits to implementing the requested changes to alarm configuration on its monitoring devices.
The case highlights broader concerns about alarm management in healthcare settings and the critical importance of ensuring that safety systems are configured to be reliably detected by clinical staff. The inquest findings underscore how multiple factors—equipment settings, staffing visibility, and clinical responsiveness—must align to prevent patient harm in high-dependency care environments.
