A coroner has raised concerns after a boy died following a medical emergency that went unnoticed because a hospital monitor alarm was set too low.

Ismaeel Islam, who was under six months old, died at the Royal London Hospital’s special care baby unit on 7 March 2025.

Coroner Mary Hassell said he suffered a desaturation and respiratory arrest on 3 November 2024 which went unnoticed for about 30 minutes because the alarm’s volume had been turned “too low to be usefully audible”.

The coroner found this medical emergency led to his death. She issued a Prevention of Future Deaths report to Masimo UK, the maker of the monitoring alarms used at the hospital. Masimo UK has 56 days to respond.

Hassell, who led an inquest into the death at North London Coroner’s Court, said the nurse caring for Ismaeel, who had health problems linked to Down’s syndrome, growth restriction and prematurity, was attending to another baby at the time and he was not in her line of sight.

The coroner acknowledged that Barts Health NHS Trust, which runs the hospital, had since introduced measures to improve the audibility of alarms and lines of sight to cots on the unit.

However, she raised concerns that the alarms could be set at a volume too low to be heard and said there was a risk of future deaths unless action was taken.

She has called for baby monitors to be locked at a maximum volume or set to maximum.

“If Ismaeel’s deterioration had been recognised immediately and treated appropriately, his life would have been saved,” she said in her report.

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