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 aged under six months, 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 as the alarm was “too low to be usefully audible”.
The emergency led to his death, she said, prompting a Prevention of Future Deaths report to the alarm manufacturer. Masimo UK expressed “deepest sympathies” to the family and say they are investigating, adding all its devices meet UK standards.
Ismaeel had health problems linked to Down’s syndrome, growth restriction and prematurity.
Hassell, who led an inquest into the death at North London Coroner’s Court, said the nurse caring for Ismaeel 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.
Masimo UK has 56 days to officially respond to the report.
A spokesperson for Masimo UK said patient safety was the company’s “highest priority” and that it took “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.”
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