A coroner has called for baby monitors to be locked at a maximum volume or set to maximum as default after a six-month-old baby boy died while staying on a special baby care unit at the Royal London Hospital.
Coroner Mary Hassell, leading the inquest into the death of Ismaeel Islam, less than six months old, said his baby monitor had been turned down "too low to be usefully audible" during the medical emergency on November 3, 2024, which led to his death. Ismaeel died on March 7, 2025.
Delay in noticing deterioration
Because the monitor was too low, his desaturation and respiratory arrest was not noticed for half an hour, Ms Hassell said. She also noted his cot was not within the line of sight of the nurse caring for him, who was with another baby.
Ms Hassell produced a prevention of future deaths report sent to Masimo UK, manufacturer of the monitoring alarms used at the hospital. She said: "If Ismaeel’s deterioration had been recognised immediately and treated appropriately, his life would have been saved."
Hospital measures and response
Ismaeel’s ill health was caused by Down’s syndrome, growth restriction and prematurity. Barts Health NHS Trust has implemented measures dealing with the audibility of alarms and cot lines of sight, the coroner said.
Masimo UK was given 56 days to respond to the report.
