Health
Coroner issues safety warning after low monitor volume contributes to infant's death
A UK coroner urged changes to medical monitor alarms after an unnoticed respiratory arrest at the Royal London Hospital led to an infant's death.
The short version
- An infant under six months old died after a medical emergency at Royal London Hospital went unnoticed for approximately 30 minutes due to a monitor alarm set at an inaudible volume.
- Coroner Mary Hassell issued a Prevention of Future Deaths report calling for baby monitors to be locked at or defaulted to maximum volume.
- Alarm manufacturer Masimo UK has 56 days to respond to the coroner's findings.
- Barts Health NHS Trust has implemented local measures to improve alarm audibility and sightlines to cots following the incident.
Key facts
- Ismaeel Islam, an infant under six months old, suffered a desaturation and respiratory arrest on November 3, 2024, at the Royal London Hospital, leading to his death on March 7, 2025.[BBC News]
- Coroner Mary Hassell determined that the respiratory arrest went unnoticed for roughly 30 minutes because the monitor alarm volume was too low to be useful.[BBC News]
- The nurse in charge was attending to another patient and did not have direct sight of Ismaeel during the deterioration.[BBC News]
- The coroner issued a Prevention of Future Deaths report to alarm manufacturer Masimo UK, giving the company 56 days to respond.[BBC News]
- Barts Health NHS Trust has updated its procedures to enhance line-of-sight supervision and alarm audibility in the unit.[BBC News]
What remains uncertain
- It remains unknown what formal response or technical changes Masimo UK will propose during its 56-day response window.[BBC News]
Sources
- Baby died after hospital monitor volume was too lowBBC News - Top Stories