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Baby died after hospital monitor volume was too low

Baby died after hospital monitor volume was too low

Summary

A baby named Ismaeel Islam died at the Royal London Hospital’s special care unit after a medical emergency went unnoticed. The alarm on his monitor was set too low to be heard, delaying help during a critical health event.

Key Facts

  • Ismaeel Islam was under six months old when he died on March 7, 2025.
  • He suffered a drop in oxygen levels and stopped breathing on November 3, 2024, but the alarm volume was too low to be heard.
  • The alarm was silent for about 30 minutes, delaying medical attention.
  • The nurse was caring for another baby and could not see Ismaeel at the time.
  • The coroner issued a report warning about low alarm volumes and called for alarms to be fixed at maximum volume or locked.
  • The hospital has started making changes to improve alarm sounds and baby monitor visibility.
  • The alarm system is made by Masimo UK, which must respond to the coroner’s report within 56 days.
  • The coroner stated that if the emergency had been noticed sooner, Ismaeel could have been saved.
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