A coroner has suggested baby monitors should have their volume ‘locked’ to a loud setting after a baby with Down’s Syndrome tragically died because his monitor was turned down too low to hear.
Baby monitors being locked to loud levels or even ‘set to maximum as a default’ would help prevent the deaths of babies who suffer health issues, senior coroner Mary Hassell said.
The London coroner’s warning comes after the tragic death of little Ismaeel Islam, who had serious health issues and passed away aged almost six months.
Ismaeel died after collapsing on a special care unit, but it has now been revealed that he could have been saved if his deterioration had been ‘recognised immediately and treated appropriately’.
The inquest heard that his monitor had been turned down ‘too low to be usefully audible’ and his cot had been moved out of sight of nurses.
A Prevention of Future Deaths report has now been published to highlight the needs that the monitor manufacturer needs to make to stop this happening in the future.
Ismaeel died at the Royal London Hospital on March 7, 2025.
His cause of death was given as pulmonary heart disease, chronic pulmonary complications, hypoxic ischaemic encephalopathy following resuscitation from a cardiorespiratory arrest, trisomy 21 with congenital heart defects and ex prematurity.
This was summarised as being a death from a natural cause – being a combination of Down’s Syndrome, growth restriction and prematurity.
Ismaeel was on a special care baby unit when he collapsed on November 3, 2024.
On that date there was a failure to recognise his desaturation and respiratory arrest for approximately half an hour.
This was because his monitor alarm had been turned down too low to be usefully audible and his cot was not within the line of sight of the nurse caring for him who was at that point with another baby.
The inquest concluded that ‘If Ismaeel’s deterioration had been recognised immediately and treated appropriately, his life would have been saved’.
A prevention of future deaths report has now been published which highlighted potential failures in the monitoring systems that need to be assessed in order to save lives in the future.
Ms Hassell, senior coroner for Inner North London, send her report to Masimo UK – a technology company who provide medical monitoring equipment – who have 56 days to reply.
Ms Hassell said: “During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.
“I heard at inquest of several measures that have been implemented by the hospital trust to make this situation less likely to occur in the future, principally dealing with the audibility of alarms and nursing line of sight.
“However, the trust told me that an approach has been made to you as manufacturer of the monitor alarms in question, to ask that the volume on these alarms be either locked or at least set to maximum as a default, but that you have not yet made a decision about this request.
“I write now to urge you to consider as soon as possible the issue of how you can maximise patient safety in this respect.”
