A coroner has recommended changes to baby monitor settings following the death of an infant at the Royal London Hospital, where low monitor volume contributed to delayed detection of a medical emergency.

Ismaeel Islam, less than six months old, died on a special baby care unit after his respiratory distress went unnoticed for approximately 30 minutes. Coroner Mary Hassell, who conducted the inquest into the death, found that the baby monitor’s volume had been turned down too low to be effectively audible during the incident on November 3, 2024. This delay in recognizing Ismaeel’s desaturation and respiratory arrest was a critical factor leading to his death.

In response, Hassell issued a report urging manufacturers of baby monitors, specifically Masimo UK—which supplied the monitoring equipment used at the hospital—to implement safeguards such as locking volume controls at a maximum level or setting maximum volume as the default. The proposal aims to prevent similar tragedies by ensuring that alarms are clearly audible to caregivers and medical staff at all times.

The report was formally submitted to Masimo UK, who were given a 56-day period to provide a response. Details on the manufacturer’s reply have not been publicly disclosed.

The coroner’s recommendations highlight concerns about current monitoring devices’ flexibility, which may inadvertently allow critical alarms to be muted or diminished, potentially compromising patient safety in neonatal and special care units. As hospitals increasingly rely on such technology for continuous monitoring, ensuring alarm audibility remains essential to timely intervention.

Efforts to balance alarm sensitivity with noise management in clinical settings continue to be a challenge across healthcare providers. Hassell’s report contributes to ongoing discussions around how medical device manufacturers and healthcare institutions can work together to optimize patient monitoring systems and reduce preventable deaths in vulnerable populations.