Ismaeel ISLAM · Prevention of Future Deaths report

On 11 March 2025, I commenced an investigation into the death of Ismaeel Islam, aged almost six months old. I concluded the inquest on 3 June 2026.

Ismaeel died at the Royal London Hospital on 7 March 2025.
His medical cause of death was:

1a pulmonary heart disease
1b chronic pulmonary complications
(chronic lung disease, arterial pulmonary hypertension)
1b hypoxic ischaemic encephalopathy
following resuscitation from a cardiorespiratory arrest 03.11.24
1d trisomy 21 with congenital heart defects (atrial septal defect;
ventricular septal defect) and lung growth disorder
2 ex prematurity (31/40), failure to thrive

Ismaeel Islam died from a natural cause, being a combination of Down's Syndrome, growth restriction and prematurity.

However, he was on a special care baby unit at the time of the collapse on 3 November 2024 that led to his death, and 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.

If Ismaeel's deterioration had been recognised immediately and treated appropriately, his life would have been saved.

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.