Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0313, written 11 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jun 2026 |
|---|---|
| Reference | 2026-0313 |
| Deceased | Ismaeel Islam |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Report to Prevent Future Deaths
Regulation 28 of
The Coroners (Investigations) Regulations 2013
Ismaeel ISLAM (died 07.03.25)
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Poplar Coroner’s Court
Bow Coroner’s Court
2
DATE OF REPORT
11 June 2026
3
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
4
THIS REPORT IS BEING SENT TO:
1. Chief Executive
Masimo UK
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 6 August 2026. I, the coroner, may extend the
period if an appropriate application is made.
5
YOUR RESPONSE
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise, you must explain
why no action is proposed.
1
I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s Publication Policy, you should
send me any representations regarding publication of your response.
These representations should be made at the same time as the response
is provided. I will pass any representations received to the Chief Coroner
for a decision.
Please note any links to webpages included in the response will not be
checked for sensitive information prior to publication, as the information
is already online.
The names of those who do not respond to PFD reports are regularly
published on the Chief Coroner’s webpages
Non-responses to Prevention of Future Death (PFD) reports - Courts and
Tribunals Judiciary.
6
ACTION SHOULD BE TAKEN
In my opinion unless action is taken to address the above concerns then
there is a significant risk of future deaths and I believe that you have the
power to take such action.
7
INVESTIGATION AND INQUEST
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
1b
1b
1d
2
pulmonary heart disease
chronic pulmonary complications
(chronic lung disease, arterial pulmonary hypertension)
hypoxic ischaemic encephalopathy
following resuscitation from a cardiorespiratory arrest 03.11.24
trisomy 21 with congenital heart defects (atrial septal defect;
ventricular septal defect) and lung growth disorder
ex prematurity (31/40), failure to thrive
8
CIRCUMSTANCES OF DEATH
Ismaeel Islam died from a natural cause, being a combination of Down's
Syndrome, growth restriction and prematurity.
2
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.
9
CORONER’S CONCERNS
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. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
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.
10
COPIES AND PUBLICATION OF THIS REPORT
I have a duty to send a copy of my report to every interested person who
in my opinion should receive it.
I also may send a copy of the report to any other person who I believe
may find it useful or of interest. I have sent the report to:
the parents of Ismaeel Islam
•
• Barts Health NHS Trust.
I also have a duty to send a copy of the report to the Chief Coroner.
You may make representations to me, the coroner, about the publication
of the contents of this report in line with Chief Coroner’s PFD Publication
Policy (2026).
3
Any representations will be sent to the Chief Coroner alongside the
report. Please refer to box 5 above for additional information relating to
the publication of reports and responses.
SIGNATURE
ME Hassell
4
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