Royal London Hospital Baby Death: Monitor Volume Too Low, Coroner Demands Changes
A coroner has issued a Prevention of Future Deaths report to the manufacturers of patient monitoring systems, following the death of a baby at the Royal London Hospital. The infant passed away after the volume of a crucial medical monitor was set to its lowest possible level, making its alarms inaudible to staff.
During the inquest, it was revealed that the alarm’s volume was indistinguishable from ambient noise at the lowest setting. The coroner highlighted that the design of the monitor, specifically its default volume settings, contributed to the incident. This design flaw meant that even a deliberate setting to the lowest level resulted in an alarm that could not effectively alert medical personnel.
The report urges the manufacturer, Philips, to implement design modifications that would either remove the lowest, inaudible volume option or ensure that all volume settings produce a sufficiently audible alert. This directive aims to prevent similar tragedies where critical alerts go unnoticed due to equipment limitations.
