Ismaeel Islam
Response Status
Report Content
Coroner
I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Poplar Coroner’s Court Bow Coroner’s Court
Legal Powers
›Show details
DATE OF REPORT 11 June 2026
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.
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. 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.
Action Required
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.
Investigation and Inquest
›Show details
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
Circumstances of Death
›Show details
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.
Details
- Report Date
- 11 June 2026
- Coroner
- ME Hassell
- Coroner Area
- Inner North London
- Reference
- 2026-0313
If you need support right now:
Samaritans — 116 123, free, 24 hours
SOBS (Survivors of Bereavement by Suicide) — 0300 111 5065, 9am–9pm
Cruse Bereavement — 0808 808 1677, weekdays 9am–5pm