Urdu Report Desk
ISLAMABAD: An inquiry committee investigating the deadly fire at the nursery of the Mother and Child Hospital at the Pakistan Institute of Medical Sciences (PIMS) has found “systemic and institutional failure” behind the tragedy that claimed the lives of 14 newborns on August 26.
The committee determined that an electrical fault was the most likely cause of the fire. However, inadequate fire safety arrangements, limited evacuation capacity, staff shortages, weak emergency preparedness, and the failure to address known risks contributed to the scale of the disaster.
The 43-page report was prepared by a committee headed by former interior secretary Shahid Khan, which was formed on the directives of Prime Minister Shehbaz Sharif on the day of the incident.
Systemic and Institutional Failure
The committee held PIMS and its senior management principally responsible at the institutional level for failing to turn known risks, previous warnings, and assigned duties into an effective safety system.
“The electrical spark explains how the fire began; the institutional system explains why it became a catastrophe,” the report stated.
It added that the 14 newborns died not because of the failure of a single safeguard, but because too many safety measures were absent, weak, delayed, or never verified as operational.
According to the report, a localised electrical failure most probably started the fire. Combustible materials and an oxygen-supported environment then intensified the flames and smoke, while inadequate detection and protection systems failed to contain the blaze.
Overcrowding, limited evacuation capacity, the absence of a rehearsed neonatal emergency system, and delayed institutional activation further hampered rescue efforts.
Electrical Fault Identified as the Most Likely Cause
Based on evidence from the National Forensics Agency, the committee identified the electrical supply cable of AC Unit No. 2, located near or above AC Unit No. 1, as the most probable point of ignition.
The report said abnormal localised electrical heating—possibly caused by excessive current, a high-resistance connection, or another localised defect—may have damaged the cable’s insulation and ignited nearby combustible material.
However, the evidence did not establish arson, multiple points of ignition, an external fault involving the Islamabad Electric Supply Company (Iesco), a pre-fire oxygen leak, or an incubator or warmer as the source of the fire.
The committee said the fire was most probably electrical in origin, although the precise defect and the person or entity responsible for preventing it would require separate determination.
The report also found that criminal guilt had not been established against any named individual at this stage. Nevertheless, it recommended further investigation into possible culpable electrical installation or maintenance failures involving AC Unit No. 2, obstruction of a mandatory emergency route, failure to act despite prior warnings, and any proven delay in seeking external assistance.
Previous Warnings Were Not Fully Addressed
The inquiry report highlighted a history of known but incompletely resolved fire safety risks at PIMS.
These included earlier correspondence from the Capital Development Authority (CDA), findings by the Federal Ombudsman in 2015, PIMS’ own acknowledgment in 2025 that its fire safety infrastructure was ageing, and the fire at the Nursing Hostel on July 6, 2026.
The Nursing Hostel incident had already exposed shortcomings in fire detection, alarms, electrical inspections, evacuation arrangements, firefighting equipment, emergency drills, and contingency planning.
The committee regretted that these warnings had not been converted into a comprehensive, time-bound, and independently verified corrective programme before the nursery fire.
It noted that although the specific defect involving AC Unit No. 2 may not have been foreseeable, the need for stronger fire preparedness was clear.
Frontline Staff Responded Quickly
After reviewing CCTV footage, the committee found that several frontline staff members responded within moments of the fire and acted promptly and courageously under rapidly deteriorating circumstances.
The report specifically mentioned Charge Nurse Nasreen Akhtar, Security Guard Maria Saleem, and Staff Nurse Razia Noreen.
It stated that frontline responders should not be blamed merely because the outcome was catastrophic, particularly when the situation became untenable within minutes.
However, the committee distinguished between individual staff responses and the hospital’s broader institutional emergency activation system.
According to the report, frontline staff responded at 6:38am, external notification was made at 6:54am, and emergency personnel arrived at 7:01am. The principal concern, therefore, was the gap between the visible fire and the activation of external assistance, rather than a prolonged delay by Capital Emergency Services (CES) after confirmed notification.
The committee said PIMS had not demonstrated a tested incident-command system capable of immediately converting fire detection into an alarm, external notification, evacuation, hazard isolation, access management, and coordinated rescue.
Overcrowded Nursery and Limited Rescue Capacity
The inquiry found that 15 medically fragile, non-self-evacuating newborns were housed in a 10-bed nursery.
Several of the babies depended on oxygen or respiratory support. Only two doctors and two nurses were immediately available, while protected evacuation resources were limited.
The report found no evidence of an adequately documented, approved, trained, and rehearsed nursery-specific fire and neonatal evacuation procedure.
It also found that a functional automatic smoke detection, alarm, or sprinkler system had not been demonstrated in the affected area.
The committee further noted that combustible materials and the oxygen-supported environment intensified the fire and smoke after ignition.
Responsibilities and Further Investigation
The committee said the evidence was not equally strong against all officials.
It found that the security chain had the clearest documented duty structure, while responsibility at the senior management level would require further confirmation of assigned functions, knowledge, and authority.
Engineering, electrical, air-conditioning, and maintenance responsibilities were described as technically central. The report identified the installation and maintenance chain related to AC Unit No. 2 as the most important unresolved technical accountability issue.
It recommended tracing responsibility to those who designed, installed, altered, inspected, maintained, supervised, or certified the relevant electrical circuit.
The report said the responsibility of the Ministry of Health, Islamabad Healthcare Regulatory Authority (IHRA), CDA, and Capital Emergency Services was stronger at the institutional, supervisory, and regulatory levels than in terms of specific individual criminal liability.
The committee stressed that any final determination of guilt must follow due process.
Recommendations for Immediate Safety Reforms
The committee recommended immediate fire, life-safety, and electrical audits at PIMS.
It called for functioning smoke detection systems, alarms, fire suppression equipment, and emergency exits, along with a dedicated neonatal evacuation procedure supported by realistic drills.
The report also recommended direct emergency notification, an effective incident-command system, preventive electrical safety and asset-management procedures, professional hospital governance, and stronger regulatory oversight.
It proposed a closed-loop compliance system under which every deficiency would be assigned to a responsible institution and officer, with a deadline, resources, interim safeguards, independent verification, and a formal closure record.
The committee stated that a measure should not be considered implemented merely because it has been approved or is under process. It should only be treated as complete once the risk has been physically removed and independently verified.
Support for Affected Families
The committee recommended establishing a Family Support and Liaison Cell to provide psychological assistance and bereavement support to affected families.
It also called for long-term clinical follow-up of the surviving newborn and the transparent and prompt processing of any lawful compensation or relief.
The report proposed establishing a permanent multidisciplinary Hospital Safety and Vigilance Committee with the authority to track safety deficiencies through to verified closure.
It further recommended that high-risk services—including nurseries, neonatal intensive care units, intensive care units, high-dependency units, and operating theatres—should continue operating only where minimum life-safety safeguards are physically functional and independently verified.
The committee also advised transferring critical services housed in legacy buildings to suitable purpose-built facilities where feasible.
