Inquiry report finds systemic, institutional failures at fault in PIMS nursery fire

Concludes criminal responsibility of an individual would have to be determined separately

ISLAMABAD:

The inquiry committee constituted by the prime minister to investigate the August 26 fire at the Pakistan Institute of Medical Sciences (PIMS) nursery that claimed the lives of 14 newborns has concluded that the tragedy culminated as a result of “systemic and institutional failures”, with the hospital and its senior management bearing primary responsibility for failing to address known safety risks.

The report, based on a 52-point investigation, found that multiple safety measures were either absent, inadequate, not activated in time or had never been independently verified.

The fire claimed the lives of 14 of the 15 newborn babies undergoing treatment at the Maternal and Child Health (MCH) nursery, while one child survived due to a nurse’s diligence.

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According to the report, the committee reviewed forensic evidence, CCTV footage, call records, engineering and maintenance documents, medical and accident records, duty and attendance records, witness statements, regulatory records and previous inquiries.

The committee concluded that criminal responsibility of an individual would have to be determined separately under the relevant rules and on the basis of available evidence.

It placed primary institutional responsibility on PIMS and its senior management for failing to convert known risks and earlier warnings into an effective safety system.

Electrical fault identified as most probable cause

In line with the preliminary report findings, the final report said the strongest technical evidence provided by the National Forensic Agency for the fire catastrophe pointed to the electrical cable fault of Air Conditioning unit no2, as the most probable point of origin.

According to the findings, abnormal localised electrical heating, excessive current, a high-resistance connection, or another electrical defect may have damaged the cable insulation and ignited nearby combustible material.

The inquiry found no evidence supporting arson, multiple points of origin, an external electrical fault attributed to Islamabad Electric Supply Company (IESCO) or the release of oxygen before the fire. It also found no evidence that an incubator or warmer had caused the fire.

However, the precise nature of the electrical fault and responsibility for preventing it required further investigation, the report said.

Maintenance records showed that the nursery's air-conditioning units had been serviced. However, there was no effective system for comprehensive electrical safety checks covering cables, terminations, insulation, earthing and breaker protection.

The committee observed that keeping electrical equipment operational did not necessarily mean that its installation was safe from fire.

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