ISLAMABAD: A government inquiry into the deaths of 14 newborns in a fire at Islamabad’s Pakistan Institute of Medical Sciences (PIMS) has found “systemic and institutional failure,” saying the tragedy was caused not only by an electrical fault but by a breakdown of multiple safeguards.

The fire broke out at the Mother and Child Health (MCH) Nursery of PIMS on Aug. 26, 2026, where 15 medically dependent neonates were receiving treatment. Fourteen infants died while one survived. The committee said the emergency became visible on CCTV at around 6:38 a.m. and that dense smoke engulfed the nursery within one to two minutes, leaving an “exceptionally narrow rescue window,” according to the inquiry report’s consolidated findings.

The inquiry identified abnormal localized electrical heating in an AC unit as the most probable point and mechanism of ignition. The precise electrical defect and responsible duty holder remain to be individualized. It rejected allegations that doctors, nurses or security personnel abandoned the infants, saying available evidence showed “prompt alarm raising, entry, rescue and treatment efforts” by frontline staff.

The inquiry committee said its investigation established that “the electrical failure most probably explains how the fire began; the institutional system explains why it became a catastrophe,” adding that PIMS and its senior management bore the principal institutional responsibility for failing to convert known fire safety risks, prior warnings and assigned duties into an effective safety system.

“The Committee concludes that systemic and institutional failure is established, but individual responsibility varies according to the strength of the evidence. PIMS and its senior management bear the principal institutional responsibility for failing to convert known fire safety risks, prior warnings and assigned duties into an effective and verified safety system, subject to due process and verification of attendance and conduct. Clinical responsibility should arise only where mandatory physical or supervisory duty is proved, while frontline responders whose rescue efforts are objectively established should not be adversely implicated,” the inquiry report read.

“The Engineering/electrical/HVAC chain remains the most important unresolved technical accountability line because the AC-2 supply arrangement is the most probable ignition source, but liability must first be individualized. Belfort and BE Engineers should be examined contractually, while Ministry, IHRA and CDA/CES responsibility is presently mainly institutional or regulatory,” it said.

“Criminal proceedings should remain confined to focused investigation of the AC-2 maintenance chain, mandatory exit obstruction, failure to act despite prior warning and any culpable delay in internal notification.”

The report said PIMS lacked a “systematic, periodic and traceable preventive electrical safety regime” covering cables, terminations, insulation, earthing, breakers and thermal hotspots, meaning operational equipment was not necessarily electrically fire safe.

It also highlighted major operational challenges at the nursery, saying 15 non-self-evacuating neonates were being cared for in a stated 10-bed facility while only two doctors and two nurses were immediately available and protected transport resources were limited.

“This constituted a serious operational mismatch,” the committee observed.

The inquiry found that the nursery did not have a demonstrated functional automatic smoke detection and fire alarm system or sprinkler protection, leaving human observation and manual communication as the primary means of detecting and responding to fires.

It raised concerns over the time taken to notify emergency services, noting that while the fire became visible around 6:38 a.m., confirmed notification to the Capital Emergency Services (CES) occurred at approximately 6:54 a.m. The committee said CES responded within minutes after confirmed activation.

The report said prior warnings about fire safety risks had not been converted into a comprehensive corrective program before the tragedy. It cited correspondence from the Capital Development Authority (CDA), observations by the Federal Ombudsman in 2015, PIMS’s own 2025 acknowledgement of aging fire safety infrastructure, and a hostel fire on July 6, 2026, as evidence that broader risks were known before the nursery blaze.

“The specific AC-2 failure may not have been foreseeable, but the need for stronger fire preparedness was,” the committee said.

The inquiry also questioned the continued use of the old MCH building despite the availability and gradual operationalization of a new Japan International Cooperation Agency-funded facility, saying the decision lacked a sufficiently documented risk assessment, justification or transition plan.

The committee said oversight responsibilities of the ministry, the Islamabad Healthcare Regulatory Authority (IHRA) and CDA/CES were stronger at the institutional and regulatory level rather than for individual culpability, describing oversight as “fragmented” with insufficient verification that critical risks had been closed.

It said resource constraints faced by PIMS did not by themselves excuse the identified deficiencies, noting that the record did not show that specific fire safety or AC-2 electrical safety proposals were rejected solely due to lack of funds.

The inquiry recommended a hospital-wide fire, life safety and electrical audit, immediate correction of identified risks, installation of automatic detection and suppression systems, improved emergency exits, preventive electrical safety programs and dedicated neonatal evacuation procedures.

It also called for focused investigations into the AC-2 electrical chain, possible obstruction of emergency routes, failure to act despite prior warnings and any culpable delay in external notification.

The inquiry committee said it had not found any individual criminally guilty at this stage but recommended that evidence be referred to relevant authorities for further investigation.

“Criminal responsibility can arise only where the investigation establishes a clear duty, knowledge or foreseeability of danger, authority to act, a sufficiently culpable act or omission, failure of a relevant safeguard and a legally sustainable causal contribution,” the report said.

It recommended administrative and disciplinary proceedings against officials where evidence showed negligence, misconduct, failure of supervision or non-performance of assigned safety duties, while stressing that final responsibility must be determined through due process.

“The enduring lesson is that patient safety cannot depend on individual courage once a fire has started. It must be secured beforehand through preventive engineering, effective fire and life safety systems, adequate staffing and evacuation capacity, professional hospital governance, prompt incident command, independent regulation and a compliance regime in which risks remain open until corrective measures are physically implemented and verified,” the report said.

“The fact-finding stage is substantially complete and the evidentiary record is sufficient for final findings, accountability proceedings and implementation of reforms.”