There comes a point after tragedy when one feels stumped: exasperated, angry, inadequate. Fourteen newborn babies died in the fire at Islamabad’s Pakistan Institute of Medical Sciences, and there was an outpouring of grief and outrage.

And then comes the danger.

The anger settles. The headlines move on. Everyday life rolls forward like a boulder. What should have been intolerable becomes another terrible thing Pakistan somehow absorbs.

This time, we must not let it.

These were babies who had barely arrived in this callous world. They had been placed in a newborns’ nursery precisely because they were at their most vulnerable and needed the most secure care the state could provide. Instead, the place designed to protect them became the place 14 of them never left.

The paradox extends far beyond PIMS. The poor, the voiceless and the excluded enter public institutions seeking protection, only to find that the protective space is itself unsafe.

The interim inquiry into the August 26 fire makes devastating reading.

The precise origin has not been established. Investigators are examining whether an air conditioner, an incubator or warmer, or wiring, plugs and sockets were involved. That distinction matters, and speculation should not replace evidence.

But something bigger than the first spark is already established.

According to the inquiry, the nursery filled with smoke within roughly two minutes. There was no approved, rehearsed evacuation procedure specific to the nursery. Emergency services reported exits and escape routes locked or obstructed, and firefighters had to force open doors. Fire and life safety arrangements were inadequate. Emergency notification and incident command were in question. Staffing on duty was below rostered strength.

Amid this there was also extraordinary humanity. Staff Nurse Razia entered the burning nursery, carried out a baby and tried to go back in. That child survived. The government has announced a Rs10 million reward for her and recommended her for a civil award.

Her courage tells us something important: systems can fail while individuals within them rise magnificently.

But heroism cannot substitute for systems.

Most disturbing, though not surprising, is that PIMS had a fire only seven weeks earlier, in its female nursing hostel. That inquiry had already identified deficiencies in smoke detection, alarms, evacuation preparedness, electrical inspection, security response and record keeping.

It recommended fire safety audits, smoke detectors, emergency lighting, marked escape routes, working extinguishers, electrical inspections and written emergency procedures.

One day before the nursery fire, that earlier inquiry was still being sent back for revision.

Consider how often this happens.

The warning had already arrived. The institution had already been told where some of its vulnerabilities lay. Yet the machinery of files, reports and administrative processing rolled on, habitual and indifferent, until fire reached a room of newborns who could neither run nor call for help.

This is why these deaths cannot be filed under “God’s will.” Faith should never become an alibi for human negligence. God gave us responsibility, reason and duty. Where preventable institutional failure contributes to death, the accountability is ours.

Removing people is easier than rebuilding institutions.

-Nasim Zehra

Prime Minister Shehbaz Sharif responded promptly, ordering dismissals and setting up an inquiry committee. After the interim report, eight officials have been suspended and departmental and criminal proceedings ordered. The report has been made public. A new executive director has been appointed, and a separate process announced to propose revamping the hospital.

These are decent first steps.

But removing people is easier than rebuilding institutions.

The real test begins now. Can PIMS become a professionally administered hospital where equipment works, staff are present, fire exits open, emergency procedures are practiced rather than filed, responsibility is identifiable, and the poor are treated with the dignity that wealth buys elsewhere?

PIMS should be the test case for whether Pakistan can convert outrage into institutional reform.

And there is a responsibility beyond government.

Journalists, anchors, parliamentarians, activists and citizens with platforms must ask an uncomfortable question. Will we still be asking about PIMS in three weeks? In three months?

Or will we move on too?

Fourteen babies cannot return. But their terribly brief lives can still force us to confront what we have accepted for too long: that after the initial roar it is fine to let the powerful off the hook, that it is fine for the state to give the poor worse safety and worse services than everyone else.

It is not fine.

The prime minister has undertaken to turn PIMS around. Now he must deliver, and the rest of us must keep the light on him, his team and the institution until he does.

Keep the focus. Keep asking. Keep humanity alive.

Nasim Zehra is an author, analyst and national security expert. Twitter: @NasimZehra