ISLAMABAD: An inquiry committee investigating the Aug. 26 fire at a nursery in Pakistan's largest hospital that killed 14 newborns has found "systemic and institutional failure" and determined an electrical fault was the most likely cause of the blaze, according to a report on Tuesday.
The fire at the Mother and Child Hospital at the Pakistan Institute of Medical Sciences, or Pims, sparked concerns over fire safety measures and calls for accountability, with criminal action ordered against eight officials. The committee, headed by former interior secretary Shahid Khan, was formed on Prime Minister Shehbaz Sharif's directives the day of the fire and presented its findings in a 43-page report.
The committee concluded that "systemic and institutional failure is established, while individual responsibility varies with the strength of the evidence." It said Pims and its senior management "bear the principal institutional responsibility for failing to convert known risks, prior warnings and assigned duties into an effective safety system."
"Fourteen newborns were lost not because one safeguard failed, but because too many safeguards were absent, weak, delayed or never verified to be working," the report declared.
The committee's conclusions followed a 52-task investigation drawing on forensic evidence, CCTV footage, call records, engineering and maintenance documents, clinical and casualty records, witness statements, contracts and regulatory records.
Electrical fault most probable cause
The report said the strongest technical evidence, from the National Forensics Agency, identified the electrical supply cable of AC Unit No. 2 near or over AC Unit No. 1 as the most probable point of ignition. Abnormal localized electrical heating — possibly from excessive current, a high-resistance connection or another localized defect — most likely caused insulation failure and ignited nearby combustible material, it said.
The evidence did not establish arson, multiple ignition points, an external fault of the Islamabad Electric Supply Company, a pre-fire oxygen leak, or an incubator or warmer as the source, the committee determined.
"The fire was therefore most probably electrical in origin, although the precise defect and the person or entity responsible for preventing it require separate determination," the report read.
The committee said maintenance records showed the nursery air conditioners had been serviced but did not "demonstrate a sufficiently systematic and traceable electrical safety regime covering cables, terminations, insulation, earthing, breaker protection and thermal hotspots."
"The critical distinction is that equipment being operational is not the same as its electrical installation being demonstrably fire safe," it said.
Report cites history of unaddressed warnings
The report pointed to a "history of known but incompletely closed risks," saying earlier correspondence by the Capital Development Authority, the Federal Ombudsman's 2015 findings, Pims' own 2025 acknowledgement of aging fire safety infrastructure, and especially a July 6 Nursing Hostel fire had already highlighted deficiencies in detection, alarms, electrical inspection, evacuation, firefighting equipment, drills and emergency planning.
"Yet those warnings had not been converted into a comprehensive, time-bound and independently verified corrective programme before the Nursery fire," the report said. "The specific AC 2 defect may not have been foreseeable; the need for stronger fire preparedness plainly was."
The report noted that 15 "medically fragile, non-self-evacuating neonates were housed in a 10-bed unit, several dependent on oxygen or respiratory support." Only two doctors and two nurses were immediately available, and protected evacuation resources were limited.
No adequately documented, approved, trained and rehearsed nursery-specific fire and neonatal evacuation procedure was demonstrated, nor was a functional automatic smoke detection, alarm or sprinkler system shown to be serving the affected area, according to the report. Combustible materials and the oxygen-supported environment further intensified fire and smoke after ignition, it said.
Frontline staff praised, institutional response faulted
Citing CCTV footage establishing "an exceptionally rapid emergency," the report rejected "any generalised allegation that frontline personnel abandoned the newborns." It said Charge Nurse Nasreen Akhtar, Security Guard Maria Saleem and Staff Nurse Razia Noreen responded within moments, and that "several acted promptly and courageously in circumstances that became untenable within minutes."
The committee distinguished between individual reaction and institutional activation, noting frontline staff acted within seconds at 6:38 a.m., external notification came at 6:54 a.m. and operational arrival at 7:01 a.m. The principal concern was the interval between visible fire and external activation, rather than the response by Capital Emergency Services, it said.
"Pims had not demonstrated a tested incident command system capable of immediately converting detection into alarm, external notification, evacuation, hazard isolation, access management and coordinated rescue," the report read.
Criminal responsibility unresolved
The report said the record "does not presently establish criminal guilt against any named person" but supported focused investigation into four possible lines: culpable electrical installation or maintenance failure relating to AC 2; culpable obstruction of a mandatory emergency route; culpable failure to act despite specific prior warning; and any proved culpable delay in summoning external assistance.
"Criminal responsibility must rest on the duty owed, knowledge or foreseeability of risk, authority to act, the act or omission, degree of negligence, failed safeguard, causal contribution and applicable offence," the report said. It emphasized that frontline responders whose rescue conduct had been "objectively established should not be blamed merely because the outcome was catastrophic."
The report stressed that the engineering, electrical and HVAC chain remained the "most significant unresolved technical accountability line," adding that contractors must be examined only against the duties actually assigned to them.
