Concludes criminal responsibility of an individual would have to be determined separately
Javeria, mother of a newborn victim, is consoled following a deadly fire at the Pakistan Institute of Medical Sciences (PIMS) hospital in Islamabad on August 26, 2026. Photo: Reuters
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 Committee therefore concludes that systemic and institutional failure is established, while individual responsibility varies with the strength of the evidence. 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,” the detailed inquiry report read.
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.
Read: PM Shehbaz awards Rs10m cheque to nurse who saved newborn during PIMS fire
“The consequences were magnified by the Nursery’s vulnerability. Fifteen medically fragile, non-self-evacuating neonates were housed in a 10-bed unit, several dependent on oxygen or respiratory support, while only two doctors and two nurses were immediately available and protected evacuation resources were limited,” the report underscored.
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.
Frontline staff acted within seconds
CCTV footage showed that the emergency developed with extraordinary speed. The fire was clearly visible at approximately 6:38:15pm, after which frontline staff moved to rescue the newborns.
Charge Nurse Nasreen Akhtar, Security Guard Maria Saleem and Staff Nurse Razia Noreen were among those who responded within moments, the report highlighted.
Razia Noreen rescued one newborn and attempted to re-enter the nursery. Dr Muhammad Abdul Rehman was also present at the scene.
By approximately 6:39:15pm, dense smoke had obscured the CCTV cameras, the report outlined.
The committee said the evidence did not support allegations that frontline personnel simply abandoned the newborns. Several staff members, it said, took immediate action under extremely difficult circumstances.
The presence of combustible material and oxygen significantly increased the intensity of the fire and smoke, the report said.
Though the report notes, no record was found of formally approved, staff-trained, and regularly practised standard operating procedures (SOPs) specifically designed for the evacuation of newborn babies from the nursery.
Delayed external response
The report, however, raised serious concerns over the institutional emergency response.
According to evidence available to the committee, external notification was made at 6:54pm, dispatch occurred at 6:55pm, and operational assistance arrived at 7:01pm. Therefore, the committee identified the gap between the fire becoming visible at around 6:38pm and the activation of external assistance as a major concern.
PIMS could not demonstrate that it had a tested Incident Command System capable of immediately triggering alarms, external notification, evacuation, hazard control, access management and coordinated emergency operations.
Security, medical and maintenance gaps
The committee found that although the duties of the security chain were clearly defined, corresponding SOPs were not in place. It also highlighted the importance of mandatory medical staffing and supervision in such a high-risk unit.
Maintenance and repair issues involving the engineering, electrical and HVAC departments require further investigation, the committee said.
The report recommended determining contractors’ responsibility on the basis of their actual assigned duties and the findings of further investigation.
It said the available record did not establish the commission of a criminal offence by any named individual, but identified areas warranting further criminal investigation.
These include possible culpable negligence in the electrical installation or maintenance of AC unit no2, obstruction of a mandatory emergency exit, failure to act despite specific prior warnings and proven culpable delay in seeking external assistance.
Committee recommends urgent reforms
The inquiry committee recommended immediate fire-safety measures and a comprehensive electrical-safety audit at PIMS. It called for effective fire-detection, alarm, firefighting and evacuation systems, along with dedicated SOPs for newborn evacuation and realistic fire and evacuation drills.
The committee also recommended an administrative system for electrical safety and asset protection, professional and merit-based hospital management, stronger regulatory oversight and an effective compliance mechanism.
Under the proposed system, every identified deficiency should have a designated responsible officer, a deadline, required resources, interim safety measures, independent verification and a formal completion mechanism.
The report stressed that merely approving a corrective measure or declaring it “under process” should not be considered implementation.
“A safety measure should only be considered implemented when the risk has actually been eliminated, and this has been independently verified,” the report emphasised.
The committee was headed by former federal secretary Shahid Khan and included Major General (retd) Dr Khurshid, Barrister Nabeel Ahmed Awan, the Establishment Division secretary and the Islamabad Capital Territory deputy commissioner.
