The PIMS fire and the failures behind it: What the inquiry report says | The Express Tribune

The inquiry committee formed by Prime Minister Shehbaz Sharif to investigate the fire that killed 14 newborns at Islamabad’s Pakistan Institute of Medical Sciences (PIMS) has now laid out a grim account of what happened — and what, in the committee’s view, failed to happen before the flames took hold.

After the committee presented its interim report, the premier approved the immediate suspension of eight officials and ordered departmental as well as criminal proceedings against those identified as responsible.

The report found serious deficiencies in fire safety, emergency preparedness and supervision at the hospital, while stopping short of settling the precise source of the blaze.

So what, exactly, did the committee find?

The answer lies not only in the question of what started the fire, but in a more consequential one: why a fire that began in a hospital nursery was allowed to become a catastrophe.

Two minutes to catastrophe

The committee reconstructed the sequence of events primarily through CCTV footage. The footage became the central piece of evidence in reconstructing the final minutes before the nursery was overwhelmed.

According to the report, Charge Nurse Nasreen was first seen rushing out of the nursery at about 6:38:15am on Aug 26 to seek help. Roughly 20 seconds later, she and security guard Maria re-entered the nursery, by which time flames were already visible. Staff Nurse Razia entered at 6:38:56am and emerged eight seconds later carrying a baby before attempting to go back inside. Dr Abdul Rehman appeared shortly afterwards. Within minutes, dense smoke had obscured the CCTV cameras.

“The Nursery environment deteriorated catastrophically within approximately two minutes,” the committee observed.

It said the footage did not support claims that frontline doctors and nurses had abandoned the newborns. Instead, it showed medical, nursing and security staff making repeated rescue attempts as the fire spread. The committee, however, distinguished those efforts from the broader question of whether the institution had adequately prepared its staff to respond to such an emergency.

The first spark remains a mystery

The inquiry has yet to determine what ignited the fire. Investigators examined multiple possibilities — an air conditioner, an incubator or infant warmer, an electrical short circuit or an overloaded plug — while Iesco records showed no external feeder fault, shifting scrutiny to the hospital’s internal electrical system.

Maintenance records indicated that several incubators had recently been serviced and returned in working order. But the report noted that those records could not verify the safety of the plugs, sockets, wiring or circuits to which the equipment was connected. The committee therefore considered an internal electrical or equipment-related origin plausible, without attributing the blaze to any single device.

“The precise ignition source remains technically unresolved,” the report said.

Yet the committee draws a distinction that underpins its findings: identifying the first spark is not the same as explaining the scale of the tragedy. “The cause of ignition and the causes of the consequences are related but analytically distinct,” it observed. The central question, it suggests, was not simply what caught fire, but what allowed it to become catastrophic.

The doors, the alarms and the call for help

One of the most consequential questions concerned the hospital’s ability to detect, contain and evacuate a fire.

The inquiry found evidence that rescue and evacuation were attempted, but it could not establish that the MCH/Nursery had an approved, communicated, trained and rehearsed fire and neonatal evacuation procedure.

The hospital had standard operating procedures, but the committee found no detailed plan for the most basic demands of a nursery fire: who raises the alarm, calls emergency services, assumes command, unlocks exits and carries critically ill newborns to safety.

The omission was especially consequential. The infants could not flee on their own.

The Capital Emergency Service also found fire and life-safety arrangements inadequate, with some emergency exits or escape routes locked or obstructed. Firefighters were reportedly forced to open locked exit doors.

The committee has yet to determine responsibility or whether the blocked exits delayed evacuation. But it described the findings as serious prima facie deficiencies.

An Overture to Disaster

What makes the findings especially stark is that the warning had come before the fire. On July 6, PIMS had experienced a fire at its Female Nursing Hostel.

The report draws attention to institutional neglect following that fire where the inquiry had already identified serious lapses in smoke detection, fire alarms, evacuation preparedness, electrical inspections, security response and record-keeping, recommending a raft of corrective measures ranging from fire-safety audits and alarm systems to emergency lighting, electrical inspections and formal emergency-response protocols.

Yet, on Aug. 25 — a day before the nursery fire — the earlier inquiry was still being returned for revision for failing to adequately address its terms of reference.

The report describes the timing as significant. While it does not suggest that finalising the earlier inquiry would necessarily have prevented the second fire, it concludes that the institutional process of converting identified failures into meaningful corrective action had remained unfinished when the nursery caught fire.

The institutional process for identifying the causes of the July fire and turning its recommendations into corrective action “had apparently not reached satisfactory closure” before the second fire.

In other words, PIMS had already been warned about fire safety.

The warning had not translated into sufficient protection.

Who was responsible?

The committee’s interim findings shift the question of responsibility beyond those who happened to be on the ward when the flames appeared.

Clinically, fewer officials than required under the duty roster were present. The report singles out the head of Neonatology, Prof Dr Sadia Riaz, and Senior Registrar Dr Nagham, recommending suspension and proceedings under the E&D Rules 2020.

The larger failures, however, were administrative. After the July fire, the committee found that PIMS had not completed essential fire-safety measures, including drills, checks of firefighting equipment and detailed emergency protocols.

It recommended proceedings against four senior PIMS officials — Executive Director Prof Dr Imran Sikandar; Joint Executive Director, MCH, Dr Mutahir Shah; Joint Executive Director (Non-Medical) Ch Waris Ali Raza; and MCH Director Dr Nosheela Amjad. It also recommended action against Capital Emergency Service Director General Dr Abdul Rehman and Assistant Director Security Muhammad Usman, citing failures including alleged dereliction of duty and absence from duty without leave.

The committee further found Belfort Security Services in breach of its contractual obligations and recommended proceedings under the relevant laws.

But these remain interim recommendations, not findings of criminal guilt. The committee said accountability must ultimately follow the chain of duty, knowledge, omission and consequence.

The call that came too late — or perhaps not

The chronology of the emergency call remains unsettled.

CCTV places the first signs of the fire at around 6:38am. CES records show its first call at about 6:54am, dispatch a minute later and arrival at roughly 7:01am. Yet witness accounts suggest an earlier call may have been made.

The committee has therefore resisted assigning blame for the apparent gap, calling for telephone records, control-room logs, emergency-service data and CCTV timings to establish what happened.

The deeper question is what occurred inside the hospital before professional help was summoned.

What changes now?

The committee has called for immediate fire, life-safety and electrical audits across PIMS, beginning with high-risk areas such as the NICU and nursery.

It has recommended testing alarms, extinguishers, emergency lighting, electrical systems and fire exits; inspecting incubators, warmers, air-conditioning units, sockets and wiring; and conducting practical evacuation drills involving medical, nursing, security and engineering staff.

It also calls for a clearly defined command structure under which a fire triggers an internal alarm, mobilises designated responders and immediately alerts CES/Rescue 1122.

Most significantly, every deficiency is to be placed on a time-bound compliance mechanism, with a named officer or agency, a deadline and independent verification.

Because the tragedy was not simply a story of how quickly the flames spread.

It was also a reckoning with what the hospital knew before the fire — and what remained undone.