An inquiry committee formed to look into the fire at the Pakistan Institute of Medical Sciences (PIMS) has said there was “systemic and institutional failure” and that an electrical failure was the most likely cause of the blaze, according to reports on Tuesday.
The fire broke out on August 26 inside a nursery at Pims’ Mother and Child Hospital. It led to the deaths of 14 babies. The incident raised concerns about fire safety in hospitals and led to demands for accountability. Criminal action has been ordered against eight officials involved.
The inquiry was set up on the day the fire happened as directed by Prime Minister Shehbaz Sharif. It was headed by former interior secretary Shahid Khan. The committee has released its findings in a 43-page report that’s available with Dawn.
The report states that “systemic and institutional failure is established, while individual responsibility varies with the strength of the evidence.”
It says that Pims and its senior management bear the institutional responsibility for failing to turn known risks, past warnings and set duties into an effective safety system.
“Administrative, disciplinary, contractual and criminal responsibility must attach where the relevant duty, omission and causal consequence are proved ” the report added.
“The electrical spark explains how the fire began; the institutional system explains why it became a catastrophe.”
“Fourteen newborns were lost not because one safeguard failed but because many safeguards were absent, weak, delayed, or never verified to be working ” the report concluded.
It explained: “The causal chain is coherent. A localised electrical failure probably started the fire; combustible and oxygen-supported conditions accelerated it; inadequate detection and protection failed to contain it; overcrowding limited evacuation capacity and the absence of a rehearsed neonatal emergency system constrained rescue; delayed institutional activation weakened response; and longstanding governance, maintenance and regulatory failures allowed these vulnerabilities to coexist.”
The report pointed out a “history of known but incompletely closed risks,” citing warnings.
These included correspondence by the Capital Development Authority (CDA), the Federal Ombudsman’s 2015 findings, Pims’ own 2025 acknowledgement of ageing fire safety infrastructure and especially the July 6 2026 Nursing Hostel fire, which 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 time-bound and independently verified corrective programme before the Nursery fire ” the report regretted.
“The specific AC 2 defect may not have been foreseeable; the need for fire preparedness plainly was ” it said, referring to the likely fault in the connected electric cable.
“The strongest technical evidence from the National Forensics Agency identifies the АС Unit No. 2 Supply cable near/over AC Unit No. 1 as the most probable point of ignition ” the report said about the cause of the fire.
It explained that there was abnormal localised electrical heating. This was due to excessive current, a high-resistance connection, or another localised defect. Most probably caused insulation failure and ignition of nearby combustible material.
The evidence does not establish arson, multiple ignition points, a fault of the Islamabad Electric Supply Company (IESCO), a pre-fire oxygen leak, or an incubator or warmer as the source, the committee determined.
“The fire was therefore probably electrical in origin although the precise defect and the person or entity responsible for preventing it require separate determination,” the report read.
It further said that the record did not establish locking in of the neonates, conspiracy, sabotage, political protection, manipulation or concealment of casualties, wholesale frontline abandonment or a prolonged delay by Capital Emergency Services (CES) after confirmed notification.
The committee said its conclusions were based on a 52-task investigation drawing upon forensic evidence, CCTV call records, engineering and maintenance documents, clinical and casualty records, duty and attendance material, witness statements, contracts, regulatory records and earlier inquiries.
With Khan as its head, the committee comprised Major General (retired) Dr Khurshid Uttra, Establishment Division Secretary Dr Barrister Nabeel Awan, Islamabad Deputy Commissioner Irfan Nawaz Memon and Dr Rashid A. Chotani (opted member).
As a recommendation, the panel said the health ministry, upon acceptance of the report, should prepare a ” corrective action plan assigning every recommendation to a responsible institution and designated officer with deadlines, resources, interim safeguards, verification authority and closure status”.
Electrical fault
According to the report, the record does not presently show guilt against any named person.
However, the report supported an 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 a specific prior warning; and any proved culpable delay in summoning external assistance.
The report said that criminal responsibility must rest on the duty owed, the knowledge or foreseeability of risk, the authority to act, the act or omission, the degree of negligence in the failed safeguard, the causal contribution, and the applicable offence.
According to the inquiry panel, the maintenance record showed that the nursery ACs had been serviced. The maintenance record did not demonstrate a sufficiently systematic and traceable electrical safety regime covering cables, terminations, insulation, earthing, breaker protection and thermal hotspots.
The committee pointed out that the critical distinction is that equipment being operational is not the same as its installation being demonstrably fire safe. The evidence reveals an institutional gap between keeping equipment running and ensuring that equipment was safe.
Frontline response and institutional shortcomings
Citing CCTV footage, which showed a rapid emergency, the report said the evidence rejects any generalized allegation that frontline personnel abandoned the newborns.
Noting that Charge Nurse Nasreen Akhtar, Security Guard Maria Saleem and Staff Nurse Razia Noreen responded within moments, the report said several acted promptly and courageously in circumstances that became untenable within minutes.
The report also highlighted the vulnerability of the nursery with 15 fragile non‑self‑evacuating neonates housed in a 10‑bed unit, several dependent on oxygen or respiratory support.
I was surprised that two doctors and two nurses were immediately available and that protected evacuation resources were limited.
No adequately documented, approved, trained and rehearsed nursery‑specific fire and neonatal evacuation SOP was demonstrated, nor was an automatic smoke detection, alarm or sprinkler system shown to be serving the affected area, the report read.
It observed that combustible materials and the oxygen‑supported environment further intensified fire and smoke after ignition.
It emphasised that frontline responders whose rescue conduct had been objectively established should not be blamed merely because the outcome was catastrophic.
The committee also called for the response to be distinguished between reaction and institutional activation.
It noted that frontline staff acted within seconds at 6:38am external notification was at 6:54am and operational arrival was at 7:01am. Therefore, the principal concern was the interval between fire and external activation rather than the response by CES.
PIMS had not demonstrated a tested incident command system of immediately converting detection into alarm, external notification, evacuation, hazard isolation, access management, and coordinated rescue.
Although the particular adjoining door visible in the CCTV footage was not established as causative of the fatalities, CES separately reported locked or obstructed routes, establishing an institutional egress concern, the report stated.
It further said that Pims’ security standard operating procedures clearly outlined responsibilities for fire safety, exit management, firefighting equipment, training, access control, keys and emergency reporting. These procedures provided one of the documentary duty chains in the entire inquiry.
“The principal institutional failure was the lack of an integrated patient safety system ” the report stated. “This absence allowed known risks to be scattered across teams, engineering departments, security units, administrative offices, contractors, and regulatory bodies. As a result, correction was incomplete, preparedness was weak responses were. The consequences turned catastrophic.”
The committee also pointed out that the Nursery continued to operate in the Maternal and Child Health building even though a new facility funded by JICA had become available and was gradually being put into use.
“This decision ” the report said, “was not supported by a documented risk assessment, clear justification, or a time-bound transition plan. It presents a prima facie management issue.”
While the hospital did face challenges with staffing and limited resources, the report emphasized that no evidence showed any specific proposal related to Nursery fire safety or AC 2 electrical safety was rejected only because of financial limitations.
“Therefore ” the report concluded, “resource constraints do not by themselves excuse the deficiencies that were identified.”
Responsibilities
Evidence led the committee to launch a criminal investigation into possible wrongful electrical installation or maintenance failure involving AC 2. The investigation also looked at blocking a required emergency exit, failing to act after a warning, and any proven delay in alerting outside emergency services.
The report stated that the files show reasons to start administrative and E&D cases against officers. When an officer has a duty, knows or can foresee a risk, has authority, and then acts or does not act in a way that shows carelessness, bad work, misconduct, missing work without permission, not supervising, or not doing assigned safety duties.
It emphasized that final blame must be decided through legal steps.
The committee said the evidence was not equally strong for every officer.
The security chain has the written duty record. Senior management responsibility needs proof that tasks are assigned, that the manager knows the job, and that the manager has power. Clinical responsibility depends on showing that a required hands‑on or supervisory duty was done.
It added that engineering, electrical, and HVAC responsibility stays key on the side but must be broken down for each person.
The report highlighted that the AC 2 installation and maintenance chain is still the important unanswered technical accountability line.
Responsibility must be traced to the people who designed, installed, changed, checked, kept up, supervised, or certified the circuit in question.
Regarding oversight, the report said the health ministry, Islamabad Healthcare Regulatory Authority (IHRA), and CDA/CES have more responsibility at the institutional, supervisory, and regulatory level than on a personal blame level.
The record shows broken oversight and not enough confirmed closure of risks.
On governance, the report said PIMS needs business assignment and professional managers for admin, engineering, safety, and emergency work.
Clinical seniority by itself cannot replace the need for hospital management skills.
Recommendations
The panel recommended that the hospital carry out audits of fire systems, life safety systems and electrical systems. The panel also urged the hospital to confirm that detection, alarm, suppression and exit systems are working properly.
The panel also called for a dedicated neonatal evacuation operating procedure, complete with realistic drills. The panel demanded emergency notification and incident command. The panel insisted on electrical safety measures and asset management systems. The panel required hospital governance that’s professional and based on merit. The panel asked for regulatory oversight.
The panel further recommended a closed‑loop compliance system. In this system, every deficiency must have an owner, a deadline, the necessary resources, an interim safeguard, independent verification and a formal closure.
The panel said a measure should not be considered implemented simply because it is approved or in process. The panel said a measure is only implemented when the risk has been physically removed and independently verified.
The committee called for a Family Support and Liaison Cell. This cell must provide bereavement support to families who have been affected. The committee also demanded long‑term follow‑up for surviving neonates. The committee asked that any lawful compensation or relief be processed in a prompt manner.
The panel also suggested that PIMS set up a fire and life safety function. The panel also suggested a multidisciplinary Hospital Safety and Vigilance Committee. This committee must have the authority to track deficiencies until they are verified as closed.
The panel further recommended the creation of a time‑bound Safety and Governance Oversight Board. This board would monitor implementation, conduct unannounced audits and report to the competent federal authority.
The panel urged the hospital to keep high‑risk services—such as nursery, NICU, PICU, ICU, HDU and operating theatres— only when the minimum life safety safeguards are physically functional and independently verified.
The panel further said that all critical services still located in legacy buildings should be moved to purpose‑built facilities where possible.
The panel recommended that PIMS be restructured around hospital administration. The panel said that administrative, engineering, biomedical, safety, finance, HR, procurement and emergency management functions should be handled by professionals who’re suitably qualified and experienced.
