PIMS fire: Inquiry finds electrical fault, systemic failures behind tragedy

ISLAMABAD: An inquiry into the August 26 fire at the Pakistan Institute of Medical Sciences (PIMS) nursery has found that an electrical fault near an air-conditioning unit was the most likely cause of the blaze that killed 14 of 15 critically ill newborns, while a series of longstanding institutional failures contributed to the tragedy.

The inquiry report, ordered by Prime Minister Shehbaz Sharif and released on Tuesday, said the strongest technical evidence from the National Forensics Agency pointed to an electrical cable near AC Unit No 2 as the most probable point of origin.

The fault may have resulted from abnormal localised electrical heating, excessive current, a high-resistance connection or another local electrical defect that damaged cable insulation and ignited nearby combustible material, the report said.

The inquiry found no evidence supporting arson, multiple points of ignition, an external electrical fault attributed to IESCO, or an oxygen leak before the fire. It also found no evidence that an incubator or warmer was the source of the fire.

The committee said the exact nature of the electrical fault and responsibility for preventing it required further investigation.

14 newborns died

The fire broke out in the MCH nursery, where 15 medically critical newborns were being treated in a unit designed for 10 beds.

Many of the infants depended on oxygen or respiratory support, making their rapid evacuation particularly difficult.

The inquiry found that only two doctors and two nurses were present at the time and that resources for safely evacuating the newborns were severely limited.

It said there was no record of an approved, trained and regularly practised evacuation procedure specifically designed for newborns.

The absence of automatic smoke detection, an alarm or a sprinkler system in the affected area was also established, according to the report.

Combustible material and the oxygen-rich environment further intensified the fire and smoke.

The committee concluded that the 14 newborns did not die because of a single failed safety measure, but because multiple safeguards were absent, inadequate, not activated in time or had never been independently verified as effective.

Frontline staff acted within seconds

CCTV footage showed that the emergency developed with exceptional speed, the inquiry said adding that the fire was clearly visible by around 6:38:15 pm, after which front line staff took immediate action.

Charge Nurse Nasreen Akhtar, security guard Maria Saleem and Staff Nurse Razia Noreen acted within moments to try to rescue the babies, the report said.

Noreen rescued one newborn and attempted to re-enter the nursery, it said adding that Dr Muhammad Abdul Rehman was also present at the scene when the fire broke out.

By around 6:39:15 pm, dense smoke had completely impaired the CCTV camera’s view.

The committee rejected the general allegation that frontline staff had simply abandoned the newborns, saying evidence showed that several personnel acted promptly and bravely under extremely difficult circumstances.

It said frontline personnel whose rescue efforts were established by evidence should not be held responsible merely because the consequences of the incident were catastrophic.

Delay in external response

The report identified the period between the fire becoming visible and the activation of external assistance as a major concern.

According to the CES record, external notification was made at 6:54 p.m., dispatch at 6:55 p.m. and operational arrival at 7:01 pm.

The committee described the gap between the fire becoming apparent at about 6:38 p.m. and external assistance being activated as unacceptable.

PIMS could not demonstrate that it had a tested Incident Command System capable of immediately activating alarms, external notification, evacuation, hazard control, access management and coordinated emergency response once a fire was detected.

Longstanding warnings ignored

The inquiry said the tragedy occurred against a backdrop of known risks that should have prompted preventive action by the hospital administration.

Previous correspondence from the Capital Development Authority and recommendations issued by the Federal Ombudsman in 2015 had identified deficiencies, the report said.

PIMS itself acknowledged in 2025 that its fire-safety infrastructure was outdated.

The report said a fire at the nursing hostel on July 6, 2026 had already highlighted shortcomings in timely fire detection, alarms, electrical inspections, evacuation, firefighting equipment, fire drills and emergency planning.

Yet those warnings were not converted into a comprehensive, time-bound and independently verified corrective programme before the nursery fire, it said.

The committee said that even if the specific defect in AC Unit No. 2 had not been identified beforehand, effective fire safety required robust and integrated preparedness, which hospital management had failed to ensure.

Systemic failure

The inquiry found a systemic and institutional failure, while saying individual responsibility would have to be determined under the relevant rules on the basis of available evidence.

It placed primary institutional responsibility on PIMS and its senior management for failing to convert known risks and previous warnings into an effective safety system.

The report said security-chain responsibilities were clearly defined but corresponding standard operating procedures were absent.

It called for further investigation into engineering, electrical and HVAC maintenance and repair issues.

The responsibility of contractors should be determined only on the basis of duties actually assigned to them and further investigation, it said.

Criminal investigation recommended

The committee said the existing record did not establish the commission of a criminal offence by any particular named individual, but identified four areas requiring further criminal investigation.

These included potentially culpable negligence in the electrical installation or maintenance of AC Unit No. 2; culpable obstruction of a mandatory emergency route; failure to act despite specific previous warnings; and proven culpable delay in seeking external assistance.

The criminal investigation should examine the relevant duties, awareness of the risk, authority to act, nature and severity of negligence, failed safety measure, its contribution to the outcome and the elements of any offence under applicable law, the report said.

Recommendations

The committee recommended immediate fire-safety measures, protection of human life and comprehensive electrical safety audits.

It called for effective fire-detection, alarm, firefighting and safe-evacuation systems, along with dedicated newborn evacuation SOPs and realistic fire and evacuation drills.

It also recommended an effective management system for electrical safety and protection of assets.

The committee called for professional, merit-based hospital management, stronger regulatory oversight and an effective compliance mechanism under which every identified deficiency has a responsible officer, deadline, required resources, interim safety measure, independent verification and formal closure mechanism.

Simply approving or initiating a corrective measure should not be treated as evidence of implementation, it said. A safety measure should only be considered implemented once the risk has been practically eliminated and this has been independently verified.

Inquiry process

Prime Minister Shehbaz Sharif constituted the inquiry committee following the August 26 fire at the PIMS MCH nursery.

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 deputy commissioner.

Dr Rashid A Chotani was later included as an expert member from the United States.

The committee submitted an interim report within 48 hours, on Aug. 28. Its zero draft was prepared on Sept. 3, the first draft on Sept. 4 and the final draft on September 6.

The inquiry was based on a 52-point investigative framework and examined 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 said it distinguished between established facts, possible technical conclusions, prima facie responsibility and unresolved matters, and did not treat initial witness accounts as technical evidence where stronger forensic evidence was available.