ISLAMABAD: An inquiry committee formed to probe the deadly fire at the Pakistan Institute of Medical Sciences (Pims) has found “systemic and institutional failure” and determined that an electrical failure was the most likely cause of the blaze, it emerged on Tuesday.
The August 26 fire at a nursery in Pims’ Mother and Child Hospital claimed the lives of 14 newborns. The incident raised concerns over fire safety measures and sparked calls for accountability, with criminal action being ordered against eight officials.
Headed by former interior secretary Shahid Khan, the committee was formed on Prime Minister Shehbaz Sharif’s directives on the day the fire occurred. It has presented its findings and recommendations in a 43-page report available with Dawn.
The committee concluded that “systemic and institutional failure is established, while individual responsibility varies with the strength of the evidence”.
It noted that 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 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 too many safeguards were absent, weak, delayed or never verified to be working,” the report declared.
It explained: “The causal chain is coherent. A localised electrical failure most 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 also pointed out a “history of known but incompletely closed risks”.
It said that earlier 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 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 regretted.
“The specific AC 2 defect may not have been foreseeable; the need for stronger fire preparedness plainly was.”
The committee said its conclusions were based on a structured 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.
Citing CCTV footage, which established “an exceptionally rapid emergency”, the report said the evidence “rejects any generalised 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 that “several acted promptly and courageously in circumstances that became untenable within minutes”.
The report also highlighted the “vulnerability” of the nursery, with 15 “medically fragile, non-self-evacuating neonates were housed in a 10-bed unit, several dependent on oxygen or respiratory support”.w
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 SOP (standard operating procedure) was demonstrated, nor was a functional 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”.
The committee also called for the response to be distinguished between individual reaction and institutional activation.
It noted that the 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 visible fire and external activation, rather than the response by the Capital Emergency Services (CES).
“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 strongest technical evidence, from the National Forensics Agency, identifies the АС Unit No. 2 electrical 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 abnormal localised electrical heating — possibly from 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, an external 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 most probably electrical in origin, although the precise defect and the person or entity responsible for preventing it require separate determination,” the report read.
According to the inquiry panel, the maintenance record showed that the nursery ACs had been serviced, but it 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. The evidence reveals a wider institutional gap between keeping equipment running and ensuring that it was safe,” the committee pointed out.
The report stressed that the engineering/electrical/HVAC (heating, ventilation and air conditioning) chain remained the “most significant unresolved technical accountability line”. It added that contractors must be examined only against the duties actually assigned to them.
According to the report, the record “does not presently establish criminal guilt against any named person”.
However, it 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 emphasised that frontline responders whose rescue conduct had been “objectively established should not be blamed merely because the outcome was catastrophic”.
More to follow
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