The fire broke out in the MCH nursery, where 15 critically ill newborn babies were being treated. According to the inquiry report, 14 babies died while one was safely rescued.
The inquiry committee conducted a 52-point investigation covering not only the cause of the fire but also the factors that turned the incident into a major tragedy. It examined the emergency response, arrangements for evacuating newborns, individual and institutional responsibility and the reforms required to prevent similar incidents.
The investigation included forensic evidence, CCTV footage, call records, engineering and maintenance documents, medical and incident records, duty and attendance records, witness statements, regulatory records and previous inquiries.
According to the report, CCTV footage confirmed that the emergency situation developed with unusual speed. By around 6:38:15pm, the fire had clearly intensified, while thick smoke had completely affected the CCTV cameras by around 6:39:15pm.
The inquiry report said frontline staff acted within seconds to try to save the newborns. Charge Nurse Nasreen Akhtar, security guard Maria Saleem and staff nurse Raziya Noreen immediately took action.
Nurse Raziya Noreen rescued one newborn baby and attempted to re-enter the nursery to save other children. Dr Muhammad Abdul Rehman was also present at the scene and participated in the rescue efforts.
The report rejected the general allegation that frontline medical staff had abandoned the newborns. It said available evidence showed that several staff members acted quickly and bravely under extremely difficult circumstances.
Electrical fault identified as most likely cause
The National Forensic Agency’s strongest technical evidence indicated that the most likely point of origin was the electrical cable of AC unit number 2, located near AC unit number 1.
The report said an unusual local electrical heating event, excessive current, a high-resistance connection or another local electrical fault may have damaged the cable insulation and ignited nearby combustible material.
The investigation found no evidence supporting arson, a fire starting from multiple locations, an external electrical fault attributed to the Islamabad Electric Supply Company (IESCO), or an oxygen leak before the fire.
There was also no evidence that an incubator or warmer was the source of the fire.
The inquiry concluded that an electrical fault was the most likely cause, but said the exact nature of the electrical failure and the person or institution responsible for preventing it required separate investigation.
Maintenance records showed that the nursery’s air-conditioning units had been serviced. However, the report found that there was no effective system for comprehensive electrical safety testing of cables, terminations, insulation, earthing and breaker protection.
The committee stressed that the fact that electrical equipment was functioning did not mean that its electrical installation was completely fire-safe. According to the report, there was a significant institutional gap between keeping equipment operational and ensuring its complete electrical safety.
Overcrowding and lack of evacuation systems worsened tragedy
The inquiry found that the sensitive conditions inside the nursery significantly increased the impact of the fire.
The 10-bed unit was treating 15 medically critical newborns, many of whom were dependent on oxygen or respiratory support. Their condition made rapid evacuation extremely difficult.
Only two doctors and two nurses were present at the time, while resources for safely evacuating the babies were extremely limited.
The committee found no record of a formally approved, trained and regularly practised standard operating procedure for evacuating newborns from the nursery.
The report also found no evidence of an effective automatic smoke detection, alarm or sprinkler system in the affected area.
The presence of combustible material combined with an oxygen-rich environment greatly intensified the fire and smoke, making the situation even more dangerous for the newborns.
Previous safety concerns
The inquiry also examined whether the hospital had previously been warned about safety shortcomings. The report noted that fire safety deficiencies had been highlighted through correspondence from the Capital Development Authority and recommendations from the Federal Ombudsman.
PIMS administration had also acknowledged in 2025 that its safety system was outdated, according to the report.
The committee said the tragedy was not the result of a single failure. Instead, the deaths occurred because multiple safety measures were absent, ineffective, not activated in time or had remained inadequate over a long period.
Recommendations
The inquiry committee recommended further investigation into the exact nature of the electrical fault and the responsibility of individuals or institutions involved in preventing it.
It also recommended electrical safety audits, stronger fire detection and alarm systems, effective firefighting arrangements and proper emergency evacuation systems.
The committee stressed the need to ensure safe evacuation arrangements for newborns and other critically ill patients and to strengthen electrical and fire safety systems across hospitals.
The report said the tragedy highlighted serious institutional gaps and stressed that comprehensive safety measures must be implemented to prevent similar incidents in the future.
