- No evidence of arson, oxygen leak as ignition source.
- Criminal probe recommended into AC maintenance chain.
- Nursery housed 15 newborns in 10-bed unit.
ISLAMABAD: A comprehensive inquiry into the Pims nursery fire that killed 14 newborns has concluded that an electrical fault in the supply cable of air conditioner number two was the most probable cause of ignition, but that the catastrophe resulted from “systematic and institutional failures”.
The report, a copy of which is available with Geo News, found that the fire became visible at approximately 6:38am and dense smoke engulfed the nursery within one to two minutes, leaving an “exceptionally narrow rescue window.”
The emergency was not reported to the Capital Emergency Service until 6:54am — a 16-minute gap the committee identified as a principal chronological concern, though CES itself responded within minutes of confirmed notification.
The committee established that the fire did not result from arson, multiple ignition points, an external IESCO fault, a pre-fire oxygen leak, or an incubator or warmer.
The most probable point and mechanism of ignition was identified as abnormal localised electrical heating in the AC Unit No 2 supply cable, though the precise electrical defect and responsible duty holder were said to remain to be individualised.
Systemic failures
The report found that PIMS and its senior management bore the principal institutional responsibility for failing to convert known fire safety risks, prior warnings and assigned duties into an effective and verified safety system.
15 non-self-evacuating neonates were housed in a stated ten-bed nursery while only two doctors and two nurses were immediately available — a situation the committee described as “a serious operational mismatch.”
The nursery did not have a functional automatic smoke detection and fire alarm system or sprinkler protection, leaving human observation and manual communication as the primary means of detection.
The committee found no adequately documented, approved or rehearsed nursery-specific fire and neonatal evacuation system capable of safely evacuating the actual patient load, and said the record did not demonstrate a systematic, periodic and traceable preventive electrical safety regime covering cables, terminations, insulation, earthing, breakers and thermal hotspots.
Prior warnings ignored
The report noted that fire and life safety risks at PIMS were known well before the tragedy.
CDA correspondence, Federal Ombudsman observations from 2015, PIMS’s own 2024 acknowledgement of ageing fire safety infrastructure and, most significantly, the Nursing Hostel fire of July 6, 2026 — just seven weeks earlier — had all flagged similar deficiencies.
The committee found that prior warnings and the July 2026 fire recommendations had not been converted into a comprehensive, time-bound and independently verified corrective programme before August 26.
“The specific AC 2 defect may not have been foreseeable, but the need for stronger fire preparedness was,” the report said.
The committee was clear that frontline personnel who attempted rescue should not be blamed for the institutional failures that preceded the fire.
“The objective record establishes prompt alarm raising, entry, rescue and treatment efforts by frontline personnel and does not support the generalised allegation that doctors, nurses or security staff abandoned the neonates,” the report stated.
It added that “responsibility must attach to the duty holder who had the knowledge, authority and opportunity to prevent or mitigate a proved failure, not simply to the individual most visible after the disaster.”
Criminal investigation recommended
While the committee said no named individual was presently found criminally guilty, it recommended focused criminal investigation into possible culpable electrical installation or maintenance failure relating to AC Unit 2, obstruction of mandatory emergency routes, culpable non-action despite specific prior warning, and any proved culpable delay in external emergency notification.
The report recommended contractual scrutiny of Belfort Security Services and engineering contractor BE Engineers, and said PIMS’s retained duties of supervision, verification and enforcement remained separate from contractor obligations.
