On the morning of August 26, a fire swept through the nursery of the Mother and Child Health ward at the Pakistan Institute of Medical Sciences in Islamabad. Fourteen newborn babies died there. The fifteenth, the only baby a nurse managed to carry out, died on September 17. Now the government says it will give the capital’s largest public hospital a chief executive, more financial and administrative freedom, and a new law to hold it together. That reform is welcome. But it answers a question the inquiry did not ask. The inquiry asked why a hospital that had been warned did not act. Until every newborn ward in the country can show that it has acted, a new title on the director’s door will not keep the next baby safe.
The Health Minister, Mustafa Kamal, told the National Assembly’s standing committee on health on Wednesday that a draft law prepared by a sub-committee of the prime minister would restructure PIMS. Its departments would get more financial and administrative powers. The draft will go to Prime Minister Shehbaz Sharif for approval. The hospital has already split itself into six major components, each to run as a separate hospital with its own head reporting to the chief executive.
None of this is wrong. PIMS is a vast, overstretched institution, and it has a governance problem as well as a safety one. But the families of fifteen babies are owed something more specific than a new organisation chart. They are owed proof that the failures the inquiry described have been fixed, at PIMS and in every other ward like it.
What the inquiry found
The government deserves credit for one thing it did quickly and well. It published its findings. The interim report, put before the prime minister on August 29, reconstructed the morning from CCTV footage almost second by second. The final report, made public on September 15, found “systemic and institutional failure” and made 34 recommendations.
What the reports describe is not a freak accident. A charge nurse came out of the nursery seeking help at 6:38am. Within about two minutes, smoke had blinded the cameras. The ward had no fire alarm and no sprinkler system. Oxygen points were fitted at each incubator, and the health minister said that day that the oxygen made the fire worse. Fifteen medically dependent newborns were being treated in a unit designed for ten. The final report named the electrical supply cable of an air-conditioning unit as the most probable point of ignition.
The morning of August 26, in minutes
Times from the interim inquiry report and the Capital Emergency Service’s records. The committee said other evidence refers to an earlier call and was still checking telephone and control-room logs.
The gap that matters most sits between the first sign of fire and the first call for outside help. The emergency service’s own records show the call arriving about 16 minutes after the nurse raised the alarm. Once called, its crew reached the hospital in six or seven minutes. The delay was inside the hospital. The committee found that PIMS’s procedures did not say who should raise the alarm, who should call the fire brigade, who should take charge, or who should unlock the emergency exits. Of the hospital’s 13 SOPsStandard operating procedures: the written rules that say who does what, and in what order, in a routine task or an emergency., only two sub-sections mentioned fire or emergencies at all. No officer was responsible for fire safety as a main job. It was an extra duty for an assistant director.
The emergency service’s report said fire and life-safety arrangements were “inadequate and compromised”, that escape routes had been found locked or obstructed, and that firefighters had to break through locked fire-exit doors. The committee treated those findings as serious but said each door’s status had to be verified before blame could be assigned to any individual.
A warning that went unanswered
The hardest finding is about the past, not the morning itself. On July 6, seven weeks before the nursery fire, a fire broke out at the hospital’s female nursing hostel. The inquiry into that fire found no adequate smoke detection, no alarms, no record of drills, and no fire-safety inspections. It recommended a full fire-safety audit, working smoke detectors, emergency lighting, and annual electrical inspections. On August 25, the day before the nursery burned, that report was still being sent back for revision.
The committee was careful to say that finishing the July inquiry would not necessarily have saved the babies. But it drew the lesson plainly, in a line that should hang in every hospital director’s office in the country.
“Identifying deficiencies without ensuring implementation does not provide effective institutional protection.”
That is the real subject of this tragedy. Pakistan does not lack inquiry reports. It lacks the habit of closing them. Changing who sits at the top of PIMS may speed up decisions. It does not, by itself, change that habit.
Seventeen or 34?
The clearest sign that the habit has not yet changed came in the same committee room on Wednesday. Mr Kamal said all 34 of the inquiry’s recommendations had been fully complied with. A few minutes later, the hospital’s own executive director, Professor Tanveer Khaliq, told the same committee that about 17 had been implemented.
The inquiry’s 34 recommendations
Statements to the National Assembly’s standing committee on health, November 11, 2026.
Both men may be speaking in good faith. The hospital has done real work. It has expanded its oversight committee, appointed senior administrators, set up a procurement committee, moved to third-party tenders, and trained about 2,000 staff to fight fires and evacuate patients. But when a minister and a hospital chief give Parliament two different numbers for the same list, the public has no way to know which is right.
The prime minister set a clear deadline on September 16. The short-term measures in the inquiry report were to be in place within three months, which means by the middle of December. That is a date the government can be held to. The way to be held to it is to publish, before then, a line-by-line account of all 34 recommendations, with what was done, who signed it off, and who checked it independently.
What every newborn ward needs
PIMS is not the only hospital at risk. In the days after the fire, checks at other public hospitals in the capital, including the Polyclinic, found serious fire-safety gaps, and the prime minister ordered the Polyclinic audited too. The reform the country needs is not one law for one institution. It is a standard every neonatal unit must meet, and must be seen to meet.
First, an independent fire, life-safety, and electrical audit of every neonatal and intensive care unit in public hospitals, federal and provincial, starting with the oldest buildings. Every smoke detector, alarm, extinguisher, hydrant, and exit should be tested and the result written down. Where automatic detection is still missing, a fire-watchA trained person or team assigned to patrol a ward around the clock and raise the alarm, used where alarms or sprinklers are missing or out of order. should cover the gap until it is fixed.
Second, alarms and sprinklers in every ward where patients cannot walk out on their own. Wards that hold them, and that pipe oxygen to every bed, need to detect a fire in seconds and slow it down.
Third, exits that open. Controlled access to a neonatal unit protects babies from abduction, and the inquiry rightly accepted that. But a security lock and a fire exit must be designed so that the first never blocks the second. Every designated exit should be checked every shift, and a locked fire exit should be treated as a disciplinary matter in itself.
Fourth, a named person and a single call. The inquiry asked for a tested protocol in which a fire sets off an internal alarm and alerts the emergency service at the same moment, with a named officer responsible for each step. That costs little and would have closed the gap that mattered most at PIMS. Staff on every shift should drill it, including horizontal evacuationMoving patients sideways, through fire doors, into a protected part of the same floor, rather than down the stairs. It is the standard plan for wards whose patients cannot walk. of incubators and ventilated babies.
Fifth, enough nurses, and no more babies than a unit can safely hold. The inquiry found fewer staff on duty than the roster required, and fifteen babies in a nursery built for ten. Safe staffing is fire safety.
Sixth, publish it. Each hospital should post its audit results and its compliance with every recommendation, signed by a named officer and checked by an independent inspector. Health regulators, federal and provincial, should have the power and the staff to inspect, and to close a ward that fails.
Accountability families can see
Accountability has two halves, and so far the public has seen only the first. Nine officials were named across the two inquiry reports. Eight were suspended in August, and in September the health minister said police had begun criminal proceedings and that the nine were unlikely to be reinstated. Asked on Wednesday what had happened since, he said the officials named had been suspended and the matter referred to the interior ministry. He gave no clear account of further disciplinary or criminal action.
Meanwhile, families have had to go to court. On November 3, the Islamabad High Court issued notices to the federal government and a long list of agencies on a petition seeking registration of a criminal case and compensation for the families, and it suspended an order by a justice of the peaceA sessions judge acting in a special capacity who can order the police to register a case when they have not done so. that had dismissed the request. Parents should not have to litigate to learn whether anyone will answer for their children’s deaths. The government should say, in public, where each case stands, and let the courts and investigators do their work without delay.
The other half of accountability is fairness. The inquiry found that frontline staff did try to save the babies, and it rejected the claim that they simply abandoned them. Staff Nurse Razia Noreen carried one baby out and tried to go back in. The state rewarded her, and it was right to. The lesson of PIMS is not that nurses and junior doctors failed. It is that they were left to face a fire with no alarm, no plan, and locked doors. Responsibility should land where the inquiry placed it: with those who had the duty and the warning and did not act.
“The nurses who ran into the smoke were not the failure. They were left to face a fire with no alarm, no plan, and locked doors.”
The easy objections
The new law and a chief executive will fix PIMS
Pakistan cannot afford sprinklers in every hospital
The prime minister said in August that no mother should again be separated from her child through anyone’s criminal negligence. That is the right promise, and the government has taken real steps toward it: quick suspensions, two published reports, a deadline, and a plan to restructure the hospital. The next step is the one that makes the promise checkable. By the middle of December, every one of the 34 recommendations should be on the public record, with a name beside it. And by next year, every neonatal ward in Pakistan should be able to say, with an inspector’s signature, that its alarm works, its exits open, and its staff know what to do in the first two minutes. Fifteen families are owed nothing less.
