- The PIMS inquiry identified shortcomings spanning detection, suppression, emergency egress, evacuation planning, training and safety governance.
- The hospital had received earlier warnings about fire-safety deficiencies, including following a fire at its nursing hostel, but the inquiry found that identified risks had not been comprehensively closed out.
- Investigators recommended fire, life-safety and electrical audits alongside a system for tracking deficiencies through to verified closure.
The investigation into the 26 August fire at the Pakistan Institute of Medical Sciences (PIMS) in Islamabad found what it described as “systemic and institutional failure”, with the hospital’s senior management held responsible at an institutional level for failing to address known risks and previous warnings.
The inquiry determined that a localised electrical failure was the most likely source of ignition. However, its findings focused heavily on the safeguards that were absent or ineffective once the fire began.
According to the 43-page report, the affected neonatal area did not have a functioning automatic smoke detection, fire alarm or sprinkler system. It also found no adequately documented, approved and rehearsed fire and neonatal evacuation procedure for the nursery.
This was particularly significant given the vulnerability of the occupants. The inquiry noted that many of the newborns were premature or medically fragile, while staff had not been adequately trained in procedures including emergency evacuation and isolation of the oxygen supply.
The investigation also examined the condition of escape routes. Pakistan’s Capital Emergency Services reported that emergency exits and escape routes were locked or obstructed, with firefighters having to forcibly open some doors and access points. The inquiry cautioned that controlled access to a neonatal unit can have a legitimate security purpose, but stressed that emergency routes must remain immediately accessible when required.
The findings point to a wider issue than the individual fire-safety systems. The inquiry identified a history of risks that had already been recognised but not fully addressed, including deficiencies highlighted by an earlier fire at the hospital’s nursing hostel in July.
Despite those warnings, the report said they had not been converted into a comprehensive, time-bound and independently verified corrective programme before the neonatal fire.
That distinction between identifying a risk and demonstrating that it has been resolved is central to the inquiry’s recommendations. The panel called for immediate fire, life-safety and electrical audits, physical testing and documentation of detection, alarm, suppression and egress systems, alongside dedicated evacuation procedures for neonatal areas.
It also recommended a “closed-loop compliance system” capable of tracking safety deficiencies through to verified closure, as well as a permanent multidisciplinary hospital safety committee.
The recommendations come as Pakistani authorities face wider scrutiny over fire preparedness in public buildings. Prime Minister Shehbaz Sharif has ordered the inquiry’s short-term recommendations to be implemented within three months, alongside broader fire-safety audits of public and private buildings. Eight officials were also suspended and criminal proceedings ordered following the initial findings.
The case underlines a challenge that extends beyond the availability of equipment: effective fire safety depends on detection and protection systems being operational, escape routes remaining usable, staff understanding their roles and identified deficiencies being tracked until corrective action has been independently verified.
In high-risk environments such as hospitals, where many occupants cannot evacuate without assistance, those layers of preparedness are particularly critical.
