Overview
- A fire on August 26 killed 14 of 15 newborns in PIMS’s Maternal and Child Health nursery, and one baby survived after a nurse rescued the child.
- The prime-minister‑mandated inquiry, which issued its final report on Tuesday, September 15, identified an electrical supply cable fault linked to Air Conditioning Unit No. 2 as the most probable ignition point.
- Investigators found the blaze became visible at about 6:38am and external emergency services were not notified until about 6:54am, a delay the committee said sharply narrowed an already tiny rescue window.
- The report documents missing or nonfunctional safety systems, overcrowding in a 10-bed nursery holding 15 non-self-evacuating neonates, no rehearsed neonatal evacuation plan, and failures by PIMS senior management to act on prior warnings.
- The committee recommends focused criminal inquiries into electrical maintenance and blocked exits, administrative proceedings, contractor scrutiny, and immediate independently verified safety audits with named officers held responsible for implementation.