Overview
- The one‑member judicial inquiry, whose final report was made public at the end of September and the start of October 2026, found the outbreak began after sewage entered Bhagirathpura’s drinking‑water network and called the incident preventable.
- The commission identified engineering failures — sewer lines placed too close to or crossing drinking‑water pipes, leaks and deterioration — and laboratory tests that showed widespread bacterial contamination including total coliform and E. coli.
- Investigators found repeated administrative and procurement delays that left replacement work unfinished, citing examples of tenders and projects delayed by months to more than two years and a specific 72‑day lapse in processing a key pipeline file.
- The panel named former additional commissioners Bhavya Mittal and Rohit Sisonia and executive engineer Sanjeev Kumar Srivastava as principally responsible while clearing several former municipal commissioners; it also sought separate inquiries into missing original engineering records from 1990–2004.
- As immediate remedies the report recommends departmental and legal probes, monetary relief (Rs 10 lakh per deceased and Rs 2–3 lakh for critically ill patients), and creation of a State Urban Water Supply Authority to strengthen planning, inspection and tender oversight.