An inquiry into the PIMS nursery fire that killed 14 newborns has identified an electrical fault in the supply cable of air conditioner as the most probable cause of the blaze, while attributing the tragedy to broader “systematic and institutional failures.”
The report said the fire became visible around 6:38am, with dense smoke filling the nursery within one to two minutes, leaving an extremely limited rescue window. The Capital Emergency Service was notified at 6:54am, creating a 16-minute gap that the committee flagged as a key concern.
Investigators ruled out arson, multiple ignition points, an external IESCO fault, an oxygen leak and malfunctioning incubators or warmers.
The inquiry held PIMS and its senior management principally responsible for failing to address known fire-safety risks.
The nursery was accommodating 15 non-self-evacuating newborns despite having 10 beds, while only two doctors and two nurses were immediately available.
It also lacked functional automatic smoke detection, fire alarms and sprinklers, and had no adequately documented or rehearsed evacuation plan for neonatal emergencies.
The committee noted that fire-safety concerns had been raised repeatedly, including after a Nursing Hostel fire on July 6, 2026, but corrective measures were not implemented before the nursery tragedy on August 26.
The report said frontline doctors, nurses and security personnel should not be blamed for institutional shortcomings, noting evidence of alarm-raising, rescue and treatment efforts.
Although no individual was declared criminally liable, the committee recommended a focused criminal investigation into possible electrical maintenance failures, blocked emergency routes, failure to act on prior warnings and any culpable delay in notifying emergency services.
It also recommended scrutiny of Belfort Security Services and engineering contractor BE Engineers, while stressing that PIMS retained responsibility for supervision and enforcement.
