PIMS Hospital Fire in Islamabad: When Government Negligence Becomes a System.

PIMS Hospital Fire in Islamabad: When Government Negligence Becomes a System

Update

The initial findings of the inquiry committee constituted by Prime Minister Shehbaz Sharif have reportedly revealed serious institutional shortcomings at PIMS. According to reports based on the committee’s submitted findings, the treatment and medical facilities at the hospital were found to be below international standards. The inquiry also identified deficiencies in fire-safety arrangements, emergency preparedness and response, while relevant PIMS staff members were reportedly found absent from their duty stations when the fire broke out. The committee has identified responsibility for the failures and recommended disciplinary or other appropriate action against those held responsible.

The final inquiry report, along with its detailed recommendations, is expected to provide a more comprehensive picture of what went wrong and what action should follow. But based on our experience and research into the working of government institutions, we believe that practical measures should not wait for another tragedy. We therefore recommend the following steps—not only for PIMS or other hospitals, but for all government institutions where public safety and essential services are involved. These measures are aimed at identifying weaknesses before they turn into disasters, strengthening accountability and making government institutions more proactive, responsive and capable of preventing avoidable tragedies.

Main Article

The fire that broke out in the neonatal ward of Pakistan Institute of Medical Sciences (PIMS), Islamabad, in the early hours of August 26, killing 14 newborn babies, is being investigated as a tragic incident.

But it should not be treated only as a story about a fire.

It raises a much larger question: why do weaknesses in government institutions remain unnoticed, uncorrected and eventually become capable of producing a major disaster?

The answer is not always one careless employee, one faulty piece of equipment or one bad decision. In many cases, institutional negligence develops gradually. A procedure is introduced, becomes routine, stops being questioned, and eventually operates at the bare minimum. Small gaps appear. Nobody owns them. Nobody audits them. And because nothing immediately goes wrong, the system continues.

Until it doesn’t.

1. Government needs a proactive culture

A well-run institution does not wait for an accident to discover its weaknesses.

Its officers should routinely look for potential failures before they happen. They should ask where procedures can break down, what risks have emerged and which safeguards may no longer be working.

This is the difference between a reactive department and a proactive institution.

A reactive system asks, “What went wrong?”

A proactive system asks, “What could go wrong next?”

Pakistan’s government departments need much more of the second approach.

2. When procedures become routine, vigilance disappears

Government departments often have carefully designed procedures. The problem begins when those procedures become routine.

Once a procedure has been followed for years, people can stop examining whether it still works.

A checklist becomes paperwork. An inspection becomes a signature. A safety requirement becomes something that is assumed to have been dealt with.

The department continues functioning, but its performance gradually falls to the bare minimum.

This is one of the most dangerous forms of institutional decline because everything may appear normal from the outside.

3. SOPs need audits, not just documents

Having Standard Operating Procedures is not enough.

Every important procedure needs periodic verification. Are emergency exits actually accessible? Are safety systems functional? Is equipment being maintained? Has staff been trained for an emergency? Have circumstances changed since the procedure was written?

An SOP that is never tested can eventually become a document rather than a working system.

Regular audits should therefore be part of normal administration, not something introduced after a tragedy.

4. Ad-hoc instructions create an ad-hoc institution

Another weakness is the culture of daily instructions.

Employees receive orders from senior officers, complete some tasks, leave others pending and return the next day to a new set of instructions.

The institution then becomes dependent on what the boss wants today, rather than on what the organisation needs continuously.

This creates a strange kind of administrative disorder: everybody is busy, but nobody is necessarily managing the whole system.

A government department needs a permanent operating structure, not a continuous stream of temporary instructions.

5. Too much centralisation, too little initiative

In highly centralised organisations, even relatively small decisions move upward through the hierarchy.

Everyone looks to the person above them.

Eventually, a senior officer may be expected to keep track of dozens of matters that should have been handled lower down.

No individual can effectively monitor everything.

The result is predictable: important details escape attention, problems remain unresolved and employees learn that waiting for instructions is safer than taking initiative.

Responsibility should come with authority.

An officer responsible for safety should have enough authority to correct a safety problem without waiting for permission from the top.

6. When responsibility is divided, ownership can disappear

Perhaps the most dangerous weakness is not a lack of responsibility but a lack of ownership.

A large government institution may have different people responsible for administration, engineering, equipment, security, fire safety, budgets and supervision.

Everyone has a role.

But when something goes wrong, it can become difficult to identify the person who was actually responsible for ensuring that the entire system worked.

This creates a gap between responsibility and accountability.

A strong institution should have clear ownership of every critical function. Someone must be answerable not merely for performing a task, but for ensuring that the required outcome is achieved.

7. Frequent transfers destroy institutional memory

Government departments also suffer when officers are transferred too frequently.

An officer may arrive, learn the department’s problems, identify weaknesses and begin understanding how the system really works—only to be transferred before meaningful improvements are made.

The next officer starts again.

Over time, institutional memory disappears.

Unresolved problems can survive from one administration to another because the people who knew about them have moved elsewhere.

Continuity is therefore not just an administrative convenience. In safety-critical institutions, it is part of accountability.

8. Old procedures cannot manage new risks

Some government institutions continue to operate according to procedures designed for a very different time.

But modern institutions have become increasingly complex.

A modern hospital, for example, depends on electrical systems, oxygen infrastructure, specialised medical equipment, air-conditioning, electronic monitoring and emergency systems. These create risks that require specialised knowledge and continuously updated safety procedures.

A procedure does not become effective simply because it is old.

Sometimes the age of a procedure is itself a warning that it needs to be reviewed.

9. The system can reward obedience instead of performance

There is another reason employees may hesitate to act proactively.

In a rigid bureaucracy, following instructions can be safer for an individual’s career than taking initiative.

If something goes wrong after following a superior’s order, responsibility can be passed upward.

But if an officer independently takes a decision and something goes wrong, that officer may become personally vulnerable.

The result is a culture in which people learn to ask:

“What have I been told to do?”

rather than:

“What needs to be done?”

Good administration must reward responsible initiative and actual outcomes—not merely obedience and paperwork.

10. Artificial intelligence can help close the gaps

This is where modern technology offers an opportunity that previous generations of administrators did not have.

Artificial intelligence cannot replace human responsibility. But it can provide a continuous monitoring layer around government procedures.

Imagine a department with dozens of employees, hundreds of tasks and numerous safety requirements.

An AI-supported system could continuously examine checklists, inspection records, maintenance schedules and SOP compliance. Instead of producing another mountain of paperwork, it could give senior management a concise exception report:

• what is working;
• what is overdue;
• what has repeatedly been ignored;
• where an inspection has not taken place;
• which safety requirement is not being met;
• where attention is urgently needed.

This would change the role of senior management.

Instead of trying to watch everything, they could focus on the places where the system itself is signalling a growing risk.

From tragedy to institutional learning

The most painful lesson from the PIMS fire is that negligence does not necessarily arrive as one dramatic decision.

It can grow quietly.

A procedure becomes routine. A check is missed. Maintenance is postponed. An exit is not properly examined. Responsibility becomes divided. An officer waits for instructions. A problem is carried forward because nothing has yet gone wrong.

Each weakness appears manageable on its own.

But these weaknesses can eventually connect.

That is where the real danger lies.

Pakistan has seen this cycle before: a serious accident occurs, public outrage follows, inquiries are announced, officials are suspended, promises of reform are made—and after some time public attention fades.

Then the system returns to normal.

The objective should be to break that cycle.

The 14 newborn babies who died at PIMS cannot be brought back. But their deaths should force us to examine something larger than the immediate cause of one fire.

We need government institutions that look for risks before disasters expose them; systems that are audited instead of merely documented; officers who are empowered to act; clear ownership of critical responsibilities; and technology that continuously identifies the gaps human beings inevitably miss.

Government negligence becomes a system when nobody is responsible for finding the small failures before they become a big one.

The real reform, therefore, is not simply to punish someone after a tragedy.

It is to build institutions in which the next tragedy is harder to happen in the first place.