The Islamabad hospital, where 14 newborn babies were killed last month in a fire, had no fire alarms, smoke detectors, or sprinkler system, an official inquiry has found.
It also had escape routes locked or obstructed when firefighters arrived.
The fire, which broke out at the Pakistan Institute of Medical Sciences (PIMS) on the morning of 26 August, was caused by an electrical fault, most likely a defect in the cable supplying one of the ward's air conditioning units, but that "systemic and institutional failure" turned that spark into a catastrophe, the report found, according to Pakistani newspaper Dawn.
"The electrical spark explains how the fire began; the institutional system explains why it became a catastrophe," the report said.
"Fourteen newborns were lost not because one safeguard failed, but because too many safeguards were absent, weak, delayed or never verified to be working."
No adequately documented or rehearsed nursery-specific fire and evacuation procedure existed, the report from an investigative committee headed by a retired civil servant found, nor was any functioning automatic smoke detection, alarm or sprinkler system in place in the affected area.
Fifteen medically fragile newborns, several dependent on oxygen or respiratory support, were housed in a 10-bed unit with only two doctors and two nurses immediately available. The report said combustible materials and the ward's oxygen-supported environment intensified the fire and smoke after it ignited.
The response was significantly delayed at an institutional level, the report found, even though frontline staff reacted within moments. Staff responded within seconds of the fire starting at 6.38am, but external emergency services were not notified until 6.54am, and the first rescue teams did not arrive until 7.01am.
When firefighters arrived at the scene, they found escape routes locked or obstructed, one firefighter told the BBC.
"The doors were locked so they had to break through the windows to enter. Even after getting inside, the doors leading towards the ward were locked," he said. The firefighter, who spoke to the outlet anonymously, said he reached the hospital after the fire was brought under control.
It was "difficult for me to even describe what we saw", he said. "The medical equipment above [the babies] had melted and collapsed onto them."
The Independent has reached out to Pims for a comment on the findings.
The hospital's executive director had previously said the door to the newborn ward was not locked but guarded, because of past incidents of babies being abducted from government hospitals.
The committee found the hospital had received prior warnings that were never acted upon, including a 2015 finding from the Federal Ombudsman, the hospital's own 2025 acknowledgement of ageing fire safety infrastructure, and a fire at its nursing hostel in July 2026 that had already exposed weaknesses in detection, alarms, electrical inspection and evacuation planning.
"Those warnings had not been converted into a comprehensive, time-bound and independently verified corrective programme before the nursery fire," the report said.
The inquiry placed principal institutional responsibility on the hospital and its senior management for failing to convert "known risks, prior warnings and assigned duties into an effective safety system," though it said individual criminal responsibility had not yet been established against any named person.
Pakistan's prime minister has ordered the inquiry's short-term recommendations to be implemented within three months, directed fire safety audits of public and private buildings nationwide, suspended eight officials, and called for criminal proceedings against them.
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