Imagine a mother who gave birth only a month ago. Because of medical complications, her newborn had to be admitted to the Neonatal Intensive Care Unit. She handed over her baby to a system she trusted — believing that, if there was one place where her fragile child would be safe, it was an intensive care unit.

She was told that attendants could not stay inside because of the risk of infection. The nursing staff restricted access, security personnel regulated entry, and the main door remained locked. Parents could see their newborn only at designated times, perhaps once or twice a day.

For a mother who had carried that child for nine months, every visit must have carried the same hope: a few more days, perhaps a few more difficult nights, and then she would finally take her baby home. The hospital visits would become less frequent, and life would slowly return to normal.

Tragically, those hospital visits did come to an end — but in a way no parent could ever have imagined.

On a day of profound religious significance, the parents were informed that their newborn had died in a fire. They rushed towards the ward, desperate to reach their child, only to encounter the same barriers that had kept them outside before. In those unbearable moments, access itself reportedly became an obstacle.

The dream was painfully simple: from the mother’s womb to her home. It was shattered within minutes.

A newborn’s right to life, health and protection is among the most basic responsibilities of any healthcare system. When such a life is lost in a fire inside a hospital, we cannot simply call it an unfortunate accident and move on. We must ask what failed before the fire, what happened during those crucial first minutes, and what could have been done differently.

Disasters can happen anywhere. Fires can start, electrical systems can fail and equipment can malfunction. But hospitals, particularly intensive care units, exist precisely because their patients cannot protect themselves. A newborn connected to oxygen, monitors and life-support equipment cannot run towards an emergency exit. Someone else has to be prepared to save that child.

And this is where the uncomfortable questions begin.

Why should a neonatal or any unit in the hospital be so inaccessible that during an emergency reaching those inside becomes difficult? If a door must remain locked for infection control or security, what is the mechanism for opening it instantly during an emergency? Were emergency exits functional? Were staff trained to evacuate newborns? Were fire drills routinely conducted? Were electrical systems and equipment regularly inspected? And could fire, rescue, engineering and hospital emergency teams be mobilised within the first few precious minutes?

These questions are not meant to identify one convenient person to blame.

After every tragedy, there is a temptation to find a name — a security guard, a nurse, a technician, a duty doctor or a department head. Certainly, if negligence occurred, those responsible must be held accountable. But if our investigation ends with one or two individuals, we may miss the much larger problem.

A hospital is a system. Patient safety depends on infrastructure, procurement, electrical safety, maintenance, fire preparedness, security arrangements, staffing, training, supervision and administrative oversight. A security guard follows instructions. A nurse works within established protocols. A department functions within an institution. If those instructions, protocols and systems are inadequate, replacing one person does not make the next patient safer.

That is why the most important question is not simply who was on duty that day? It is whether the system had prepared those on duty for a disaster that could unfold in minutes.

There is another difficult issue we must confront. During a crisis, institutions can become concerned about controlling information, restricting movement and protecting their reputation. But when lives are at stake, institutional reputation must come second. The first instinct must be to rescue, to call for help and to open every possible route to those who can save lives.

The golden minutes of an emergency belong to the victims, not to the institution.

The Pims tragedy should, therefore, become more than another inquiry followed by suspensions, transfers and, eventually, silence. It should compel hospitals across Pakistan to examine their neonatal and intensive care units and ask one very simple question: If a fire starts tonight, can we get every baby out safely?

If the answer is anything other than an unequivocal yes, we have work to do.

For the parents, no inquiry can bring their child back. They had imagined leaving the hospital one day with their baby in their arms. Instead, they left with a loss that will remain with them for the rest of their lives. The least we owe them is to ensure that another mother does not stand outside another locked door, waiting helplessly while her child is in danger.

No single security guard, nurse, doctor or administrator can explain a tragedy of this magnitude. Accountability must be established wherever negligence occurred, but we must also have the courage to look beyond individuals.

No single person is responsible for the Pims incident. The whole system is. We all are.

— The writer is a public health consultant

Published in Dawn, August 28th, 2026