PIMS tragedy aftermath

It should not take the deaths of 14 newborns for a major public hospital to discover that its most basic safety systems are inadequate. Yet that is what the PIMS inquiry has effectively revealed. The prime minister has now given authorities three months to implement the short-term measures identified after the fire, but the more important test is whether this deadline finally produces the institutional discipline that repeated warnings and previous recommendations failed to achieve. The inquiry's findings are difficult to dismiss as an unfortunate accident. It identified systemic and institutional failures at PIMS, with senior management bearing primary responsibility for failing to address known safety risks. The fire was most probably caused by an electrical fault, but what turned a fire into a catastrophe was a chain of deficiencies around it. Fire-safety arrangements were inadequate, emergency procedures were weak, the nursery was overcrowded and there was no formally approved and regularly practised procedure for evacuating newborns. External assistance was also called only after a significant delay. The prime minister has ordered implementation of the inquiry's short-term recommendations within three months, called for WHO recommendations to be incorporated into the improvement plan and sought assistance from PKLI on fire safety. He has also ordered free provision of medicines and facilities at PIMS, called for reputable personnel to be appointed and directed that Polyclinic Hospital be audited and restructured. Fire-safety audits have also been ordered. Every corrective measure needs an identified responsibility and independent verification. This is particularly important for a public institution that serves some of the country's most vulnerable citizens. A hospital's real standard is judged by whether its systems function when lives depend on them. The three-month deadline at PIMS is therefore an opportunity to demonstrate that the state can act on institutional failures before they produce another tragedy.