hen fourteen newborns died in their cots, warmers and incubators at the Mother and Child Health Centre of the Pakistan Institute of Medical Sciences on August 26, they should have been in one of the safest wards in the federal capital. Instead, the nursery had never had a routine inspection by the healthcare regulator created to protect them.

The babies could not move, run or call for help when thick smoke and flames swept through the neonatal nursery. They depended entirely on adults, hospital managers, government departments and a regulatory system tasked with ensuring that healthcare establishments meet minimum standards of safety and care.

The system failed them.

The Islamabad Healthcare Regulatory Authority did not routinely inspect the PIMS before the fire because of a serious flaw in the Islamabad Healthcare Regulation Act, 2018. While private healthcare establishments must be registered, inspected and licensed, public hospitals are deemed registered under Section 28 of the law.

The federal government, not the IHRA, is responsible for certifying that public hospitals comply with the authority’s minimum safety standards. Public hospitals must apply for licences for the services they provide but the PIMS had not applied for a licence, IHRA officials say.

The country’s premier public hospital remained in a regulatory vacuum. The IHRA set standards but did not inspect the facility. The government was responsible for certifying compliance but did not ensure that the PIMS had secured a licence or undergone the scrutiny that should have preceded its operation.

The inquiry into the fire ordered by the prime minister could not conclusively determine the source of ignition. It did find failures in fire-safety arrangements, emergency exits, evacuation planning, preparedness and coordination. It noted the possibility of an electrical or equipment failure.

The failure was not limited to an air-conditioner, an incubator or a socket. It included a failure to identify risks until they became fatal.

Dr Quaid Saeed Akhunzada, IHRA’s first chief executive officer and a public-health expert, says that the PIMS tragedy must be seen as a collapse of preventive oversight. A regulator’s purpose, he says, is not to appear after a disaster, issue notices and hold meetings but to inspect, identify danger, order corrective measures and close unsafe services so that the patients are not harmed.

The IHRA board of governors is already under scrutiny over its independence. Last year, during parliamentary proceedings, objections were raised to the membership of people who owned or were associated with private healthcare establishments that fell under the regulator’s jurisdiction.

Such affiliations do not automatically prove misconduct. However, they create room for conflict.

Dr Muhammad Riaz Shahbaz Janjua, IHRA’s former chairman, associated with HBS Dental Hospital, had maintained that his affiliation was disclosed before his appointment. However, the National Assembly’s health committee questioned whether private hospital owners should serve on a regulatory board in the first place.

The board has now collapsed with the resignation of its chairman and a majority of members in the aftermath of the PIMS tragedy. The federal government has to reconstitute it. Experts say that merely replacing some members will not address the flaws unless the law is amended to make public hospitals subject to independent inspection, licensing and enforcement.

The observation extends beyond Islamabad.

In Sindh, repeated HIV outbreaks among children have exposed failures in infection prevention, unsafe injections, reuse of syringes and weak oversight of healthcare providers. The latest outbreaks, including cases detected among children in Karachi, have renewed demands for an independent inquiry into how unsafe practices continued despite the Sindh Healthcare Commission’s work.

Public healthcare experts say a regulator cannot limit its role to raids on unqualified practitioners while neglecting infection-control failures, unsafe procedures and patient-safety risks in clinics, laboratories and hospitals, including facilities run by qualified professionals.

HIV outbreaks have repeatedly shown that a child can be infected not only by an unqualified practitioner but also through unsafe care in a health facility where disposable syringes, sterilisation, blood screening and infection-control rules are not routine.

The Punjab Healthcare Commission conducts inspections against Minimum Service Delivery Standards. However, the province has faced serious questions after outbreaks linked to unsafe medical practices, including reported HIV infections of hundreds of children in Taunsa.

In Khyber Pakhtunkhwa, the Healthcare Commission is legally empowered to license public and private establishments but reports indicate that a large number of facilities continue to operate without licences. Balochistan and other regions face similar challenges of weak inspection capacity, limited staff, poor enforcement and under-regulated health facilities.

Dr Zakiuddin Ahmed, a leading expert in healthcare quality, says that patient safety requires a culture in which hazards are identified before they cause harm. That means regular independent inspections, trained staff, functional alarms and emergency exits, equipment maintenance, infection-control audits, complaint systems and penalties that are actually enforced.

Patients cannot inspect electrical wiring, oxygen systems, fire alarms, sterilisation practices or emergency exits before seeking care. Newborns, critically ill patients and those under anaesthesia are entirely dependent on the state and healthcare system to protect them.

On August 26, fourteen newborns paid the price of that dependence. Their deaths should force the people to ask whether health regulators exist to issue certificates and conduct occasional raids or to ensure that every hospital ward, nursery, clinic and laboratory is safe before another family loses a child.

The writer is an investigative reporter, currently covering health, science, environment and water issues for The News International.