Why Indian hospitals turn into raging infernos

It was a cold morning in November 2021. Chand Sayyed was squatting just outside the intensive care unit at the Ahmednagar Civil Hospital, located on the ground floor, when he saw smoke emanating from the ward’s window.

Sayyed’s 65-year-old mother was inside, on oxygen support and too weak to walk on her own. Sayyed rushed towards the doors of the ICU, but a ward boy stopped him, and assured him that staffers were handling the problem.

Minutes passed, and the smoke thickened.

Now, Sayyed and other relatives of patients pushed past the ward boy. By the time they entered the ICU, the smoke was so thick “you could not see your own hand”, 38-year-old Sayyed recounted. They could hear screams of patients, most of them elderly people.

Sayyed and his cousin grabbed the nearest bed and pulled it out. The patient was his mother’s neighbour in the ward. She had an oxygen mask on, but the mask was filled with smoke. She did not stir when Sayyed shook her. He realised she was dead.

In that moment, he also realised that his mother could not have survived the brutal fire.

There were 17 Covid-19 patients in the ICU. Eleven died that day; over the next few days, three more died.

Minutes before Sayyed saw the smoke, nurses Sapna Pathare and Anant Channa were sipping tea in a room to one side of the ICU, when a patient yelled, “Sister! Sister!”

Both stepped out and saw smoke emanate from the false ceiling above beds numbered 17, 18 and 19. Bed number 17 was occupied by Sayyed’s mother Chababi Sayyed.

There was a fire extinguisher in the ICU near the nursing station. Channa grabbed it, pulled its trigger and aimed it at the ceiling. Meanwhile, Pathare rushed out and told nurse Asma Shaikh, who was sitting at a counter outside the ICU, filling out case papers for a deceased patient.

Shaikh called guards for help. “It all happened in a few minutes,” she said. “The entire ICU was filled with smoke. We could not see anything.”

District officials said that they suspected that the fire started from an overheated air conditioner, and that smoke spread between the false ceiling and the main ceiling, before entering the ward. The heat from the fire and smoke melted the plaster of Paris of the ceiling, which collapsed suddenly, allowing smoke to spread quickly in the ward.

Nurses Channa, Shaikh, and Pathare lost their jobs. The resident doctor on duty, Vishakha Shinde, was suspended.

All four were arrested on November 9, on allegations of causing death by negligence. They were placed under a week of police custody, then transferred to a magistrate’s custody for a week, after which they were released on bail. The district’s civil surgeon, Dr Sunil Pokharna, was also suspended, and arrested on November 9. He received bail the same day.

The entire staff of the hospital went on a strike for six days to protest the arrests. “If the hospital had a fire alarm, a smoke detector, a sprinkler, the fire would have been detected earlier,” said nurse Surekha Andhale. “Why are nurses and doctors being punished for negligence by the district management and state government?”

This argument is not without merit. Documents accessed by Scroll.in show that a proposal to install a firefighting system in the hospital was moved from one department to another for eight months that year, as it awaited approval. The state government finally sanctioned Rs 2.60 crore to install a system on November 9, three days after the mishap killed 14 patients.

The lapses in the hospital’s safety systems are far from unique.

Eleven months earlier, in January 2021, in the immediate aftermath of a fire in Bhandara Civil Hospital, which killed 10 babies, the public health department of Maharashtra had ordered all hospitals in the state to undergo fire safety audits. A total of 484 hospitals were audited initially, of which 90% were found to be functioning without a no-objection certificate, or NOC, from the fire department. An NOC is issued to a hospital once the fire department carries out an audit and certifies that a hospital has a firefighting system in place.

The problem isn’t restricted to Maharashtra. Scroll.in filed Right to Information applications with the Central government and the Delhi government, seeking data on hospitals that function without fire NOCs. The government does not maintain such data centrally, and so transferred the RTI requests to several major government hospitals in Delhi and across India. So far, only 10 hospitals have responded, of which eight provided data.

Of these, four Central government-funded hospitals are operating without or with only partial NOCs from fire departments. These are: Ram Manohar Lohia Hospital in Delhi, Lady Hardinge Medical College Hospital in Delhi, Post Graduate Institute of Medical Education and Research, the largest public hospital in Chandigarh and All India Institute of Medical Sciences , Bhubaneswar, one of the largest public hospitals in Odisha. The Chandigarh hospital recorded 385 incidents of fire mishaps between 2016 to 2021, or one fire on an average every 5.6 days.

This laxity has had serious consequences. Media reports compiled by Scroll.in dating from August 2020 to the present show that 122 people have died in 29 incidents of major hospital fires across India in just 20 months. The compilation included only fires that led to massive damage or fatalities. Twelve of the 29 hospitals involved were government facilities, like the Ahmednagar hospital.

On the morning of November 6, the day of the fire, the Ahmednagar fire department received a call from the hospital, which is the largest in the district. Sub officer Balasaheb Ghatvisave told Scroll.in that a team reached the hospital, three km away, in less than 15 minutes, and helped staffers and relatives pull patients out. The three patients who survived were lucky that their cots were positioned next to the exit, said Girish Jadhav, a local Shiv Sena leader who has been involved with issues of fire safety in the district’s hospitals.

Even before the fire brigade arrived, after bringing the elderly woman out of the ICU, Sayyed, a van driver, returned inside for his mother, groping through dark smoke to reach her bed. “The next bed my cousin Shakir and I pulled out was hers,” Sayyed said. “Alongside, some nurses were also trying to get patients out.”

His mother’s mouth was slightly open. An oxygen mask placed tightly over her face was filled with smoke. She was unresponsive.

A nurse injected something into her, and wheeled her into another ward, where she declared Chababi Sayyed dead.

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Millions of Indians depend on hospitals run by the government. In many districts, these hospitals, such as the Ahmednagar Civil Hospital, offer the only available healthcare. At any given time, typically, their corridors are spilling over with people, and their wards are packed with patients. Yet, these hospitals remain alarmingly prone to fire tragedies.

A 2020 study in the International Journal of Community Medicine and Public Health analysed 33 major fire mishaps in Indian hospitals between 2010 and 2019, of which 25 occurred in government hospitals. Only 19 of the 33 hospitals had a functional firefighting system.

Dr Rashmi Sharma, associate professor of community medicine at GMERS Medical College, Ahmedabad, co-author of a study on hospital fires in the Indian Journal of Community Medicine in 2020, said government hospitals were the most serious violators of fire safety regulations.

“Of the 19 fire incidents that I studied since 2011, 90% occurred in government hospitals,” she said.

Manoj Choudhury, director of Edifice Consultants Private Ltd, an architectural and construction firm, echoed this idea. “A lot of designing is compromised to save cost,” he said. “Government hospitals always go for the lowest bidder, that will also dilute specification on quality. This is why public projects are prone to such mishaps.”

Under the National Building Code of India, hospitals fall under the C1 category – such buildings must have special infrastructural arrangements for fire safety.

Thus, hospitals must by law have fire lifts for the fire brigade to use, fire alarms, smoke detectors on every floor, fire extinguishers and fire hydrants. Smoke outlets and air inlets must be provided in basement spaces, and ventilating ducts must be installed in multi-storey buildings. Electrical fittings and wirings must be installed in separate ducts that are sealed by non-combustible material.

“The National Building Code is comprehensive and detailed. But most hospitals don’t even follow it,” said Choudhury. “It is ignorance towards safety norms that causes fire mishaps.”

In 2019, the Central government revised an existing model bill on fire safety, which many states had used as a framework for state-level laws. (Fire services fall under the state list, and the model bill was drafted to serve as an advisory document for states.) The revised model bill included several new suggested provisions – including, for example, that buildings over 15 metres in height should be equipped with automatic sprinkler systems, fire alarms and fire extinguishers, and have a dedicated officer to oversee fire safety. Fire officials from Maharashtra, Madhya Pradesh and Gujarat told Scroll.in that no state had yet fully adopted the provisions of the model bill into their own laws.

Hospitals require particular caution when it comes to fire safety. Sharma explained that intensive care units, air-conditioned wards, operation theatres, paediatric or neonatal ICUs, and X-ray and dialysis rooms are prone to fires due to the presence of heavy equipment. “Oxygen-rich environment provides fuel to the fire,” she said.

For this reason, Choudhury said, hospitals should not use combustible materials, such as plaster of Paris, for walls or ceilings in wards – rather, they should use fire-resistant sheets, made of materials such as certain resins. “The wall material must be able to resist fire for at least two hours,” he said. “That withholds progression of fire until the fire brigade comes.”

It is also essential for a hospital to plan and manage its electrical loads. The International Journal of Community Medicine and Public Health study found that in 78% of the 33 cases it looked at, the fires started due to electrical problems. Air conditioners were “the most common source” of the fires.

Almost a third of the fires originated in or near ICUs, the study found. Rahul Kadri, partner and principal architect in IMK Architects, which has constructed hospitals in Mumbai, Hyderabad, Pune and Latur, explained that when a hospital space is modified into an ICU, it is necessary to ensure that there is enough power supply, and adequate electrical wiring to carry high loads.

“Each bed in an ICU needs ventilator, monitors, multiple machines,” Kadri said. “The design and requirement of an ICU are different from normal wards, and their electrical load is always high.”

The Ahmednagar Civil Hospital’s ICU building was, in fact, not constructed for intensive care services. Rather, it was built in 2016-’17 under the National Health Mission, to treat paediatric, dialysis, burn, and orthopaedic cases.

In May 2020, as the Covid-19 pandemic raged across the country and cases spiralled upwards in Ahmednagar, with no government-run ICU in the district, one of the buildings of the civil hospital was converted into a Covid-19 ICU. Shiv Sena’s Girish Jadhav alleged that the work was hastily done. But the district’s civil surgeon’s office told Scroll.in that an electrical audit was carried out to gauge whether the wiring system could tackle the load of the equipment in the ICU.

A major reason why government hospitals remain vulnerable to electrical problems is a shortage of staff. Government hospitals, like most government buildings, are constructed by a state’s Public Works Department – the department’s engineers are also responsible for the regular maintenance of infrastructure and electrical wiring.

“There are three sanctioned posts for sectional engineer and one for deputy engineer,” said Jagdish Kale, the deputy electrical engineer of Ahmednagar district. “I am the only one permanently posted. Other two posts of sectional engineer are occupied by officials with additional charges.”

The workload on Kale is immense. The electrical department looks after the electrical wiring and fitting needs of all government buildings in a district. Their shortage means complaints of sparks or circuit breaker trips in a hospital may go unheeded for a long time.

Amal Mohite, assistant engineer in Brihanmumbai Municipal Corporation who worked as an electrical engineer in Mumbai’s Sion Hospital for over a decade, said hospitals with 50 or more beds should ideally have a dedicated electrical engineer.

But state health officials in Madhya Pradesh, Gujarat and Maharashtra told Scroll.in that the only hospitals in their states that had posts for electrical engineers were those that were attached to medical colleges, which were typically larger in size; rural hospitals, and even district hospitals, did not have such posts.

Mohite said that when small complaints like sparking, tripping, overheating are ignored, they tended to lead to fires. “A hospital is always growing, adding ventilators, ICUs, more equipment,” he said. “The electrical load keeps increasing and regular audit is very important.” While some corporate hospitals conducted electrical audits, Mohite said, most government hospitals in India did not.

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All these problems were in evidence when a fire struck the sick newborn care unit, or SNCU, in Indore’s Maharaja Yeshwantrao Hospital, or MY Hospital, in 2017.

On the evening of November 23, 2017, there were 47 newborns admitted in 28 cots of the SNCU – owing to a shortage of cots, two babies were put on almost every cot. At around 4.30 pm, nurse Lalita Bagle noticed smoke coming out of a ventilator. She immediately picked up the baby who was on that ventilator, rushed to the next ward and placed the baby on a cot there.

Seconds later, there was a blast in the oxygen pipeline that ran close to the ventilator. The tiles and ceiling of the SNCU cracked under the impact. Nurses and staffers rushed all the babies to the neighbouring ward. When the flames continued to spread, the babies were shifted to an adjoining terrace.

There were no water sprinklers, hosepipes, fire alarms or smoke detectors in the hospital. The hospital staff tried in vain to use two fire extinguishers that were placed in the ward to douse the fire, before the fire brigade arrived and controlled it.

The fire, suspected to have started due to a short-circuit in the ventilator or the switchboard, damaged the entire SNCU, a unit where newborns in critical condition are admitted.

The one newborn to die the day fire struck was a five-day-old baby girl. The hospital has maintained that the baby had died 15 minutes before the fire started. A post-mortem report submitted to the Indore bench of the Madhya Pradesh High Court, in a public interest litigation filed after the fire, stated that she died due to cardiorespiratory failure.

Mulayam Singh Rajak, 28, the baby’s father, finds this hard to believe.

“My baby’s body was blackened when the nurses handed her to me,” he said. “How do I believe she had died before the fire?”

Dr VS Pal, the superintendent of the hospital at the time of the fire, told Scroll.in that the baby was the last to be removed from the ward, and hence, “some soot was found on her skin”.

The baby girl, whom the family never got a chance to name, was Rajak’s firstborn, and had had respiratory problems after birth. “We could not afford a private hospital so we shifted her to MY Hospital,” he said.

After the fire, Rajak, a construction worker, registered a police complaint against the hospital. “But nothing happened after that,” he said. “I am a daily wager. For how long could I pursue this case?”

MY Hospital is the largest government hospital in Indore, Madhya Pradesh’s economic hub. It was constructed in 1946, but the SNCU was relatively new, established in 2012 by the National Health Mission, a programme of the Union government.

A senior doctor at the hospital said that the SNCU had limited equipment at its inception. “Over the years, ventilators, CPAP machines, baby warmers, increased. Our ward’s bed capacity grew,” the doctor said.

Despite this, the doctor added, the electrical load of the ward was never re-calibrated after 2012. “We were plugging multiple equipment into one power source,” the doctor said. “A year or so before the fire, we had asked the National Health Mission to increase the electrical load bearing capacity in the ward. But there was no action.”

Pal said it was the PWD’s job to carry out electrical audits and upgrade wiring systems.

“This is not a doctor’s job,” he said. “Every year, new technology is added to the hospital. The electrical wiring is old and needs regular replacement accordingly.”

But the hospital had also failed to meet some of its own obligations, such as obtaining an NOC from the municipal fire department. However, in court, where it was called upon to defend itself against public interest litigation demanding, among other things, that it install a firefighting system and pay compensation to Rajak’s family, it argued that it had been constructed in 1946, much before fire safety norms were introduced in the 1970s. This was despite the fact that in 2015, the Madhya Pradesh state government had ordered all government hospitals to ensure that their premises were compliant with fire safety regulations.

This recalcitrance was particularly surprising given that the 2017 fire was not the hospital’s first in recent times. Three months earlier, in August, the canteen in the hospital had caught fire, damaging some furniture, forcing the evacuation of around 100 patients from the outpatient department.

Even after the SNCU fire, the hospital and state government were slow to act to install firefighting equipment. In 2019, the Madhya Pradesh government sanctioned Rs 2.42 crore to install a firefighting system in the hospital.

But it was only four years after the fire, in November 2021, that the hospital obtained an NOC from Indore Municipal Corporation.

In her basement office opposite the High Court in central Indore, advocate Shanno Shagufta Khan, who works with the Human Rights Law Network, has two thick files on MY Hospital. She has been fighting the PIL against the hospital, and has been closely monitoring it ever since the fire gutted the SNCU. “They installed a fire system because of the court case,” she said. “But there are thousands of hospitals across India that have no such pressure and don’t bother to be fire compliant.”

When Scroll.in visited the hospital in March this year, the SNCU was still operating out of a makeshift ward within the paediatric ICU ward. A senior doctor said this arrangement increased the risk of infections to newborns, but added that they had no other option. The new SNCU, hospital officials said, was delayed due to the pandemic.

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In 2020, the problem of poor fire safety in Indian government hospitals reached the Supreme Court.

Following two major fire mishaps, in Rajkot and Ahmedabad, on December 18 that year, the court took suo moto cognisance of the problem, and directed all states to carry out fire audits in all Covid-19 hospitals, and ensure that they received fire NOCs in four weeks. The court also asked each hospital to appoint a nodal officer to ensure fire compliance.

State fire officials in Gujarat, Madhya Pradesh and Maharashtra told Scroll.in that meeting the court’s four-week deadline for all hospitals had proven difficult, but that the process was underway.

In the course of the proceedings, the Gujarat government admitted in an affidavit to the court that 1,101 public and private hospitals in the state did not possess a fire NOC. In Madhya Pradesh’s capital Bhopal, Sajid Khan, in-charge of Bhopal’s fire services, told Scroll.in that over 400 hospitals without a fire NOC reached out to the fire department to process one after a major fire at the SNCU of the Kamla Nehru Hospital in November 2021 – while the hospital claimed that four children died, news reportssuggested the toll was much higher.

Despite acknowledging the problem, the Gujarat government issued a notification giving state hospitals till June 2022 to acquire building-use certificates, for which a fire NOC is a requirement – in effect, it appeared to extend the court’s deadline for obtaining the latter clearance also.

The same month, the court rapped the state government for this move, after which the government issued a clarification, saying that the extension did not apply to fire NOCs.

A senior Gujarat government official told Scroll.in that over the past year, 5,688 hospitals in the state had been audited, of which 5,633 had received an NOC. The government was taking action against the remaining hospitals, by issuing notices to them or even sealing them, added the official, who asked to remain anonymous since the Supreme Court’s suo moto proceedings were still underway.

Maharashtra, too, failed to meet the court’s deadline. It was only between last year and this year that 525 government hospitals in the state submitted proposals to the government to install firefighting systems.

Ahmednagar Civil Hospital was one of them. The hospital had undergone a fire audit in 2012, and received a provisional NOC from the Ahmednagar fire department, on the condition that the hospital install a firefighting system to get a final NOC.

“We told them to install water hydrants, smoke detectors, sprinklers, and a fire alarm system – they only had extinguishers,” said Shankar Misal, head of the fire department in the Ahmednagar Municipal Corporation.

Fireman Balasaheb Ghatvisave, who holds an additional charge of sub officer, said the hospital officials cited lack of funds whenever they were asked to install a fire system.

Ahmednagar’s former civil surgeon, Dr Sunil Pokharna, said he had submitted multiple proposals to the health department, even before the Supreme Court order, to install fire equipment. “We were never sanctioned funds,” he said. “I could not pay from my pockets.”

Even after the Supreme Court directive of 2020, the installation of a firefighting system at the Ahmednagar hospital was slowed down by red tape. A medical officer in the hospital pointed out that since this was the first time that proposals to install fire safety systems were being processed at such a large scale in the state, the functions of the PWD and the health department were unclear. As a result, the Ahmednagar hospital’s file went back and forth between the hospital and the two departments for eight months.

“When two departments look after one hospital, accountability is diluted. That is what happened here,” a senior health official in Maharashtra said.

The hospital underwent a fire audit in February 2021, conducted by the Pune-based India Automation and Fire Services. The audit, a copy of which Scroll.in accessed, shows the hospital still had no fire safety system, apart from fire extinguishers, and that no firefighting training had been given to the staff. The auditors prepared a list of items to be installed. On April 27, 2021, the PWD submitted an estimate of Rs 2.60 crore to the hospital for this work. The hospital forwarded the file to the health department on April 28, 2021, for approval.

“We sent the proposal twice to the health department. First they said few signatures were missing. Later, they returned the entire file and said PWD needs to provide a technical sanction first,” an administrative officer in the hospital said. A technical sanction is essentially an approval of the technical specifications of the proposal.

The Ahmednagar hospital wasn’t the only one to receive this instruction. In June 2021, the public health department instructed all district hospitals to obtain a technical sanction from PWD’s chief engineer for their fire safety proposals, and then submit the proposals for the health department’s approval. Six months had already passed since the Bhandara mishap.

The Ahmednagar hospital’s file was returned to the PWD in June 2021. It was only three months later, in October, that the PWD’s chief engineer in Mumbai signed the proposal, thus granting it technical sanction. “By then Diwali holidays had neared,” said Dr Yogesh Divte, from the hospital’s administration department. “We were going to send the file for administrative approval in health department after the holiday, but the fire occurred.” He argued that the PWD should have granted the proposal its technical sanction before sending it to the hospital in the first place, or processed it swiftly. Sandeep Patil, chief engineer of PWD, Maharashtra, did not respond to calls or messages.

The Maharashtra government only sped up the process after the Ahmednagar fire in November. Since then, all the state’s public hospitals have undergone a fire audit. Of the 525 government hospitals that have submitted proposals to install firefighting equipment, 451 have received approvals as of March, according to data that Scroll.in accessed from the state health department. Of these, 131 hospitals will receive Rs 126 crore from the state public health department and 320 hospitals will receive Rs 92 crore from the District Planning and Development Council.

But this is only the first step – most hospitals are yet to install firefighting systems. “The process of calling for tender will start now,” a district health officer said. “It will still take several months.”

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In Ahmednagar, work is finally underway to install firefighting equipment in the civil hospital. When Scroll.in visited the hospital in March, sprinklers were being installed, and a new ICU was being set up. Resident doctor Shinde had been reinstated, while the three dismissed staff nurses were still visiting various district officers officials to try and get their jobs back.

Dr Pokharna, demoted from position of civil surgeon in Ahmednagar, is now posted as a medical officer in Shirur Rural hospital, 50 km from Ahmednagar. “The fire safety equipment in this rural hospital expired in January this year,” he said. “I have informed the government. But no funds have come my way so far. What if another fire breaks here. Will I be held responsible again?”

Those who lost loved ones in the Ahmednagar fire remain in shock five months later.

Bharat Kadam still cries over the death of his 70-year-old mother. “We both had a close bond,” said 41-year-old Kadam, the youngest of his siblings. “I still haven’t entered her room after her death. Not a day passes by when I don’t remember her and cry.” Days after his mother’s demise, he deleted all the pictures he took while she was in the hospital. “Taki wo dard bhool jau,” he said – so that I forget that pain.

His mother, Kodabai Madhukar Kadam, had developed breathlessness, and was admitted in the hospital on November 2 after testing positive for Covid-19. Kadam would stay in the hospital day and night, sleeping out in the compound, visiting home only in the morning to bathe. On November 6, he fed Kodabai breakfast, and gave her medicine for her blood pressure. “She was much better,” he said. “We were hoping for discharge soon. She asked me to go home and get lunch. The staffers cleaned the ICU daily from 9 am till noon.”

While he was away, he got a call from a relative that the ICU had caught fire. “I rushed back,” he said. “There was chaos everywhere. Families were evacuating their patients on their own. Some had broken windows to let the smoke out.”

Kadam does not know who brought his mother’s body outside. When he saw her, she was coated in a layer of white dust. The right side of face and leg were charred. She had already been declared dead.

Kadam said he was shocked to learn that the hospital had no fire safety system. “This was the first time I took my mother to a government hospital, before that we always went to private hospitals,” he said. “I hope the government does something to prevent this in the future. It is horrifying.”