Why Bomba Didn’t Charge ‘Fire Hazard’ Sultanah Aminah Hospital

By Boo Su-Lyn | 09 March 2020

The Fire and Rescue Department usually doesn’t take legal action on government buildings, officials tell an independent inquiry.

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KUALA LUMPUR, March 9 — The Fire and Rescue Department (Bomba) knowingly allowed Sultanah Aminah Hospital (HSA) to operate illegally without a fire certificate for over a decade, an inquiry found. Then, a blaze in 2016 killed six patients.

The independent investigation by a seven-member committee led by former Court of Appeal judge Hishamudin Yunus noted that the Fire and Rescue Department was aware that since unsuccessfully applying for a fire certificate in 2002, the government hospital in Johor Baru had failed to comply with 25 fire safety requirements, including the installation of a water sprinkler system.

HSA’s management, according to the inquiry, had also failed to obtain the necessary funding from the Ministry of Health (MOH) to ensure that the Johor public hospital was safe from fire hazards.

“The Fire and Rescue Department was aware of the high risk of fire hazards that beset the hospital,” said the inquiry, according to its 225-page report on the deadly HSA fire on October 25, 2016, as sighted by CodeBlue.

Unfortunately, the committee noted, Fire and Rescue Department enforcement officers lacked the “will and sense of urgency” to prosecute HSA because this involved a government facility.

According to the investigating committee, the Fire and Rescue Department inspected HSA on January 7, 2003 and issued the MOH hospital a notice on January 15, 2003, giving the facility 90 days to comply with the original 20 fire safety requirements (this was later expanded to 25).

“HSA did not comply with any of the requirements,” said the inquiry.

But the Fire and Rescue Department did not act against the public hospital, only issuing a reminder on May 23, 2006, over three whole years later. Yet, despite this “rather belated reminder”, HSA still took no action to comply with the Fire and Rescue Department’s January 2003 notice, said the inquiry.

Then, on October 25, 2016, at about 8.50am, a fire broke out at the South Intensive Care Unit (ICU) ward of HSA, killing six out of seven patients there, most of whom were only in their 20s and 30s.

According to the inquiry, the Fire and Rescue Department is empowered under the Fire Services Act 1988 to ensure compliance with fire safety regulations. Under Section 28 of the Act, read together with the Fire Services (Designated Premises) Order 1998, hospitals (including government hospitals) are required to have a fire certificate, failing which premise owners are guilty of an offence.

Former Johor Fire and Rescue Department director Othman Abdullah. Picture from Facebook @bombajdt.

Then-Johor state Fire and Rescue Department director Othman Abdullah told the inquiry that it was not Bomba’s responsibility to ensure that premise owners obtained a fire certificate.

“We only ensure that if they don’t get a fire certificate, we will give notice. We’ll ask them to comply. If still cannot, we will take them to the deputy public prosecutor to be brought to court,” Othman was quoted saying in a transcript of his questioning.

When inquiry chairman Hishamudin asked why the Fire and Rescue Department allowed HSA to operate as a fire hazard for 14 years from 2002, when the MOH hospital applied for a fire certificate, to 2016 when the deadly blaze broke out, Othman said Bomba had issued five to six notices against HSA.

Othman agreed with the chairman’s suggestions that HSA had displayed a nonchalant attitude by not taking measures for 14 years to obtain a fire certificate and, in the process, endangered patients and hospital staff. The Fire and Rescue Department official also agreed that it was Bomba’s responsibility to take stern action.

‘Kalau Tutup HSA, Havoc Lah’

Below is a selected transcript of the inquiry in Bahasa Malaysia, with CodeBlue’s translation in English:

Chairman: Boleh saya cadangkan di sini, di mana pihak Hospital pun tidur, Jabatan Bomba pun tidur sama? [Can I suggest here that, when the hospital is sleeping, the Fire and Rescue Department is also sleeping?]

Othman: Tak setuju. Sebab kita bagi notis. Bomba nak membantu HSA. Kalau tutup HSA, ‘havoc’ lah. [Disagree. Because we gave a notice. The Fire and Rescue Department wants to help HSA. If HSA is shut down, havoc lah.]

Chairman: Pihak Bomba ada kuasa di bawah undang-undang. Mengapa tak ambil tindakan mahkamah? [The Fire and Rescue Department has powers under the law. Why not take legal action?]

Othman: Kebiasaannya, kalau premis kerajaan ini, bila kita ambil tindakan mahkamah, dia akan berhenti sampai ke peringkat TPR (Timbalan Pendakwa Raya). Dia tidak bawa terus ke mahkamah. [Usually, for government premises, when we take court action, it will usually stop at the deputy public prosecutor. It’s not taken directly to court.]

Chairman: Bila di peringkat Timbalan Pendakwa Raya, itu dah di luar kawalan Jabatan Bomba. Tapi sekurang-kurangnya, Jabatan Bomba mesti menunaikan tugasnya dengan mengambil tindakan undang-undang. Apa Timbalan Pendakwa Raya nak buat, itu kamu dah lepas tangan. Setuju? [At the deputy public prosecutor’s stage, that’s already out of the Fire and Rescue Department’s hands. But at least, the Fire and Rescue Department must fulfill their responsibility by taking legal action. Whatever the deputy public prosecutor wants to do, that’s beyond your control. Agree?]

Othman: Setuju. [Agree.]

Chairman: Jadi, saya cadangkan dalam keadaan HSA ini, sebabnya berlaku kebakaran dan tragedi itu, selain daripada sikap HSA, juga adalah sikap Jabatan Bomba yang tidak mengambil tindakan yang tegas, bila kita nampak Hospital itu dalam keadaan bahaya, setuju? [So, I suggest in HSA’s situation, because of the fire and the tragedy, besides HSA’s attitude, it was also the Fire and Rescue’s Department’s attitude where it did not take stern action when it saw that the hospital was in a dangerous condition, agree?]

Othman: Setuju. [Agree.]

Chairman: I am going to record that. I leave it at that.

No Action On Government Buildings

Fire and Rescue Department officials at Sultanah Aminah Hospital (HSA) in Johor Baru, Johor, during a fire at the South Intensive Care Unit (ICU) on October 25, 2016. Picture from Facebook @BombaMalaysia.syed.

Norliza Mohamed, then-head of the fire investigation division unit at the Fire and Rescue Department, admitted to the inquiry that Bomba does not take action against government departments — even though non-compliance with its notices can lead to prosecution — only against private companies.

Chairman: Kalau syarikat, akan didakwa. Kalau bangunan kerajaan, hospital ke, Jabatan Haiwan ke, macam mana, akan didakwa atau tidak? [If companies, will be prosecuted. If government buildings, whether it’s hospitals, the Animal Department, or whatever, will they be prosecuted?]

Norliza: Sebenarnya tidak didakwa. [Actually they won’t be prosecuted.]

Chairman: Tidak didakwa kalau bangunan kerajaan? [No prosecution for government buildings?]

Norliza: Ya. [Yes.]

Chairman: Alasannya? [Reason?]

Norliza: Kerana kami government to government. Kita masih memerlukan pihak hospital dari segi bantuan. Jadi jika didakwa juga di mahkamah, akan menjejaskan hubungan baik antara government dengan government. [Because we’re government to government. We still need the hospital’s assistance. So if we still charge in court, this will affect the good relations between government and government.]

Chairman: Akan menjejaskan hubungan baik antara government dengan government. Tapi dari pandangan pihak Bomba, salah itu tetap salah? [Will affect the good relationship between government and government. But from the Fire and Rescue Department’s point of view, wrong is still wrong?]

Norliza: Salah tetap salah. [Wrong is still wrong.]

Chairman: Cuma tidak didakwa? [Just not prosecuted?]

Norliza: Ya. [Yes.]

Chairman: Jadi kamu memilih untuk tidak dakwa untuk mengekalkan hubungan baik? [So you chose not to charge to maintain good relations?]

Norliza: Ya. Dan sebenarnya kita memerlukan kerjasama yang erat antara Bomba dan juga pihak hospital. [Yes. And actually, we need close cooperation between the Fire and Rescue Department and the hospital.]

Fire and Rescue Department officials at Sultanah Aminah Hospital (HSA) in Johor Baru, Johor, during a fire at the South Intensive Care Unit (ICU) on October 25, 2016. Picture from Facebook @bombajdt.

Inquiry Details

The six patients who died in the October 2016 fire at HSA were Logeswaran Krishnasamy, 20; Choo Lin Fung, 37; Toh Ah Wah, 60; Yusuf Hasan, 53; Kaliama Muniandy, 23; and Neeramaladevi Chandran, 24.

The seven-member independent investigating committee, which was appointed by then-Health Minister Dr S. Subramaniam under Barisan Nasional, comprised chairman Hishamudin, deputy chairman Dr Abu Bakar Suleiman (former Health director-general), and members Adanan Mohamed Hussain (former Public Works Department director-general), Soh Chai Hock (former Fire and Rescue Services Department director-general), Shahronizam Noordin (manager of Occupational Health Safety Division, National Institute of Occupational Safety and Health), Ezumi Harzani Ismail (member of the Board of Architects, Malaysia), and Mohd Zailan Sulieman (senior lecturer, School of Housing, Building and Planning, University of Science Malaysia).

The committee conducted its inquiry in 2017, after hearing evidence from 40 witnesses and receiving 217 exhibits. The witnesses included medical officers, nurses, a pharmacist, and a cleaner who were at the scene of the October 2016 fire at the South ICU; firefighters from the Fire and Rescue Department who put out the fire; technical experts from the Fire and Rescue Department, the Public Works Department, and the Energy Commission that probed the fire; and the-then Johor state health director, who was the former HSA director, among others.

Ministry of Health secretary-general Dr Chen Chaw Min (centre) together with members of the independent inquiry into the fire at Sultanah Aminah Hospital (HSA) in Johor Baru, Johor, on October 25, 2016 that killed six patients. Inquiry chairman Hishamudin Yunus is fourth from right. Picture from Facebook @shahnorizam.noordin.

The investigating committee handed its report to MOH in June 2018 under the Pakatan Harapan (PH) administration. On October 2, 2019, the Cabinet decided that MOH was to publish the report. Then-Health Minister Dzulkefly Ahmad did not do so.

However, Dzulkefly confirmed with CodeBlue last February 24 that the HSA report has been declassified as a state secret.

After a political tussle, PH lost federal power last March 1 when Muhyiddin Yassin — leading a new coalition called Perikatan Nasional comprising Bersatu, Umno, MCA, MIC, and PAS, supported by Sarawak’s GPS — was sworn in as prime minister. The new health minister is Dr Adham Baba, while Deputy Health Minister I is Dr Noor Azmi Ghazali and Deputy Health Minister II is Aaron Ago Dagang.

Part 1: Inquiry Blames Unprepared Staff, MOH, Bomba For Sultanah Aminah Hospital Fire Deaths

Part 3: Company Gave HSA Faulty Fire Extinguisher, Falsified Data: Inquiry Hears

Part 4: Take Legal Action Against Medivest, HSA Fire Inquiry Tells Government

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