KUALA LUMPUR, March 12 — An inquiry urged the government to institute legal proceedings, if necessary, against a company to recover financial losses from a deadly 2016 fire at the uninsured Sultanah Aminah Hospital (HSA).
The independent investigation led by former Court of Appeal judge Mohd Hishamudin Yunus into the fire alleged that Medivest Sdn Bhd, which has a 10-year contract with the public hospital ending 2025 to provide support services, only took out insurance covering its own property and against liability to third parties.
The fire on October 25, 2016 killed six out of seven patients in the South Intensive Care Unit (ICU) of the Ministry of Health (MOH) hospital in Johor Baru, Johor, and caused losses of about RM8.9 million to the government from damage to equipment, machinery, and installation. Most of the victims were only in their 20s and 30s.
“In our view, the failure on the part of Medivest to take out the necessary insurance policy to protect the government properties at HSA, as required by Clause 30(1)(b) of the CA (concession agreement), is a very serious breach of the agreement,” said the inquiry’s 225-page report, as sighted by CodeBlue.
“This was a very irresponsible conduct on the part of Medivest that had caused a great loss to the government and the public.”Report of the Independent Committee to Investigate the Fire Incident of 25 October 2016 at the Sultanah Aminah Hospital, Johor Bharu
If Medivest still hasn’t taken out the insurance policy, the committee urged MOH to issue a notice to the company to do so within a specified period.
The inquiry told MOH, HSA, and the police to seriously investigate and act on hospital workers’ police reports against Medivest staff on complaints of forgery. Two matrons from HSA filed police complaints against Medivest on September 21, 2016 and August 3, 2015 about the forgery of their rubber stamps and one of their signatures.
But the inquiry found that HSA management, MOH, and the police did not pursue the matter seriously and, as such, urged them to “take legal actions on the wrongdoers”.
The investigation also recommended that MOH and HSA management lodge police reports over alleged data falsifications in the hospital’s Central Management Information System, after their 2015 warning letters to Medivest apparently went unheeded.
The committee further urged HSA and MOH to investigate the illegal act of disconnecting the circuit protective conductors (CPCs) from the earth terminal for the ICU electrical system at the hospital, an act which the inquiry said made the building “totally unsafe”. A witness told the inquiry that he suspected a Medivest staff had intentionally done this because only the company’s workers had access to the area. Disabling the earthing system prevents tripping of power supply, which HSA had repeatedly complained about.
“We recommend that in the appointment of private companies to provide hospital support services, the selection process must be done on a competitive basis and in a transparent manner,” it added. “It must be done through an open tender system.”
According to the committee, Medivest’s concession with the government was renewed in 2015 for 10 years, without any open tender called, to service all government hospitals in Johor, Melaka, and Negri Sembilan, even though the company was the weakest of three hospital support services companies.
Medivest, then known as Tongkah Medivest Sdn Bhd, was first appointed in 1996 on a 15-year contract — later entering an interim concession agreement with the government between 2011 and 2015 — to provide five hospital support services: facilities engineering management services, biomedical engineering maintenance services, cleansing services, linen and laundry services, and clinical waste management services.
The inquiry also told the Project Monitoring Committee (PMC) — which is headed by Health director-general Dr Noor Hisham Abdullah and serves to scrutinise Medivest’s performance — to function effectively, as per the concession agreement, noting that “in the present case, the PMC had failed to carry out its functions.”
“In all earnestness, we say that if the government believes in giving the best medical service to the public, then there must be a change of attitude on the part of both the ministry and the PMC towards their respective responsibilities.”
The independent investigation found that the PMC only met in December 2016, almost two years after Medivest was appointed in April 2015, even though the concession agreement requires meetings three times a year.
Recommendations For Better Procedures
The investigation recommended the creation of a Fire Safety Division in MOH to oversee all government hospitals on fire safety.
“The ministry, as well as the hospital authorities, must have a greater and more serious appreciation about fire safety in government hospitals,” said the inquiry.
It also told MOH and hospital authorities to ensure staff are constantly prepared for fire outbreaks, including ensuring regular fire drills in all wards, training staff on how to use hose reels and fire extinguishers, placing accessible and adequate fire extinguishers in wards, appointing an emergency response team and a fire safety officer for wards, and setting a standard operating procedure (SOP), like the Pelan Tindakan Bencana Dalaman.
The inquiry found that the entire HSA management and MOH did not appear to take fire safety seriously, pointing out that none of the South ICU staff had undergone training in fire drills or emergency evacuation, despite four previous fire outbreaks since 2008. The government hospital’s fire safety and disaster management guidelines “were never taken seriously or implemented by both the management and staff”.
“The staff must familiarise themselves with the SOP and be well trained on evacuation procedures, particularly, the evacuation of ICU patients.”Report of the Independent Committee to Investigate the Fire Incident of 25 October 2016 at the Sultanah Aminah Hospital, Johor Bharu
“The ministry and the hospital authorities are to ensure that the provisions in the Pelan Tindakan Bencana Dalaman issued by the ministry are seriously implemented in all government hospitals,” said the inquiry.
As HSA lacked a “pre-incident planning” for the fatal 2016 fire, the committee recommended that all government hospitals liaise with the Fire and Rescue Department (Bomba) to formulate one, including providing Bomba with a copy of the hospital building layout plan.
The inquiry told MOH and hospital authorities to ensure that all government hospitals have fire certificates, with the ministry to make the necessary funds available for facilities that do not have one yet.
“Budget constraints should no longer be an excuse for not providing such funds.”
The investigation urged Bomba to take appropriate legal action against government hospitals that persisted in not having a fire certificate, especially facilities that pose a high fire hazard risk.
The inquiry noted that Bomba knowingly allowed HSA to operate without a fire certificate for 14 years before the 2016 fire, ever since the hospital unsuccessfully applied for one in 2002. Department officials told the committee that Bomba was reluctant to file charges against HSA because it was a public hospital, and the department did not want to jeopardise intra-government relations.
The committee acknowledged that too strict of an enforcement by Bomba may cause practical difficulties due to interruption of medical services, but also pointed out that Bomba and hospitals have a legal and moral duty to ensure that patients, hospital staff, and hospital visitors are not subjected to fire hazard risks.
“Both the Fire and Rescue Department and governmental hospitals must take this tragic incident as a lesson learnt on what could happen when the law is flouted,” said the inquiry.
“Both governmental authorities must cooperate and work closely with each other and endeavour to ensure that such fire tragedy will never ever happen again in any government hospital partly because there was laxity in enforcement.”Report of the Independent Committee to Investigate the Fire Incident of 25 October 2016 at the Sultanah Aminah Hospital, Johor Bharu
The inquiry recommended the replacement of electrical cables and wires in hospitals after 15 years, according to acceptable safety standards. MOH and hospital authorities were also told to have a maintenance engineer inspect the electrical wirings in government hospitals every year without fail, as well as employ electrical engineers at all public hospitals, particularly large facilities like HSA. According to the committee, MOH’s Engineering Services Division had rejected in 2010 HSA’s funding application for electrical rewiring.
“The full rewiring should be done in stages so as not to interrupt the running operation of the hospital; but there should not be any delay in the completion of the work.”
The inquiry urged government hospitals not to place any storage room inside an ICU ward, but if this can’t be avoided, then the storage room must be designed according to building by-law requirements. The deadly 2016 fire had started in the storage room of the South ICU that was filled with combustible items and violated building design regulations for fire risk areas.
The storage room must also be equipped with smoke detectors, heat detectors, a sprinkler, and a fire warning system, the inquiry said.
Using appropriate building materials and following by-law requirements in the construction of government hospitals was recommended, particularly regulations for compartmentation and fire separation. Medical gas valves should also be appropriately located for ICUs.
“We recommend that every ward in a government hospital should have at least three exits/ routes that are not obstructed for the purpose of patients’ evacuation in cases of emergency.”Report of the Independent Committee to Investigate the Fire Incident of 25 October 2016 at the Sultanah Aminah Hospital, Johor Bharu
The committee noted that during the fatal 2016 fire at HSA, the one emergency exit door was locked, with the location of the key uncertain, and it was obstructed by a counter.
The inquiry further recommended that hospital authorities ensure that all means of escape in hospitals, like corridors, passageways, and emergency exit doors, are clearly marked as escape routes with signages in place. These are not to be blocked by storage materials or equipment that restrict people’s exit in an emergency.
Hospital authorities were also told to “vigilantly” ensure that emergency lightings and fire exit signs lightings are functioning at all times; these were not working during the deadly fire, resulting in total darkness in the South ICU when the lights went off as hot and thick black smoke engulfed the entire ward within seconds.
The investigating committee attended a briefing at Hospital Kuala Lumpur (HKL) on February 7, 2017, to witness a staff demonstration on evacuation during fire outbreaks.
The inquiry found HKL to be “a lot more organised regarding fire safety and disaster management”.
Dr Abu Hassan Asahari Abdullah, chairman of the Jawatankuasa Bencana at the MOH hospital, told the committee about fire safety training and safety evacuation drills at HKL.
The public hospital in the capital city put in place early response to fire incidents and simulation training for evacuation. The committee was also shown the ease of releasing the brakes of the beds in the ICU, something which HSA staff were unable to do during the fire.
“As HKL has been able to organise fire safety and management, which includes having emergency response teams for disasters, and conducts training in this area, as was demonstrated to us during our visit to HKL, this can surely also be done at other government hospitals,” said the inquiry.
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, among others: 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.
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 that comprises 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.
Dr Adham told reporters Tuesday that Prime Minister Muhyiddin Yassin and MOH would look into the inquiry’s report.
Part 1: Inquiry Blames Unprepared Staff, MOH, Bomba For Sultanah Aminah Hospital Fire Deaths
Part 2: Why Bomba Didn’t Charge ‘Fire Hazard’ Sultanah Aminah Hospital
Part 3: Company Gave HSA Faulty Fire Extinguisher, Falsified Data: Inquiry Hears