Five Years After Malaysia’s Deadliest Hospital Fire, Will The Truth Remain Buried?

The Health Ministry has yet to publish an independent committee’s report on the Oct 25, 2016 fire at Sultanah Aminah Hospital that a committee member describes as a preventable tragedy.

KUALA LUMPUR, Oct 25 — Five years ago, on October 25, 2016, the south intensive care unit (ICU) of Sultanah Aminah Johor Bahru Hospital (HSA) caught fire, killing six patients. Their families received no compensation from the federal government.

The HSA tragedy was the worst hospital fire in Malaysian history — ignited by a disastrous confluence of alleged errors or inaction by hospital staff and management, top Ministry of Health (MOH) leadership, a concessionaire, and the Fire and Rescue Department, as well as illegal acts and by-law violations — in a culture that did not appear to take fire safety in government hospitals seriously, based on the leaked investigation of an independent committee.

Then-Health Minister Dr S. Subramaniam under the Barisan Nasional administration appointed the independent committee of inquiry — led by former Court of Appeal judge Mohd Hishamudin Yunus — to investigate the 2016 fire disaster at the Johor public hospital. The committee’s appointments were endorsed by the Cabinet in February 2017.

Unlike a royal commission of inquiry, which usually conducts public proceedings, the independent committee of inquiry into the HSA fire held its hearings over 36 days in 2017 closed-door, during which it heard evidence from 40 witnesses and received 217 exhibits.

CodeBlue understands that the independent committee’s proceedings on the MOH hospital fire disaster were held closed-door on the wishes of MOH acting on advice of their legal adviser.

The independent committee handed its report to then-MOH secretary-general Chen Chaw Min, under the Pakatan Harapan (PH) government, on June 6, 2018.

However, in the 18 months since then until October 24, 2019 — three years after the deadly fire — then-Health Minister Dzulkefly Ahmad did not publish the independent committee’s findings that were classified under the Official Secrets Act (OSA) 1972.

This October 24, 2019 date is important because the government is currently attempting to get three negligence lawsuits — filed by the parents of three deceased victims: Logeswaran Krishnasamy, Choo Lin Fong, and Kaliama Muniandy — dismissed on the basis that they were filed beyond the three-year statute of limitations.

The plaintiffs said they filed suit only in September 2020 after reading CodeBlue’s March 2020 articles about the leaked independent committee’s report. Incidentally, this writer was investigated under the Penal Code and OSA over the publication of the articles.

In the three ongoing court cases, the defendants — the HSA director, the Johor state health director, the Health director-general, and the government — refused to give plaintiffs the independent committee’s report as requested, claiming that it is a top-level official secret.

Until today, five years after the tragedy, MOH, now under Health Minister Khairy Jamaluddin in Prime Minister Ismail Sabri Yaakob’s government, has yet to publish the report.

A Fire and Rescue Department official told CodeBlue on June 30 last year that HSA did not have a fire certificate as of then. Johor Fire and Rescue Department director Yahaya Madis did not respond to CodeBlue’s questions today on whether HSA has managed to obtain fire certification.

Dzulkefly Explains Why Report Was Not Published

Former Health Minister Dzulkefly Ahmad. Picture from

Dzulkefly said when he presented the independent committee’s report to the Cabinet, the PH government was fully supportive of declassifying it and making it public.

However, at the post-Cabinet meeting, MOH’s then-legal adviser and secretary-general told Dzulkefly that there were ongoing lawsuits by the families of a few victims of the fire and that these cases should be concluded first before publishing the report to supposedly avoid sub judice contempt.

“For this reason, the decision was made for the report not to be made public as of yet,” Dzulkefly told CodeBlue.

“Suggest now for YB KJ to get advice from the AG (Attorney-General). If AG says no issue of sub judice, then I hope that the report will be made public without delay. The government must always be seen to be transparent and to ensure accountability in all matters.”

Dzulkefly said he was unclear exactly which lawsuits MOH’s legal adviser and secretary-general were referring to then. The Cabinet under PH had decided on October 2, 2019 for MOH to publish the report and subsequently declassified it from the OSA on October 15, 2019, according to a parliamentary reply by then-Health Minister Dr Adham Baba under the Perikatan Nasional government on August 13, 2020.

The parents of Neeramaladevi Chandran, one of the patients killed in the HSA fire, only filed suit on October 24, 2019 and settled it in court with the government on August 12, 2020 for RM136,000 in damages, whereas the three ongoing lawsuits by the families of Logeswaran, Choo, and Kaliama were only filed in September 2020.

CodeBlue understands that only four suits were filed in total over the 2016 HSA fire that led to the deaths of six patients, including Yusuf Hasan (aged 53 then) and Toh Ah Wah (aged 60 then). Logeswaran, Kaliama, and Neeramaladevi were only in their early 20s when they perished in the fire, whereas Choo was 37 years old.

Several lawyers, including the Bar Council, have urged the government to release the independent committee’s report for the sake of public interest, pointing out that its publication would not put the government at risk of sub judice amid litigation as the report is evidence that is directly relevant to the court cases. The three cases are scheduled for hearing on November 3 at the Johor Baru High Court.

Dzulkefly said many remedial measures have already been implemented at HSA and MOH facilities nationwide.

The former health minister also stressed that all health care facilities across the public and private sectors in Malaysia must adopt a single standard for facility layout and operations, citing the standards in the Private Healthcare Facilities and Services Act 1998 that does not regulate government health care facilities.

“Suggest YB KJ to introduce a new policy where all new and upcoming MOH facilities must follow or, wherever possible, exceed these standards. There cannot be a different set of rules and standards for government facilities as opposed to private facilities.”

Ex-Health DG: HSA Fire Tragedy Was Preventable

IMU Group chairman Dr Abu Bakar Suleiman moderating a session on value-based healthcare during the Malaysian Healthcare Conference 2019 at Kuala Lumpur on March 7, 2019. Picture from

Former Health director-general Dr Abu Bakar Suleiman, who was also deputy chairman of the independent committee, said the committee had recommended making its report public.

“The tragedy that occurred at the ICU at HSA was preventable,” Dr Abu Bakar told CodeBlue.

“The Minister of Health should ensure that those responsible for such a tragedy should be held to account. The families of those that perished in that tragic event should be compensated for their loss.”

Dr Abu Bakar noted that the independent inquiry highlighted issues related to the management of fire safety at the hospital, state, and federal MOH levels that led to the deadly HSA fire. The independent committee’s report also raised issues related to the management of the company that was given a contract to perform maintenance services at HSA, as well as issues identified with the performance of that company.

“The Minister of Health should ensure all the issues raised had been addressed, and appropriate remedial action taken so that such an event will not happen again in any public hospital in future,” said Dr Abu Bakar.

“Fire safety is a basic component of patient safety and must receive full attention of management at Ministry and hospital levels.”

The independent committee’s chairman, Hishamudin, said it was incumbent on Khairy to make the report public, telling CodeBlue: “This will be in keeping with the principle of good governance and transparency.”

He added that within the 100 days of Khairy taking office, the health minister should conduct an audit to find out to what extent the independent committee’s recommendations have been implemented.

Last October 7, Khairy pledged to publish the independent inquiry’s report on the HSA fire disaster, pending advice from MOH’s legal adviser over ongoing litigation.

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