Yesterday marked 10 years since the tragic fire at Hospital Sultanah Aminah Johor Bahru (HSAJB) on 25 October 2016, which claimed the lives of six patients in the hospital’s intensive care unit. A decade later, despite promises, the Malaysian government has still not made public the findings of the independent inquiry established to investigate the tragedy.
The Galen Centre for Health & Social Policy expresses its profound disappointment and dissatisfaction with the continued failure of successive governments to honour their commitments to transparency, accountability and public disclosure.
Ten years is far too long for families to wait for answers. The report of the independent inquiry commissioned by the government was completed in 2018 and declassified in October 2019. The findings remain hidden from the Malaysian public.
Health Minister Dzulkefly Ahmad personally received the inquiry’s findings during his first tenure as minister. He made a commitment to make the report public and initiated its declassification. The Cabinet agreed, and the report was declassified on October 15, 2019. Yet, seven years later, Malaysians and the loved ones of those who died are still waiting.
What is still preventing the health minister from fulfilling the commitment that he made? The government cannot keep hiding behind administrative explanations and procedural excuses. Even the key government officials involved have all retired. There must be accountability for promises made to the Malaysian public, especially to the families of those who died.
The independent committee, chaired by former Court of Appeal judge Mohd Hishamudin Yunus, submitted its findings in June 2018. Reporting on the 225-page inquiry has highlighted serious deficiencies in fire safety preparedness, staff training, emergency evacuation procedures, equipment, and institutional oversight.
These findings raise important questions about the safety of patients and health care workers across Malaysia’s public health care system. They should have informed transparent, system-wide improvements in hospital fire safety and emergency preparedness.
Fire drills, emergency evacuation training, functioning alarm systems and specialised procedures for moving critically ill patients are fundamental requirements of any modern health care facility. These are not optional measures.
Public hospitals should be held to safety standards no less stringent than those expected of private health care facilities. If the Ministry of Health cannot demonstrate that the public health care system has implemented the lessons from HSAJB, how can Malaysians be confident such a tragedy will not happen again? Every patient and health care worker deserves assurance that the government has learnt from this tragedy.
The Galen Centre also notes that previous justifications for withholding the report, particularly pending litigation, no longer hold true. The remaining reported civil lawsuits involving victims’ families were settled in early 2025. There should be no further delay.
The Human Rights Commission of Malaysia (Suhakam), through its chairman and former inquiry committee chair Hishamudin, recently reinforced the urgency of making the findings public.
The Galen Centre calls on the health minister to immediately publish the full independent inquiry report and provide a public accounting of which recommendations have been implemented, which remain outstanding, and the measures taken to ensure the safety of patients and health care workers in government hospitals.
An independent inquiry serves little purpose if its findings are concealed from the very people it was intended to protect. Keeping the report out of public view undermines confidence in the government’s commitment to transparency and patient safety.
Don’t kick the report to the next health minister to deal with it. Ten years is enough.
The author is the chief executive of the Galen Centre for Health and Social Policy.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
