KUALA LUMPUR, Oct 23 — On October 25, 2016, six patients died in a blaze at the south intensive care unit (ICU) of Sultanah Aminah Johor Bahru Hospital (HSAJB), the deadliest hospital fire in history.
An independent closed-door inquiry chaired by former Court of Appeal judge Mohd Hishamudin Yunus, who is currently chairman of the Human Rights Commission of Malaysia (Suhakam), blamed a lack of preparedness by hospital management and staff for the fatalities.
The independent committee’s 225-page report, as sighted by CodeBlue in 2020, found that none of the south ICU staff had undergone training in fire drills or emergency evacuation; the Fire and Rescue Department knowingly allowed HSAJB to operate illegally without a fire safety certificate; and a fire extinguisher provided by Medivest Sdn Bhd to the hospital had malfunctioned during the fire tragedy.
Nearly a decade later, the Ministry of Health (MOH) has yet to publish the independent committee’s report that it received in June 2018 during Dzulkefly Ahmad’s first stint as health minister under the Pakatan Harapan (PH) administration.
“He must publish it. There is no more reason not to, especially since the Cabinet declassified the Report way back in 2019,” Hishamudin told CodeBlue.
“Safety measures for hospital staff and patients are imperative. No two ways about it. It is the constitutional and legal responsibility of the government.
“All the fire safety measures to be undertaken by the government, as set out in the recommendations of the Report, must be implemented by the government if they are yet to be implemented.”
A letter sent by Hishamudin in his capacity as Suhakam chairman to Dzulkefly last September 15 urged the minister to publish the independent committee’s report on the 2016 HSAJB fire tragedy, as per a recommendation in the report.
“This demand is based on public interest and relates to the cause, circumstances, and follow-up action following the fire incident at Sultanah Aminah Hospital. Such an act would also be in line with transparency and good governance,” wrote Hishamudin in his letter.
Hishamudin’s September 2026 letter attached his two previous letters to Dzulkefly on April 1, 2019, and August 15, 2018, to make the independent committee’s report public.
Then-Health Minister Khairy Jamaluddin said in 2022 that the MOH would publish the independent committee’s report if there were no pending claims in court.
In 2021, then-Deputy Health Minister Aaron Ago Dagang, who is currently the national unity minister, similarly cited an ongoing court case as a reason for the government withholding publication of the independent inquiry’s report.
The parents of three victims – Logeswaran Krishnasamy, Choo Lin Fong, and Kaliama Muniandy – filed negligence lawsuits against the government in September 2020 after reading CodeBlue’s March 2020 articles on the independent committee’s report. These three victims died at the age of 20, 37, and 23 respectively.
In February 2022, the High Court in Johor Bahru struck out their lawsuits because the claims were filed more than three years after the incident, exceeding a three-year statute of limitations under the Public Authorities Protection Act 1948.
A year later, the Court of Appeal overturned the High Court ruling on the basis of public interest and remitted the trial back to the High Court, pointing out that the appellants had relied on the government’s representations urging them not to file suit until the conclusion of the independent inquiry. But the victims’ next-of-kin weren’t informed upon completion of the independent committee’s report in June 2018.
Zaman & Associates – which represented the families of four victims killed in the HSAJB fire: Logeswaran, Choo, Kaliama, and Toh Ah Wah – told CodeBlue yesterday that their clients’ four civil lawsuits against the government were settled in court in early 2025 for “reasonable” compensation. Toh died at age 60.
The parents of Neeramaladevi Chandran, a 24-year-old victim of the HSAJB fire, settled their lawsuit against the government in court in August 2020 for RM136,000 in damages, after filing suit on October 24, 2019.
There are no reports of the next-of-kin of the sixth victim, Yusuf Hasan who died at age 53, having filed suit.
Before the deadly blaze at the south ICU on October 25, 2016, the same ward in the Johor state hospital suffered four previous fire outbreaks in 2008, 2010, May 2016, and October 14, 2016, according to the independent committee’s report.
HSAJB reportedly experienced another fire outbreak the very next day, at its emergency and trauma ward, after the fatal October 25, 2016 blaze. Four years later, in June 2020, another fire outbreak hit a medical ward at HSAJB.
Galen Centre: ‘Shameful’ For Government To Hide Report
Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib denounced the failure of various health ministers and administrations to publish the independent committee’s report.
After the 2016 HSAJB fire tragedy that occurred during Health Minister Dr S. Subramaniam’s tenure, the independent committee’s report was handed to Dzulkefly in the PH government.
Dzulkefly was succeeded by Dr Adham Baba under Prime Minister Muhyiddin Yassin, Khairy under Ismail Sabri Yaakob’s administration, and Dr Zaliha Mustafa in the Madani government under Prime Minister Anwar Ibrahim, before resuming a second stint as health minister.
“I think it is shameful that the promise of making the HSA inquiry report has been repeatedly broken. The current health minister made the promise and made the effort to declassify the report. The Cabinet agreed and the report was declassified on October 15, 2019,” Azrul told CodeBlue.
“Yet, the report is still hidden from public view. Why? He has a responsibility to the six families and the Malaysian public to ensure that the inquiry report is made public.
“Malaysians need to know what went wrong, what could be done better, and most importantly, how we can make our health care facilities safer. The report covers this. Don’t kick the report to the next health minister to deal with it.”
Azrul said training personnel in fire and emergency evacuation drills is standard practice for any modern health care facility and mandatory for all private hospitals under the Private Healthcare Facilities and Services Act 1998 (Act 586). Public health care facilities are exempt from Act 586.
“‘Code Red’ exercises test staff response times, internal alarm systems, and specialised patient movement protocols. In the case of HSAJB, it was clear that there were failures in the latter. How can other hospitals, both public and private, learn from the HSAJB incident when the learnings and findings remain deliberately hidden?”
Using Litigation As An Excuse Is ‘Sheer Dereliction Of Duty’
Former Malaysian Medical Council (MMC) member Dr Milton Lum said the independent committee’s report should have been published a “long time ago” when it was handed to Dzulkefly in the latter’s first term as health minister in 2018.
He pointed out that the report contained lessons for both MOH and private health care facilities.
“There are lessons for everybody,” Dr Lum told CodeBlue. “To use the court case as an excuse not to publish is a sheer dereliction of duty.”
The senior consultant obstetrician and gynaecologist said successive administrations keeping the independent committee’s report under wraps “pained” him greatly.
“Why should it take so long for the families to get closure? Why do people have to go to court? Dr Dzul should answer these questions. Parliamentarians should ask him these questions.”
CodeBlue has requested comments from MOH and Dzulkefly’s office on whether the independent committee’s report will be published, now that there are no pending claims in court.
The Madani government has about a year or so left in office before the automatic dissolution of the 15th Parliament in December 2027.
The seven-member independent investigating committee, which was appointed by Dr Subramaniam on November 21, 2016, comprised:
- Chairman Mohd Hishamudin Yunus
- Deputy Chairman Dr Abu Bakar Suleiman (former Health director-general)
- Adanan Mohamed Hussain (former Works Department director-general)
- Soh Chai Hock (former Fire and Rescue Department director-general)
- Ezumi Harzani Ismail (Board of Architects deputy president)
- Shahronizam Noordin (senior manager, Department of Education and Training, National Institute of Occupational Safety and Health)
- Mohd Zailan Sulieman (lecturer, School of Housing, Building and Planning, Universiti Sains Malaysia)
Read CodeBlue’s articles, which were published in March 2020, on the independent committee’s report that we had sighted back then:
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
Part 4: Take Legal Action Against Medivest, HSA Fire Inquiry Tells Government
