Investigating The Hospital Sultanah Aminah Tragedy – Part 2

There is a huge possibility that the culprit of the tragedy is electrical fire.  In a previous article I discovered that out of the five fire incidents prior to the tragedy, three were electrical fires, the last incident bekng on the 15th October 2016. What I discovered next is alarming:

A Harian Metro headline of a scoop that was first exposed by TV9’s daring and no-nonsense senior broadcast journalist Zulhazri Abu Bakar

We wonder if fire prevention and electrical safety audits took place at the Hospital Sultanah Aminah (HSA) at all. The Minister of Health, in a briefing to the members of the Dewan Rakyat assured us that it has been done.

Impressive! Electrical maintenance is being done every quarter, half yearly and annually.

But look at how messy the wiring is, and this photo was taken after the second electrical fire incident that occurred in the Operating Theatre on the First Level. Let us take a closer look:

The above does not resemble The quality of electrical work done by a person certified by the Energy Commission to carry out such works. And by the look of it, this has definitely gone through several annual electrical inspection and maintenance schedules but obviously no corrective action has been taken. My question is, were the scheduled audits and maintenance mere paper exercises? Or in the words of safety practitioners – tick the boxes exercise?

According to the JBPM statistics collected between 1990 and 2002, electrical fire is the largest contributor of fire incidents. Regulation 67 of the Electricity Supply (Regulation) Act, 1990 requires a minimum of one inspection per month by a competent person of electrical installations not exceeding 600 Volts!

For larger voltage installations it is obvious that the frequency has to be increased! All these regulations are in place to provide the guidelines for building owners to perform routine inspections and maintenance to minimise incidents of electrical fires!

Obviously the concessionaire tasked with ensuring that everything is in good order, Medivest Sdn Bhd (formerly known as both Tongkah Medivest and then Pantai Medivest) had not done its job as required! The Energy Commission’s Regional Director Idris Jamaludin was spotted heading a nine-men team of electrical and gas experts into the HSA and we anxiously await their findings.

The Minister continues:

The HSA had requested last month for a fire drill to be conducted. This request I was told, was turned down by the Fire and Rescue Services Department (JBPM) because the HSA was not equipped with a fire-fighting systems control panel and nor were there the respective floor plans included in its fire safety plan! 

How could fire drills be conducted if the fire safety plan is not complete? Which begs a question from me – when was the last Fire Certificate issued to the HSA?

Word has it that between 2014 and 2016, no fire and evacuation drill nor fire-fighting training was ever conducted. The last drill and training that was recorded was in 2009! Therefore it is safe to say that the last Fire Certificate was obtained then! How is it possible that Medivest Sdn Bhd, a company that was given the 30-year concession to maintain the operational safety of our hospitals be allowed to do things against whatever safety laws and regulations that are there to protect lives and government properties? Are they not suppose to conduct at least one training per annum as briefed to the Dewan by the Minister?

This is by no means a witch hunt. This is borne out of frustration and the utter disbelief that such complacency and incompetence are allowed to flourishby especially the state health department and the top management of Medivest Sdn Bhd.

Lives have been lost! Dozens more affected by their loss and injury! Millions of Ringgits worth of government properties have been lost because some people do not do their job as expected!

Heads therefore must roll!

Investigating The Hospital Sultanah Aminah Tragedy

The ICU Ward on the 2nd floor of the HSA on fire. Six people lost their lives in the tragedy
The ICU Ward on the 2nd floor of the HSA on fire. Six people lost their lives in the tragedy
A fire broke out at the Intensive Care Unit on the Second Floor of the Sultanah Aminah Hospital in Johor Bahru on the morning of the 25th October 2016 that killed six patients and injured one hospital staff.  It was said that the hospital staff was one of the nurses who refused to leave the doomed patients undergoing intensive care inside the ward.  They had to be pulled away to safety.  One of the dead was a man who had had a brain surgery two days earlier.  Taking the patients off their life-support system to safety was definitely a Catch-22 situation for the hospital staff and this would be a tragedy they would carry with them for the rest of their lives.  The Fire Forensics team of the Fire and Rescue Services Department will now have to secure the fire scene, protect the trace and transient evidences, identify fire patterns and try determine the cause of the fire.

A Board of Inquiry will be held and with all the evidences and statements from witnesses to be made available to them once the investigation has been completed, they would have to determine the root causes of the incident, what went wrong, why they went wrong, what barriers or control measures that have failed, and what barriers or control measures that were not adhered to.

This was not the first fire incident that has occured at the Hospital Sultanah Aminah (HSA). There had been at least five other incidents, three of which occured in the Intensive Care Unit ward itself. On the 30th July 2008, a fire broke out at the ICU ward where the latest tragedy had occured destroying properties inside the store room. Then on the 20th October 2009, a fire broke out at the Ground Floor of the Main Block at the Phase IV Development Site Office.  In early January 2010 a fire broke out at the Southern ICU Ward. This was caused by a damaged electrical fuse. On the 17th April 2010, an overloaded power supply switch caused a fire inside the Main Block’s Air Handling Unit’s room.  And finally I was told that about three weeks ago, sparks were spotted coming out from the panel inside the ICU ward where the latest incident took place.

Given that fire is not uncommon at the HSA, I am sure that the hospital does have a Fire Response Plan as prepared according to the Arahan Perkhidmatan 1986, Bab Lapan Peraturan Am. This Arahan Perkhidmatan would require the HSA to hold fire drills and fire-fighting training as well as the inspection by the Fire and Rescue Services Department of fire-fighting equipments AT LEAST ONCE A YEAR. I used to hold one each week for the Drilling Rigs under my charge, fortnightly on board the offshore support vessels and once a quarter for each of the Mass Rapid Transit project package.

The Fire Safety Policy of the HSA would also require for a Fire Safety Team (PAKKHSA) to be formed and a Fire Security Officer to be appointed.  The Fire Security Officer would be tasked among others would be to conduct scheduled fire-fighting equipment inspections together with the entity that is responsible for the maintenance of these equipment – Pantai Medivest Sdn Bhd.  Pantai Medivest I am sure would in turn appoint local contractors to sub-contract the inspection and maintenance works out.

My questions would be:

  1. When was the last time a fire drill held?
  2. When was the last time an evacuation drill held?
  3. When was the last time the PAKKHSA underwent a fire-fighting training?
  4. When was the last time hospital staff trained on how to handle portable fire-fighting equipment?
  5. When was the last time that fire and fire fighting equipment inspections were conducted?
  6. What were the findings made during the post-mortem of each of the drills and whether they had been addressed?
  7. What measures were taken to ensure that the electrical sparks that appeared in the ICU ward three weeks ago do not recur?
  8. Did Pantai Medivest physically verify the corrective actions taken to prevent the recurrence of the sparks?
  9. When was the last time Pantai Medivest audited its contractors as part of its contractors anagement plan?
  10. When was the last time that the State Health Department audited Pantai Medivest’s performance as well as its adherence to the HSA’s and MOHs fire safety policies?

The above would be the basic question that I would be asking but of course my questions would not limited to just those. The more we find out during the investigation the more questions that would be raised.  My only hope is that a truly thorough investigation would be conducted especially that Pantai Medivest is the common denominator at all Government Hospitals in the country, and any weakness not identified would be another costly tragedy waiting to happen, and by learning nothing from this tragedy the six would have died in vain.