An inquiry report which has been made public says that the incident took place due to a “system failure”. The chronic lack of refilling oxygen tanks went “unnoticed, unsupervised and unchecked”.
“There is no back of oxygen storage/ supply system in the hospital as recommended by the Health Technical Memorandum (HTM),” and the supply chain department failed to provide the required number of flow metres for cylinders and highlighted that the hospital has no emergency rescue squad either.
The report further states that the services contract with the oxygen supplier had expired in June 2017 and no "office order regarding renewal/ extension of contract is available in the record provided by manager pharmacy."
The management suspended seven including hospital director, facility, and supply chain managers.
Representatives of the company earlier spoke to media and claimed that the responsibility lay with hospital authorities. They have stated that they were not asked by the hospital to provide more oxygen as per its requirements.
The tragedy, which occurred between the night of Saturday and Sunday morning, has caused Chief Minister of Khyber-Pakhtunkhwa Mahmood Khan to take notice and promise an independent investigation if the hospital fails to provide an adequate report.