An official inquiry into a Pakistan hospital fire that killed 14 babies last month has found the neonatal unit lacked fire alarms and sprinklers, while firefighters reported that escape routes were “locked or obstructed”.

One firefighter, who asked to remain anonymous, told the BBC he had heard from other rescue workers that entering the Pakistan Institute of Medical Sciences (PIMS) hospital in Islamabad was “extremely difficult”.

“The doors were locked so they had to break through the windows to enter. Even after getting inside, the doors leading towards the ward were locked.”

PIMS has not provided a comment on the report and its findings.

The firefighter said he arrived once the blaze had been put out.

It was “difficult for me to even describe what we saw,” he said. “The medical equipment above [the babies] had melted and collapsed onto them.”

The report from an investigative committee headed by a retired senior civil servant found “systemic and institutional failure” which meant what began as an electrical spark became a “catastrophe”.

For many inside the hospital on the morning of 26 August, the first warnings were shouts.

Abdul Ghafoor was in a nearby ward with his mother, who was a patient, when he heard someone warning that a fire had erupted. He went upstairs to see if he could help.

“The entire ward was filled with smoke, we could not see anything,” he told the BBC.

CCTV from the corridor outside shows how quickly the fire spread. According to the report, the first indication that something was wrong came at 06:38 when a nurse can be seen running from the ward to get help, returning 20 seconds later with a security guard.

Another nurse, Razia Noreen, is then seen rushing into the ward, emerging seconds later with one of the babies who turned out to be the only one to survive.

Within a minute, the report says, dense smoke had obscured the camera.

Hivsa Walid, her newborn niece and sister-in-law were in the ward next door. Hours later she told the BBC that they had heard a loud commotion and then realised it was a fire when they saw smoke emerging from the unit where the babies were sleeping.

“In that moment, I couldn’t understand what was going on. We just focused on getting downstairs and saving ourselves.”

On the day of the fire, authorities suggested the fire had started from a spark in the ward’s air conditioner.

The report agrees that this was the most probable source of the fire, due to an overheating electrical supply cable – although it remains unclear what exactly the electrical defect was.

The fire then spread quickly, igniting plastics, equipment and bins.

Several babies in the ward were on oxygen support, but the report says that while oxygen may have intensified the fire, there isn’t evidence that it created a pathway for it to spread.

The air conditioning units had undergone maintenance, but the report says this is not the same as a safety check. Back in 2018, the hospital’s air conditioning units had been approved to be replaced and upgraded, but eight years later this hadn’t happened.

The report states that there was no functioning smoke detection, fire alarms or sprinkler system. It found no evidence that the staff in the unit had been trained or had ever rehearsed how to evacuate the ward of newborns, many of whom were premature or “medically fragile”. It also found staff had not been trained on how to isolate the oxygen supply in the case of an emergency.

Several people described chaos and confusion in the hospital.

“There should have been fire extinguishers and protocols, but no one was doing anything,” Walid said. “Everyone was just running.”

Ghafoor said that he was part of a group of seven or eight who tried to find a way to relieve the thick smoke; they managed to break glass panels at the end of the corridor before firefighters arrived.

The emergency services weren’t notified about the fire until 06:54, the report says, nearly 20 minutes after it first began. It says the first rescue workers arrived at 07:01.

Like the firefighter who spoke to the BBC, Ghafoor also said rescue staff struggled to get through some of the hospital’s doors.

At the time, the hospital’s executive director had told BBC News that the door to the newborns’ ward was not locked, but guarded, because of previous incidents of baby abductions from government hospitals.

The report says that while “ordinary access restrictions may be legitimate for security purposes… they cannot render designated emergency routes inaccessible when needed.”

The report also found that the hospital had received previous warnings about fire risks. A month before, a fire had broken out at its nursing hostel, raising issues with smoke detection, alarms and general fire preparedness.

It says that the hospital and its senior management “bear the principal institutional responsibility for failing to convert known risks, prior warnings and assigned duties into an effective safety system”.

Pakistan’s prime minister has directed the inquiry’s short-term measures to be implemented within the next three months and ordered fire safety audits of public and private offices and buildings.

He has also suspended eight officials and asked for criminal proceedings to be initiated against them.