What happened here
1 / 7 On 9 December 2011, smoke from a basement store at AMRI Hospital in Kolkata spread into the wards above and 92 people died, most of them patients who could not get out on their own. The alarm had been switched off, the windows did not open and the fire brigade was called late. For any hospital the lesson is plain: keep the basement clear, keep smoke out of the wards, and have enough trained staff to move patients at any hour.
Quick answers
What happened in the AMRI Hospital fire in Kolkata?
In the early hours of 9 December 2011, a fire started in the basement of AMRI Hospital in Dhakuria, Kolkata. Smoke rose to the upper floors and 92 people, mostly patients, died, as per later court reporting. First-day reports said at least 89, and some accounts say 93.
Why did so many patients die in the AMRI Hospital fire?
Most victims died from suffocation, not burns. Smoke from combustibles stored in the basement spread upward, the building had no openable windows, and critically ill patients could not escape on their own.
What went wrong with the alarm and early response at AMRI?
According to the case account, the fire alarm had been switched off to avoid false alarms, and staff tried to fight the fire themselves. The fire brigade and police were informed only when the fire was out of control.
What lessons does the AMRI fire teach hospitals?
Keep combustible materials out of basements, keep alarms, smoke control and emergency lighting working, provide openable windows, and have enough trained staff to move patients who cannot evacuate on their own at all hours.
In the early hours of 9 December 2011, a fire started in the basement of AMRI Hospital at Dhakuria in south Kolkata. It killed 92 people. Most of them were patients, and almost all of them were killed by smoke, not by flames. By the end of that day, news reports counted at least 89 dead; 92 is the toll given in later court reporting, and some accounts, including this page earlier, say 93.
Reports differ on the exact time. Local residents told reporters they saw smoke coming out of the basement at around 3:30 am, while other accounts put the start of the fire earlier.
What happened that night
The basement had been turned into a pharmacy and godown. It was stacked with things that burn hard and give off thick smoke: PVC pipes, mattresses, oxygen and LPG cylinders, and engine oil. The Tribune reported at the time that the basement had been built illegally and used as a store.
Once the fire took hold, smoke rose through the air-conditioning shafts into the floors above, where patients were asleep. Most nurses, doctors and other staff got out. Many critically ill patients could not. The building had no windows that opened, so the smoke stayed inside and people suffocated in their beds.
What the government did next
Chief Minister Mamata Banerjee, who also held the health portfolio, publicly blamed the hospital management for “criminal negligence”. She ordered criminal cases and arrests, and cancelled the hospital’s licence. Six directors of the hospital group gave themselves up to the police and were arrested on charges that included culpable homicide not amounting to murder.
The state government also set up a commission of inquiry under Justice Tapan Mukherjee, a retired judge of the Calcutta High Court.
Where the case stands
On 30 June 2016, the Alipore district and sessions court framed charges against 16 accused, including directors and hospital officials. The charges included culpable homicide not amounting to murder under Section 304 of the IPC, along with offences under the West Bengal Fire Services Act. In April 2017, the Calcutta High Court asked the state government what it was doing to finish the trial quickly. In July 2017, the High Court reduced the charge against one former director to causing death by negligence, while still holding that the board had failed to carry out the fire service’s directions.
We could not find a verdict in reliable reporting. Until we can, treat this as a case still before the courts.
Where things went wrong
- The alarm was switched off. According to the case account, the building’s fire alarm had been turned off to stop false alarms, so nobody got a warning. The central AC did not trip on its own and kept pushing smoke to the upper floors. Fire and smoke dampers did not work.
- Staff fought the fire alone and called no one. Hospital staff tried to put the fire out themselves. They did not sound the alarm or call the fire brigade, and those first minutes were lost. Internal hydrants and sprinklers either did not work or staff did not know how to use them.
- The fire brigade and police were called late. They were told only after the fire was out of control. Locked doors and gates were opened only once they arrived.
- Neighbours were kept out. Security staff did not let local residents in to help. Some young men from the neighbouring slum climbed the rear boundary wall and joined the rescue, but by then it was very late.
- Firefighters were not equipped for this. Crews reached late and went into the smoke without breathing apparatus. In the early stage they also had no searchlights or ladders to start a proper rescue.
- The windows would not open. The outer glass facade was double-glazed and very hard to break. With no openable windows, the smoke had nowhere to go.
- The lights failed. Emergency lighting did not work, or there was not enough of it, and the building was in total darkness. Because of the dark and the smoke, no rescue was tried through the inside staircases or lifts. Staff had not been trained for an emergency.
- Rescue was makeshift. Rescuers broke the facade glass and used rope ladders from outside. It saved many lives, but it was dangerous. Some patients were seen jumping from windows onto hydraulic platforms.
- The basement was a store. A space that should have been kept clear was full of combustible stock, including oxygen and LPG cylinders.
- Fire engines could not get close. A DG set and a gas bank had taken up half the approach road, and fire vehicles struggled through the narrow passage that was left.
- Every check failed. From the regulators to the state’s disaster response, each layer that should have caught these problems missed them.
What every hospital and nursing home should take from this
- Follow the rules because lives depend on them. Management must meet every statutory requirement, and not just to get the NOC signed.
- Have a written emergency plan. Give every staff member a clear job for each kind of emergency. Train them and hold real mock drills on site, regularly.
- Keep fire systems ready, every hour of every day. Firefighting and life-safety systems must be commissioned properly and maintained so they work when needed.
- Back up the power. A reliable emergency supply should keep life-safety systems, lifts and emergency lights running even when the main power is cut.
- Protect the staircases. Every emergency staircase and lift should open into an enclosed lobby that blowers can pressurise when the alarm goes off, so smoke and flame cannot climb. At least one emergency staircase should open straight outside at ground level.
- Fit windows that open. At least 15% of windows should open easily in an emergency. Mark them with signs and check them regularly.
- Keep basements clear. Give them mechanical ventilation and smoke exhaust. Store nothing combustible there, and do not allow changes that turn them into stores for consumables or stationery.
- Leave room for fire engines. Approach and peripheral roads should allow a 20-metre turning radius for fire tenders and hydraulic ladders, and carry the 40-tonne weight of fire vehicles.
If someone in your family is admitted
Most of us will never run a hospital. But many of us will spend a night beside a parent or child in a ward. Take two minutes to find the nearest staircase and check that the way to it is clear. If you see a locked exit, or cartons and cylinders stacked in a stairwell, tell the nursing station and ask for it to be fixed. That small question is how this kind of tragedy starts getting prevented.
More on Kolkata: see our Kolkata fire and emergency safety guide for fire brigade numbers, every fire station and the local risks to know.
- Fire starts in the basement pharmacy and godown; residents report smoke at about 3:30 am
- Smoke spreads to the wards through the AC shafts; at least 89 dead by the end of the day
- Six directors surrender and are arrested; the hospital licence is cancelled and a commission of inquiry is set up
- Alipore court frames charges against 16 accused, including Section 304 IPC
- Calcutta High Court asks the state what it is doing to speed up the trial
- High Court reduces the charge against one former director to causing death by negligence
- Trial still in the sessions court under Calcutta High Court monitoring, with nearly 400 witnesses yet to be called (Outlook)
- No verdict found in reliable reporting
Why consequences escalated
- Stock stored in the basement, from PVC pipes and mattresses to cylinders and engine oil, made thick smoke right under the patient floors
- Nothing stopped the smoke going up: the AC kept running, smoke travelled through its shafts and the dampers failed
- With the alarm off and staff fighting the fire alone, the early minutes were lost before the fire brigade was called
- Sealed glass windows kept the smoke trapped inside
- Bed-bound and critical patients cannot walk out, so a hospital needs enough trained staff on every shift, nights included, to move them
- Alarm, smoke control, fire doors, lighting and a clear chain of command have to work together; one weak link is enough to cost lives
Failures and risk multipliers
- Using the hospital basement to store combustible stock and gas cylinders
- Switching off the fire alarm to stop false alarms
- Fighting the fire without sounding the alarm or calling the fire brigade
- Keeping doors and gates locked until outside help arrived
- Turning away neighbours who came to help
- Letting the AC carry smoke up to the wards
- Too few trained staff at night, with no clear roles for moving patients
- Leaving patients who needed to be moved at once to wait for outside rescue
Actions that reduce risk
- Empty the basement of combustible stock and cylinders and store them only where your approvals allow
- Never switch off the fire alarm; if it gives false alarms, get it serviced
- Make sure the AC shuts down when the fire alarm goes off, and test the fire and smoke dampers
- Check that your fire approvals still match how the building is actually being used
- Keep every exit, staircase and the fire engine approach road clear, with doors that open from inside without a key
- Test alarms, emergency lights, hydrants, sprinklers and extinguishers on schedule
- Train every shift, night staff included, to move bed-bound patients, and run realistic drills
- Make calling the fire brigade the first step in your plan, not the last
- Write down every defect, give it an owner and close it by a fixed date
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