Karachi: Sindh Labour Department officials have formally initiated proceedings to dismiss 37 employees of the KVSS (Valika) SITE Hospital after a high-level inquiry into the HIV outbreak among children found that the possibility of reuse of syringes and other disposable medical items could not be ruled out because of severe shortages of syringes, IV cannulas, IV sets, gloves, personal protective equipment (PPE), sanitizers and other essential infection prevention and control (IPC) supplies at the hospital.
Acting on the findings of the inquiry committee headed by Dr Naila Zaheer, Chief Medical Officer, City Circle of the Sindh Employees’ Social Security Institution (SESSI), authorities have issued 37 fresh show-cause notices to a former medical superintendent, two former deputy medical superintendents, two consultant paediatricians, the head of laboratory, the hospital matron, numerous staff nurses and nurse aides, asking them to explain why they should not be removed from service for alleged gross misconduct and criminal negligence.
Documents available with Vitals News show that the fresh show-cause notices supersede earlier disciplinary proceedings initiated after an initial inquiry ordered by the Sindh Ombudsman. The latest action follows a comprehensive inquiry constituted by SESSI to investigate the circumstances surrounding the HIV outbreak that affected dozens of children treated at the hospital.
The inquiry committee concluded that investigators could not scientifically establish a single definitive source of HIV transmission. However, after examining hospital records, interviewing doctors, nurses and other employees, and reviewing infection prevention and control practices, it found that the possibility of healthcare-associated transmission through the reuse of syringes and other disposable medical items could not be excluded.
According to the report, the hospital was facing acute shortages of disposable syringes, IV cannulas, IV sets, gloves, PPE, disinfectants, sanitizers and several other infection-control consumables during the period when the outbreak occurred. Staff members from different departments told investigators that shortages had become routine and that they frequently had to borrow supplies from other wards to continue treating patients.
The committee observed that these deficiencies created conditions in which internationally accepted infection prevention and control standards could not be consistently implemented.
The inquiry also documented serious administrative and managerial failures. It found that the HIV status of patients was not consistently communicated to frontline healthcare workers, limiting their ability to adopt enhanced infection prevention precautions while treating infected patients.
Investigators further identified weak supervision, poor enforcement of infection prevention and control protocols, inadequate documentation, inappropriate deployment of staff, and deficient administrative oversight as major systemic failures that compromised patient safety.
The report revealed that 78 children contracted HIV after receiving treatment at KVSS SITE Hospital. The first case was detected in April 2025, while the number of cases rose sharply in August that year.
The inquiry committee confirmed that five of the infected children later died. It found that most affected children had received treatment at the hospital before testing positive, while nearly all of their parents tested HIV-negative, making mother-to-child transmission an unlikely explanation for the majority of infections.
The committee also found inconsistencies between hospital inventory records and claims made by clinical departments regarding shortages of disposable supplies. It recommended a comprehensive audit of procurement, distribution, stock management and payments for medical consumables to determine whether the shortages resulted from procurement failures, poor inventory management or other administrative irregularities.
Based on these findings, SESSI has initiated major penalty proceedings under the SESSI Efficiency and Discipline Rules, 1973, against 37 employees of Valika Hospital. The notices warn that the allegations amount to gross misconduct and criminal negligence and that removal from service may be imposed after completion of the disciplinary proceedings.
Those served with show-cause notices include former Medical Superintendent Dr Mumtaz Ali Sheikh, former Deputy Medical Superintendents Dr Qamar-ul-Haq and Dr Ambreen Khan, consultant paediatricians Dr Amanullah Memon and Dr Huma Aman, Head of Laboratory and Pathologist Dr Syed Naqeeb Ali, Matron Rukhsana Yasmeen, and 37 hospital employees in total, including numerous staff nurses and nurse aides who were directly involved in patient care or supervisory responsibilities during the outbreak period.
The notices state that the inquiry committee held different officials responsible for different lapses. Senior administrators have been accused of failing to ensure adequate infection prevention systems, an uninterrupted supply of disposable medical items, and effective supervision of clinical services.
Consultant paediatricians allegedly failed to ensure adherence to infection prevention and control protocols within their units, while laboratory and nursing officials have been accused of negligence in implementing or supervising standard infection prevention measures.
Some nurse aides have specifically been accused of failing to report serious irregularities to senior management despite allegedly being aware of the situation. According to the notices, this amounted to gross misconduct because they failed to bring the matter to the attention of higher authorities in writing despite the seriousness of the circumstances.
All officials have been directed to submit written explanations within 14 days explaining why major penalties should not be imposed. They have also been informed of their right to seek a personal hearing before the competent authority. The notices warn that failure to submit a reply within the stipulated period could result in ex parte proceedings and removal from service.
Among its recommendations, the inquiry committee called for strict enforcement of infection prevention and control protocols, uninterrupted availability of single-use disposable syringes and other consumables, comprehensive audits of procurement and inventory systems, better communication of patients’ infectious status to healthcare workers, stronger supervision and documentation, and fixing responsibility for administrative failures to prevent similar healthcare-associated outbreaks in the future.