The devastating fire at the trauma centre ICU at SCB Medical College and Hospital in Cuttack exposed a series of failures, including a disabled sprinkler system and defunct smoke detector system.
A preliminary probe found that the ICU's automatic sprinkler system failed to activate as its control valve had been left closed, while the fire alarm system had been switched off for several days.
The fire originated from two ventilator machines in the ICU, which mechanically assists breathing for critical patients, and soon spread, filling the room with smoke.
Eight of the victims were from Odisha, while one each had traveled from neighboring West Bengal and Bihar for treatment.
The incident unfolded in confusion and terror for the families gathered outside, with most having been asleep in corridors, on verandahs, or in open waiting areas when panic began spreading through the hospital.
