Judicial panel blames institutional failure for deaths due to water contamination in Indore; says the tragedy could have been avoided

A judicial commission set up to investigate the deaths of more than 30 people due to water contamination in Indore said the tragedy was preventable, blaming institutional failure, systematic lapses and delays in replacing aging infrastructure.

A single-judge bench of former Madhya Pradesh High Court judge Sushil Kumar Gupta, which submitted its report on August 18 to the Indore Bench of the High Court, cited a delay of “approximately 859+ days” in calling for important tenders, necessary approvals and completion of works in Bhagirathpur, the epicenter of the tragedy. According to the probe report, then Indore Municipal Corporation (IMC) Additional Commissioner (Water Supply) Rohit Sisonia and then Executive Engineer (Water Supply) Sanjeev Shrivastava were “primarily responsible” for several delays.

Between December 2025 and February 2026, more than 100 people suffered from illnesses such as acute gastroenteritis, acute diarrhea, vomiting, and severe dehydration after consuming contaminated IMC water. The tragedy claimed more than 30 lives and tarnished the image of Indore, which had been awarded India’s cleanest city for eight consecutive years.

However, citing hospital records, the report links only 22 deaths to the tragedy.

72 day delay

The report cited a 72-day delay in the tender process to replace the damaged water main between October 15 and December 26, 2025, just days before the tragedy, between Mr Sisonia and Mr Shrivastava after the former wrote just one word “Discuss” in the file.

“This represents a major and abnormal delay in the entire tender process. Once the Additional Commissioner noted ‘Discuss’, it was expected that: clarifications would be prepared quickly, objections would be resolved and the file would be resubmitted without undue delay. Instead, the file remained pending for about 72 days,” the report said.

However, the report is clear about two IAS officers and former IMC commissioners – Dilip Kumar Yadav, who was appointed in September 2025 and removed during the tragedy, and his predecessor Shivam Verma, who has been the Indore district administrator since September 2025. It states that Mr. Sisonia was the competent authority to grant final approval to the tender, which was within his financial limits.

While Mr. Verma forwarded the charge before the technical opening of the bid, Mr. Yadav “did not exercise any administrative control or have any decision-making authority over the final approval of the bid or the delay incurred in its processing,” the panel notes.

Missing records

The report also states that the IMC and the Indore Development Authority (IDA) “failed to produce” several records, including inspection reports and documents related to the laying of sewerage in Bhagirathpura between 1990 and 1995 and drinking water supply pipelines between 1999 and 2004. The report labels “gross investigation and recommending conversion and preservation of detailed public records” in administrative neglect. until their “disappearance or unavailability”.

“The explanation regarding the destruction of records in 2010 is not supported by documentary evidence. No memo, destruction register or approval record was submitted to show that the missing records were destroyed lawfully,” the report said, adding that it was not possible to identify the officials responsible for the two projects due to the missing records and fix the responsibility.

The report also said that out of 52 water samples taken by the Madhya Pradesh Pollution Control Board (MPPCB) during the tragedy, 50 were found positive for total coliform infection and 40 for E. Coli, confirming bacterial contamination of the water.

“The immediate cause of the contamination was the ingress of sewage into the drinking water distribution, while the cause consisted in the incorrect planning and implementation of the sewer network itself,” he states, attributing the mixing to the parallel laying of sewer and water pipes, their crossing, and in some places even the sewer line above the water pipe.

“The prescribed minimum horizontal and vertical distances between the sewer and water pipes were not observed. Such a design was technically unsafe and inherently capable of causing contamination of drinking water in the event of a leak or failure of any of the systems. The commission further found that the aging of the sewer network resulted in pipe damage, perforation, leakage periods and structural failure.

In addition, the Commission blames the tragedy on the long-term existence of vulnerable infrastructure, deficiencies in inspection and preventive maintenance, inadequate monitoring of drinking water quality, delays in taking corrective action and lack of coordination between concerned departments.

“The commission is satisfied that these failures contributed substantially to the Bhagirathpura incident,” it notes.

‘cumulative failure’

As Justice Gupta concludes his inquiry, he writes: “The Commission therefore concluded that the Bhagirathpura contaminated water incident was not the result of a single negligent act, but was the cumulative result of failures occurring at various stages over several decades.

It adds that the responsibility is shared by various agencies and officials of the IMC, IDA and Mr. Shrivastava, “who remained posted continuously from 2013 to 2026 and despite being the senior technical officer responsible for the maintenance of the water supply system in the affected area, failed to ensure adequate inspection, preventive maintenance, timely replacement and effective monitoring of the compromised pipe network”.

“The facts on record leave no doubt that the incident was preventable; in a constitutional system governed by the rule of law, such a failure cannot go unpunished and accountability must necessarily follow,” says Justice Gupta.

Published – 1 October 2026 22:37 IST