Judicial panel blames institutional failure for Indore water contamination deaths; says tragedy was preventable

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“The immediate cause of contamination was the ingress of sewage into the drinking water distribution system, while the root cause lay in the improper planning and execution of the sewerage network itself,” the report says, blaming the mixing on parallel laying of sewage and water pipelines, their crossing over and even sewage line running above the water pipeline in some places.  | Photo Credit: A.M.FARUQUI

The Judicial Commission formed to probe the death of more than 30 people due to water contamination in Indore has said the tragedy was preventable while blaming institutional failure, systematic lapses and delays in replacing the ageing infrastructure. 

The one-member panel of former Madhya Pradesh High Court judge Sushil Kumar Gupta, who submitted his August 18 report to the Indore Bench of the High Court, flags delays of “approximately 859+ days” in inviting important tenders, necessary approvals and completion of work in Bhagirathpura, the hotspot of the tragedy. The probe report has held the then Indore Municipal Corporation (IMC) Additional Commissioner (water supply) Rohit Sisonia and then executive engineer (water supply) Sanjeev Shrivastava “primarily responsible” for several delays. 

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

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

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

“This constitutes the principal and abnormal delay in the entire tender process. Once the Additional Commissioner recorded ‘Discuss,’ it was expected that: clarifications would be prepared promptly, objections would be resolved, and the file would be re-submitted without undue delay. Instead, the file remained pending for about 72 days,” the report notes. 

The report, however, gives a clean chit to two IAS officers and former IMC Commissioners — Dilip Kumar Yadav, who was appointed in September 2025 and removed amid the tragedy, and his predecessor Shivam Verma, who has been the Indore District Collector since September 2025. It said the competent authority to accord final approval to the tender, which was within his financial limit, was Mr. Sisonia.

While Mr. Verma handed over the charge before the tender’s technical bid opening, Mr. Yadav “neither exercised any administrative control nor possessed any decision-making authority over the final approval of the tender or the delay that occurred in its processing”, the panel notes.

The report also says that the IMC and the Indore Development Authority (IDA) have “failed to produce” several records, including inspection reports and documents related to laying a sewage network in Bhagirathpura between 1990 and 1995, and a drinking water supply pipeline between 1999 and 2004. The report flags “gross failure and administrative negligence” in preservation and transfer of public records while recommending a separate and detailed investigation into their “disappearance or non-availability”. 

“The explanation regarding destruction of records in 2010 is unsupported by documentary evidence. No note-sheet, destruction register, or approval record has been produced to establish that the missing records were lawfully destroyed,” the report says, adding that it was unable to identify the officials responsible for the two projects due to missing records and fix responsibility.  

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

“The immediate cause of contamination was the ingress of sewage into the drinking water distribution system, while the root cause lay in the improper planning and execution of the sewerage network itself,” it says, blaming the mixing on parallel laying of sewage and water pipelines, their crossing over and even sewage line running above the water pipeline in some places. 

“The prescribed minimum horizontal and vertical clearances between sewerage and water supply pipelines were not maintained. Such execution was technically unsafe and inherently capable of causing contamination of potable water in the event of leakage or failure of either system. The Commission has further found that due to ageing of the sewerage network, deterioration of the pipelines, perforation, leakage and structural failure occurred over a period of time,” it says. 

Apart from this, the Commission blames the tragedy on prolonged existence of vulnerable infrastructure, deficiencies in inspection and preventive maintenance, inadequate monitoring of drinking water quality, delay in taking corrective measures, and lack of effective coordination among the concerned departments.

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

As Justice Gupta concludes his probe, he writes, “The Commission, therefore, concludes that the Bhagirathpura contaminated water incident was not the result of a single act of negligence but was the cumulative consequence of failures occurring at different stages over several decades.”

He adds that the responsibility is shared among various authorities and officials of the IMC, IDA, and Mr. Shrivastava, “who remained continuously posted from 2013 to 2026 and, despite being the senior-most technical officer responsible for maintenance of the water supply system in the concerned area, failed to ensure adequate inspection, preventive maintenance, timely replacement and effective monitoring of the vulnerable pipeline network”.

“The facts brought on record leave no manner of doubt that the incident was preventable; in a constitutional system governed by the rule of law, such failure cannot remain without consequence, and accountability must necessarily follow,” Justice Gupta says. 

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