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23 August 2024 at 9:59:04 pm

Fatal Negligence

Newborns dying in a fire inside a government hospital is a devastating indictment of a system that is supposed to protect its most vulnerable patients. The Amravati District Women’s Hospital tragedy, where a blaze killed three infants, joins a long list of preventable institutional failures. Thirty-nine babies were inside the three-compartment facility when the fire erupted after a ventilator in the neonatal unit caught fire. Thirty-six were eventually rescued. Parents and eyewitnesses have...

Fatal Negligence

Newborns dying in a fire inside a government hospital is a devastating indictment of a system that is supposed to protect its most vulnerable patients. The Amravati District Women’s Hospital tragedy, where a blaze killed three infants, joins a long list of preventable institutional failures. Thirty-nine babies were inside the three-compartment facility when the fire erupted after a ventilator in the neonatal unit caught fire. Thirty-six were eventually rescued. Parents and eyewitnesses have alleged that the fire alarms did not sound and the automatic sprinklers failed to activate even as the district administration has said the hospital underwent regular fire audits and had applied for this year’s audit. An audit is meaningful only if it establishes that equipment works when lives depend on it. Maharashtra has already witnessed the deadly consequences of fire-safety failures in public hospitals. In 2021, eleven Covid-19 patients died in a fire at the Ahmednagar district hospital even though a fire audit conducted months earlier had recommended a firefighting system. The Amravati tragedy demands more than the familiar ritual of a high-level inquiry, compensation and promises of “strictest action”. The announcement of ex gratia payments cannot compensate parents who have lost a child they had barely begun to know. The investigation must establish not merely what ignited the fire, but why it was allowed to become fatal. Was the ventilator properly maintained? Were electrical and medical devices routinely inspected? Did alarms function? Were sprinklers operational? Was the NICU appropriately located and equipped for evacuation? Were staff trained and drills conducted? And most importantly, who was responsible for ensuring that every safeguard worked? There is another troubling detail: the neonatal unit was reportedly housed on the third floor, rather than at ground level, and questions have arisen over whether the unit was part of the building’s original plan. The state has built an elaborate architecture of laws and child-protection standards which seldom matches the situation on ground. Whether in government hospitals, schools or anganwadis, safety has become a box to be ticked rather than a responsibility to be lived. The most vulnerable children are consequently left dependent not on systems, but on the vigilance and heroism of individual staff members. That is an appalling way to run the childcare infrastructure of one India’s most developed states. A NICU is perhaps the worst possible place for institutional complacency: its patients are immobile, medically dependent and extraordinarily vulnerable to smoke, heat and even brief disruption of life-support equipment. The government must ensure that the Amravati deaths do not become another entry in the grim ledger of hospital tragedies followed by inquiries, outrage and forgetting. The real test will be whether the state can prevent the next newborn from dying in a hospital that was supposed to save him.

Why Half-Delegation Doubles the Load

“Delegation without release doesn’t free you … it multiplies your work.”

Every founder says they want to delegate. Few actually do. What most leaders practice isn’t delegation. It’s half-delegation: tasks pushed down, but ownership of standards and outcomes quietly held back.


The illusion is powerful. On paper, the team looks empowered. In reality, every loop still circles back. The founder steps out… only to re-enter through side doors: WhatsApp overrides, midnight edits, “just a quick check” messages.


Instead of freeing them, half-delegation doubles the load.


The Factory Example

At “The Factory” (our case study of this series), the founder had finally hired senior managers. Production head, operations head, finance lead. “Now I can focus on strategy,” he told us. For a few weeks, it seemed to work. He stepped back from the daily stand-ups. Managers ran reviews on their own.


But then patterns emerged:

  • WhatsApp messages at midnight correcting quality details.

  • Quick edits to client proposals after teams had already approved.

  • Vendor negotiations reopened because “he knew the history better.”


From the team’s perspective, nothing had changed. They were still executing under his shadow. From his perspective, he was working twice as hard. Delegated tasks still lived in his head. He tracked them, worried about them, and re-entered them after the team had already moved.


This is the cost of half-delegation: two versions of the same work … one done by the team, one replayed in the founder’s brain.


Why Half-Delegation Happens

Founders don’t cling because they want control. They cling because they fear loss.

Loss of quality.

Loss of client trust.

Loss of consistency.


So they push the task out, but keep the standard inside. They let the team act, but reserve the right to intervene.


It feels safer. In truth, it’s corrosive. Teams learn their work isn’t final. Leaders drown in mental residue. And the cycle repeats.


Delegation Debt

We call this delegation debt: the compounded load that builds when you hand off action but not ownership.


At The Factory, delegation debt showed up in endless corrections. Managers stopped making confident calls because they knew he would revisit them anyway. Every decision took twice as long … once when the team acted, again when the founder “checked.”


It would have been less work if he had done it himself. At least then the loop closed once.


Cognitive Residue

Even when founders don’t step back in, they often carry what we call cognitive residue … the mental fragments of tasks supposedly delegated. The factory founder described it perfectly: “I tell them it’s theirs. But I still think about it at night. I still wonder if they’ll get it right.”


That residue meant he never truly switched off. Even when he didn’t intervene, he stayed tethered. Delegation in words, ownership in mind.


Phantom Ownership

The cruelest part is what happens to teams. They think they’ve been trusted. They take ownership. Then suddenly, the founder reappears with edits, corrections, or vetoes.


That’s phantom ownership where responsibility looks transferred but still defaults back to the founder. It breeds frustration. Teams stop trying to own outcomes because they know ownership isn’t real. And leaders complain about lack of accountability … without realizing they’ve sabotaged it themselves.


Breaking the Cycle

Half-delegation isn’t better than no delegation. It’s worse. At least when you own it fully, the loops close once. In half-delegation, every loop closes twice: once in the system, once in your head.


Breaking the cycle requires three deliberate shifts:

Define Done. Don’t just assign the task. Make clear who decides it’s finished.

Make Standards Visible. If quality benchmarks live in your memory, they’re still yours. Write them down.


Exit Publicly. Tell the team where you’re stepping out and mean it. If you return, explain why, once. Then fix the system, not the person.


The Human Confession

One founder put it bluntly: 


“I thought I was delegating. Turns out I was just postponing my work … until I came back to redo it.”


That’s the heart of half-delegation. It doesn’t free you. It delays you. And in the process, it erodes the team’s confidence while doubling your own burden.


Final Reflection

The illusion of control is seductive. It feels like safety. In reality, it’s slow poison. True delegation isn’t about pushing tasks down. It’s about releasing ownership. Until you do, you’re not freeing capacity — you’re multiplying debt.


If you find yourself re-entering loops you “gave away,” you’re not delegating. You’re shadow-managing. And your team is learning that nothing they do is ever final. The day you release not just the task but the standard is the day you start to scale. Until then, every handoff will keep coming back.


Read more in-depth insights at: www.ppsconsulting.biz/blog


(The writer is Co-founder at PPS Consulting. Views personal.)

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