BHOPAL: For nearly eight years, complaints of leaking pipelines and black, foul-smelling water reached the assistant engineer in charge of Indore’s Bhagirathpura locality. He knew drainage and drinking-water lines ran dangerously close and recalled bacteria being detected in tests. Yet he did not report the concerns to his superiors, saying he was unsure whether it was his responsibility or that of the drainage department.
The statement is at the centre of a report by a one-man judicial commission probing the December-January 2025-26 Bhagirathpura water contamination crisis. The commission linked the outbreak to 22 deaths and found that the tragedy was wholly preventable.
Saroj Kumar Prajapati, who served as Indore Municipal Corporation (IMC) in-charge Assistant Engineer for Zone-IV, Bhagirathpura, from August 2017 to June 2025, told the commission he had received complaints about damaged and leaking pipelines but had not brought them to the attention of his superiors. The panel termed this a “serious lapse” and found him prima facie responsible in relation to the incident.
The final report, dated August 18 was submitted to the Madhya Pradesh High Court, was prepared by a commission headed by former high court judge Sushil Kumar Gupta. It was uploaded on the high court website on Wednesday.
The report described the tragedy as the result of “systemic lapses, negligence, and failure of duty” by the government and authorities concerned, and said accountability “must necessarily follow”.
Civic body in the dock
The commission placed primary institutional responsibility on the IMC, observing that its statutory duty to provide safe drinking water cannot be passed on to others. It also faulted engineering officers and officials involved in pipeline tenders, while noting that final individual liability in some cases would require further examination of official records.
The report linked 22 deaths to the gastroenteritis outbreak. Hospital records described the deaths as “probably related” to the epidemic, while medical witnesses told the commission that a death audit attributed all the deaths to it.
Water network vulnerable to sewage contamination
The panel found the locality’s water network inherently vulnerable to contamination. Engineers acknowledged that sewer and drinking-water lines ran close to each other, crossed at several points and, in some places, had the sewer line laid above the water pipe. The prescribed separation between the lines had not been maintained.
The commission concluded that faulty layouts, deterioration and leaks allowed sewage to enter the water supply. Technical officers also accepted that adherence to engineering standards could have prevented the contamination.
Laboratory results highlighted the extent of the contamination. Of 52 private borewell samples collected by the Madhya Pradesh Pollution Control Board on January 3, 2026, 50 tested positive for total coliform bacteria and 40 for E. coli. Municipal testing of 73 samples on December 30, 2025, found 54 beyond permissible limits on the parameters tested, with faecal coliform detected in 39.
The commission also identified an overflowing septic tank behind a police outpost as a potential contamination point. However, it cautioned that the tank could not be treated as the sole source of the wider groundwater pollution without further scientific investigation.
Senior engineer also censured
Senior water supply engineer Sanjeev Kumar Srivastava, who remained in the department from 2013 to 2026, also came in for sharp criticism. Given his long tenure, the commission said it was difficult to accept that he was unaware of the deterioration of the infrastructure.
The panel said Srivastava could not be absolved of failures in supervision, monitoring and preventive maintenance.
Delayed files and projects
The report examined several instances where repair and replacement work was delayed before the outbreak.
In one case, a Rs 2.40 crore pipeline proposal was marked “Discuss” by Additional Commissioner Rohit Sisonia on October 15, 2025. The discussion with Srivastava took place only on December 18. The file was resubmitted for approval to open the financial bid on December 26, about 72 days later. The bid was opened on December 29, as the public health crisis was unfolding, and the agreement was executed on January 13, 2026.
“A delay of 72 days merely for clarification and discussion appears excessive and unreasonable unless supported by documented compelling reasons,” the report said.
It placed primary responsibility on the office that processed and resubmitted the file, particularly Srivastava and his staff, while also examining Sisonia’s supervisory role. The commission said the exact allocation of responsibility required scrutiny of file movement registers and official notings.
Another project, worth roughly Rs 2.25 crore and due for completion by May 14, 2024, was completed only in January 2026, nearly 20 months late. The commission held contractor Malwa Engineering, Indore, primarily responsible and flagged lapses in engineering supervision and contract enforcement.
A third tender, worth about Rs 97 lakh, was cancelled and re-invited several times. The report recorded roughly 126 days between the opening of a financial bid and the recommendation for a fresh tender, followed by another 92 to 94 days before the tender committee considered it at a later stage.
The commission said these delays went beyond mere paperwork failures. Had the tenders been finalised and replacement work completed on time, there was a significant possibility that the contamination could have been prevented. The delays were described as “a contributing factor” in the incident.
Missing records hamper inquiry
The inquiry also encountered missing records while trying to establish who designed and approved the water and sewerage networks.
Neither the IMC nor the Indore Development Authority (IDA) produced essential engineering documents for sewerage works carried out between 1990 and 1995 or the water supply project undertaken between 1999 and 2004. Blueprints, alignment drawings and approvals were unavailable despite repeated demands.
The IDA cited a record-destruction exercise in 2010, but its chief executive could not conclusively say whether the files had been destroyed during that exercise or explain their disappearance.
The commission called the explanation unsupported and sought a separate investigation into the missing records, including whether negligence or deliberate suppression was involved. The absence of records prevented it from identifying those responsible for the original construction deviations.
Officials not held responsible
The report did not assign blame to every official who held office during the period.
It declined to hold then Municipal Commissioner Dilip Kumar Yadav responsible for the tender delay or the contamination, citing the allocation of approval powers and the absence of evidence of negligence on his part.
On Mayor Pushyamitra Bhargav, the commission said a 66-day gap before his signature on an earlier proposal did not, by itself, establish personal negligence, as there was no evidence that the file remained with him throughout that period.
