The locked gates and barred windows that kept 45 women from escaping a fire early Saturday at a drug treatment center pointed to conditions now common in post-Soviet Russia's state-run institutions.
An official described a scene that hinted at horrific panic as patients struggled to escape the fire - Moscow's deadliest in decades.
"Judging by the placement of the bodies, they really tried to get out," said Deputy Emergency Situations Minister Alexander Chupriyan. He said all 45 victims - reportedly 43 patients and two staffers - were dead by the time firefighters arrived.
Inspectors who visited the hospital in February and March had recommended its temporary closure because of safety violations, said Russia's chief fire inspector Yuri Nenashev.
Experts say fire deaths have skyrocketed in Russia since the collapse of the Soviet Union, in part because of a disregard for safety standards. Russia records about 18,000 fire deaths a year - roughly 10 times the rate in the United States.
The fire erupted in a wooden cabinet in a kitchen at one end of a second-floor corridor, officials said. The main exit was blocked by a locked gate that staff members could not open in time, and the only other way out was cut off by smoke, Nenashev said.
The barred windows were shut with locks that hospital personnel, who had the keys, did not manage to open, said Maj. Gen. Viktor Klimkin, Moscow's top fire safety oversight official.
Patients blamed tight security measures - meant to keep patients in - for the high death toll.
Nenashev said he was "90 percent certain" the blaze was deliberately started. Mayor Yuri Luzhkov said it appeared to be arson or extremely careless handling of flammable materials. A city prosecutor said investigators were looking into other possibilities, and that the fire might have started in a pile of discarded materials.