A fire broke out at a hospital on the outskirts of Rome, killing at least three people and forcing nearly 200 patients to be evacuated overnight, officials said on Saturday (December 9).

A fire broke out in the emergency room on the ground floor of the hospital of St. John the Evangelist in the Tivoli region on Friday, the Italian holiday. Prosecutor General Francesco Menditto said the fire spread to several other wards, “but the smoke was everywhere.”

Firefighters and police rescue teams worked overnight to use fire truck ladders to rescue patients in high-rise wards, and eventually 193 patients were evacuated. Officials said patients in the ICU were immediately transported by ambulance to other hospitals, while other patients were taken to a nearby municipal gymnasium and then transferred to other hospitals.

Lazio region president Francesco Rocca said at the scene that three people died and the cause of the fire was under investigation. He acknowledged “significant delays” in updating sprinkler systems and other safety infrastructure in Italy’s aging hospitals.

The fire department initially said four people died. Mendito said at the press conference that only three deaths were directly caused by the fire, and the fourth death was not related to the fire.

He said prosecutors do not believe the fire was deliberately set, but the hypothesis guiding the investigation involves a manslaughter charge. He did not release the identities of any suspects.

(This article is based on an Associated Press report.)