Report of the National Cremation Investigation by Dame Elish Angiolini DBE QC

6 Aberdeen (Hazlehead) Crematorium

6.1 Introduction

A total of 37 cremations of infants and babies conducted at Aberdeen (known locally as Hazlehead) Crematorium were referred to the Investigation. The earliest of these took place in 1981 and the most recent in 2012. In addition, the Investigation was also asked by the Minister for Public Health to assist the next of kin of six adults who were cremated at Aberdeen Crematorium during this period. These next of kin were concerned that an infant may have been cremated along with their loved one.

Families of these adults contacted the Investigation after the Chief Executive of Aberdeen City Council released a press statement on 9 June 2014. This followed receipt of an anonymous letter from a person purporting to be a former member of staff. The press statement issued by the Council included the following announcement:

"I have received a serious allegation regarding practices at Hazlehead Crematorium. The allegation relates to the joint cremation of babies and adults.

In light of the allegation I now have to reconsider the findings of our independent audit which were published last year and I have advised Lord Bonomy's Infant Cremation Commission of this development"

Aberdeen Crematorium is situated about four miles west of Aberdeen city centre in a woodland setting. It is the only crematorium serving Aberdeen. The crematorium opened in 1975 and is run by Aberdeen City Council. There are two chapels that can accommodate 96 and 270 persons respectively. There is a memorial chapel and a Garden of Remembrance. There is no dedicated children's area in the garden but there is a memorial stone in the garden. Books of Remembrance for babies are displayed within the crematorium offices.

Aberdeen Crematorium is a member of the professional organisation known as the Federation of Burial and Cremation Authorities ( FBCA ^[10] ).

At Aberdeen cremated remains can be collected by next of kin or Funeral Directors on their behalf or scattered in the Garden of Remembrance. Remains are scattered one week after the cremation takes place to allow for any change of mind by the next-of-kin. These remains are scattered in a different area of the garden depending on the month in which the cremation took place. Although it would not be possible to pinpoint the exact location, the area in which ashes have been dispersed can be identified by the month the cremation took place.

Each month is marked by a large stone though these are not clearly visible to the public. The crematorium deals with a relatively small number of infant and stillborn baby cremations (16 in 2013) but a much higher number of non-viable foetus cremations (1020 in 2013). A large number of the non-viable foetus cremations would have been shared cremations with other non-viable foetuses.

Aberdeen Crematorium is equipped with four Facultatieve Technologies FT11/ FT111 double-ended, gas-fired cremators which were installed in 2010. Prior to the installation of these cremators the crematorium used double-ended Parkgrove Electric Cremators which had been fitted in 1995/6 and upgraded in 2000/1. Prior to 1995/6 the equipment used was the Dowson and Mason Twin Reflux Gas Cremator which had been used since 1975.

A privately owned crematorium, Parkgrove Crematorium, is situated at Friockheim, a 50 mile journey from Hazlehead on non-motorway roads, south of Aberdeen. It was opened in April 1993. Parkgrove Crematorium has been providing babies' ashes to next of kin since it opened. Electric cremators have always been used at Parkgrove. The owner of Parkgrove Crematorium, Ken Parke, manufactured the electric cremators and installed the same electric cremators in 1995/6 in Aberdeen Crematorium. The Investigation found that Parkgrove Crematorium was returning ashes from infant cremations while Aberdeen was not, although they were using exactly the same electric cremators between 1995 and 2010.

6.2 Management

i Structure

Aberdeen City Council is headed by a Chief Executive who has responsibility for all services. The Chief Executive from 1 March 2011 through to 30 June 2014, Valerie Watts, explained:

"I was Chief Executive of Aberdeen City Council. I had about five direct reports. I had a Director of Education and Community and Sports Service, Social Care and Wellbeing, Infrastructure and Planning, Corporate Services and Environment. Over and above that we ran the Office of Chief Executive which included media and communications member support. The crematorium came under the Director of Environment. He had three Heads of Service, one specifically with the remit of refuse collection, grounds maintenance etc. and the crematorium came within the grounds maintenance end of the business. That came under Mark Reilly's remit. Pete Leonard was Director, Mark Reilly was Head of Service and he would have had a number of managers that would have reported into him. If my memory serves me correctly I think the manager of the crematorium would have reported into him directly or directly into his grounds maintenance manager."

Since 2010 Aberdeen Crematorium has been managed within the Directorate of Housing and Environment of Aberdeen City Council. The Investigation was told that the management arrangements had been restructured on several occasions during the period since the crematorium opened in 1975. The Directorate of Housing and Environment is headed by a Director under whom there are a number of Heads of Service/Assistant Directors. Reporting to the Head of Service is the post of Environmental Manager and beneath that level was Crematorium Manager (also known as the Superintendent) until February 2013 when the post of Performance and Development Manager was created between the Environmental Manager and the Crematorium Manager.

The post of Crematorium Manager has responsibility, among other things, for management of the crematorium and its staff, development of policies and strategies, management of finance and maintenance of standards.

There have been significant changes in the staff holding these posts since the crematorium opened. An organisational review (recommended in 2008 after an Accounts Commission inquiry) led to major changes in 2010.

During the period 1993-2014 Derek Snow was the Crematorium Manager at Aberdeen Crematorium. Derek Snow started in 1986 as a Crematorium Attendant. As Crematorium Manager, he had five different line managers between 2002 and 2010. Steven Shaw took up the role of Environmental Manager, and became Derek Snow's line manager, in 2010. The new role of Performance and Development Manager created in February 2013 (reporting to the Environmental Manager and taking over line management of the Crematorium Manager) was filled by Graham Keith in June 2013.

Derek Snow was responsible for the management of staff and the immediate operation of the crematorium.

He was assisted by a number of different Cremator Operators over the period he held the role. Derek Snow was dismissed on 28 June 2014.

ii Management approach

Most line management meetings at the crematorium appeared to focus on budgets and finance rather than policy or practice. Valerie Watts, Chief Executive between 2011 and June 2014, explained:

"There were lots of different methods of communicating within and across the Council which I would have used. Everything was driven by the committee system where committee reports were brought to the appropriate committee or indeed the full Council to inform the elected members and the administration and that was largely in relation to the setting of policy and direction. Once the elected members of the committees made those decisions around policy and direction it came back to me as Chief Executive and my management team to enact those policies. Then every week we had senior corporate management team meetings which were a two-way communication system with me communicating issues down to my manager and then they in turn raising issues for the corporate management team table to communicate issues across the wider SMT (Senior Management Team)"

The issue of the cremation of foetuses and babies and whether or not remains were recovered and returned to parents does not seem to have been discussed. There was no overall strategic management of the crematorium. Aberdeen City Council had significant challenges elsewhere. Pete Leonard, Director of Communities, Housing and Infrastructure since 2010, explained to the Investigation,

"...in terms of the focus of senior management attention, you focus on the things that you know need fixing and you focus on the things you know to improve and areas where you need to make savings and you've got to try and bring the public and elected members with you, that's very much a focus."

Aberdeen City Council were dealing with financial pressures from around 2008. The Chief Executive between March 2011 and May 2014, Valerie Watts said,

"When I first went to the post £120 million of savings had to be found but at the same time you had to do the right thing, you had to align the corporate plan with the Council policy."

Dame Sue Bruce, Chief Executive of Aberdeen City Council between December 2008 and December 2010 told the Investigation,

"I was appointed at Aberdeen City Council when they were facing a particularly difficult financial time and I had to address major issues across the Council. Throughout my period at Aberdeen City Council I was not aware of any difficulties with the operational practices at the crematorium at Hazlehead"

Mark Reilly, Head of Services said,

"When I came in to Aberdeen (May 2010) it was because Aberdeen had gone through quite a difficult time"

A significant change for the crematorium was the appointment of the Performance and Development Manager to fill what was seen as too wide a management span and too shallow a hierarchy within the senior management team. Senior managers within the Directorate had very wide and extensive areas of responsibility. It was clear during the Investigation that the current Environmental Manager, Steven Shaw and those above him had remote and ad hoc involvement in the management of the crematorium or the staff. The Investigation was told by the current Crematorium Manager, Angus Beacom, that,

"…staff felt that, in their words, not mine, they had been somewhat neglected by senior management"

Pete Leonard, Director of Communities Housing and Infrastructure told the Investigation,

"I guess I was fairly light touch in my management in terms of, I don't think I had visited the site for some time."

Pete Leonard confirmed that the purchase of new cremators was an expensive capital project and that he " was more focused on keeping track of that",

"I guess the crematorium for me was a case of things seem to be going ok so a light touch management was ok and I wasn't really getting involved.

The crematorium, I guess, never really featured on my radar. I wish it had, but it never featured on my radar so it was kind of left alone."

The Head of Services, Mark Reilly, told the Investigation,

"…Now there was a gap between Steven (Shaw, Environmental Manager) and Derek Snow (Cremation Manager) that I didn't particularly care for. I wanted to really look at the structure of Bereavement Services and crematoria and how that works and get one manager overseeing both."

The Investigation found that despite issues about infant cremation coming to public attention following the media coverage about Mortonhall Crematorium in December 2012, no changes in practice were instigated at Aberdeen until November 2013 and July 2014.

Through interviews with these managers a picture emerged of a crematorium managed with a 'hands off' approach from senior managers. Steven Shaw, Environmental Manager told the Investigation,

"The crematorium was not a priority in terms of my management command. Until this [Mortonhall media coverage] emerged I don't think we ever discussed the cremation of babies and infants, never raised it"

Derek Snow, former Crematorium Manager told the Investigation,

"My job title is Manager but I was only a manager when the Council wanted me to be a manager. I've had a lot of staffing issues and I went to my then boss Steven Shaw. He didn't want to know, he told me 'you deal with it, you're the manager'. I did not feel supported by my managers latterly, by which I mean since the new regime came in with Pete Leonard as Director. I have four managers. The only person I felt I got any help with in the end was Graham Keith."

The crematorium was regarded by these senior managers as a successful business and as well managed by Derek Snow with very few complaints from next of kin.

Previous line managers interviewed by the Investigation confirmed this impression of Derek Snow and the crematorium. In interviews with former Environmental Managers Sandy Scott (2008-2010) and David Forsyth (2006 - 2008) there was clear evidence of a system of one to one meetings and annual appraisals with Derek Snow. However, the issue of cremation of infants never came up at these meetings.

iii Management response to Emergence of Issues at Mortonhall Crematorium in December 2012

The then Chief Executive, Valerie Watts, arranged to visit Aberdeen Crematorium on 10 April 2013. She told the Investigation,

"I suppose rightly or wrongly through me personally wanting to go and hear and see and get a feel for myself rather than leave it to my Director or Head of Service to tell me these things I felt that it was a sensitive and important enough issue I felt that I wanted to go myself. My Head of Service came with me that day, Ciaran Monaghan. I wanted him to come with me as my witness. I thought if it was important enough for the Chief Executive to go (and I don't mean that to sound boastful) but I thought if I am giving it enough of my attention I wanted him to be there to see what I was asking and what answers I was being given. It was quite a sombre day and I came away from it thinking that you've got to assess whether or not you're being told the truth. There was nothing that happened that day to give me any indications that I was being lied to."

The Investigation requested documentation in relation to this visit and was advised by Ciaran Monaghan who was Head of Service, Office of Chief Executive, at the time of the visit, that,

"There is no longer any information on file about the visit other than an appointment briefing note…from which I can confirm that the visit took place from 4.00pm on Wednesday 10 April 2013 and that the Chief Executive was met by Derek Snow."

He went on to say,

"There is no record on file of the names of the individuals met or of the questions asked or answers given... I am not aware of any specific follow up action that flowed from the visit."

Senior managers told the Investigation they had been unaware that Aberdeen Crematorium did not give ashes to next of kin for infants, stillborn babies and non-viable foetuses. They were unaware that the practice taking place at Aberdeen differed from that taking place at other crematoria. They were unaware too that other crematoria in Scotland were returning ashes to parents after the cremation of non-viable, stillborn and infant cremations. Of all of the management posts, only the Crematorium Manager was based on site at the crematorium. The others managed remotely with some making periodic visits. There was an absence of any strategic management of services and an apparent complete reliance on the account of Derek Snow about the quality of the service provided.

It was only at the time of the publication of an article in the Edinburgh newspaper, the Evening News, about Mortonhall Crematorium in December 2012 (when the failure to give ashes back at Mortonhall was highlighted) that senior management in Aberdeen began to pay attention to the crematorium. However, despite the concerns being discussed in the media about Mortonhall at that time, no action was taken to change working practices at Aberdeen until November 2013. This was almost twelve months later and only following a visit to Seafield Crematorium by Aberdeen management prompted by Lord Bonomy.

Pete Leonard, Director of Communities Housing and Infrastructure, told this Investigation,

"And we had lots of conversations, so we'd be saying, well if some people are saying that they're recovering ashes, how is that? Are they using different temperatures and all this? There's a lot of speculation about 'well, we're not sure how they're doing it, but they're probably doing things like turning the ovens off at night and leaving the baby in to 'slow cook' and do we really want to be doing that and what if the parents found out about that?' and there were issues being thrown in around emissions and if you turn the heating down then you might be breaking the emissions law. There didn't seem to be any shared industry knowledge or best practice."

Mark Reilly reported that he had a conversation with Derek Snow in January 2013, in which,

"I was told, we don't get any children's ashes because of the burner and the fierceness of the burners…and I was told we particularly didn't get anything up to about eighteen months-it could be sixteen months or whatever, it could be twenty months."

Steven Shaw said of that explanation,

"To be honest I didn't really give it that much thought at the time. It wasn't until everything blew up that I started asking these sort of questions and trying to learn more about it."

Pete Leonard, referring to a conversation with Derek Snow and a Cremator Operator, told the Investigation,

"0-3 years is what they said roughly but then they kind of said all depending on the weight of the child etc."

When asked if the term 'up to eighteen months' ever came up, he said,

"It probably was eighteen months actually, yes, but I'm sure they said up to three years old as well, but certainly eighteen months was mentioned but up to three certainly came into it sometimes."

Steven Shaw said he spoke to Derek Snow at this time and he confirmed that the long term practice of not giving ashes for non-viable foetuses, stillborn babies and infants under eighteen months to two years was correct. This assurance was accepted by senior management.

Steven Shaw told the Investigation,

"I think the age of eighteen months seems to ring a bell. He gauged that up to eighteen months there is no ashes. From eighteen months up to maybe two years we would maybe get something."

He also said that he had found out that they used to get ashes when baby trays were used but that the trays were stopped by 'Health and Safety'. No evidence of any injury was presented to the Investigation. No records of any Health and Safety reports or intervention relating to the use of a baby tray were provided to the Investigation. He advised the Investigation that he was told,

"It was all down to supposedly having the most up-to-date cremators in the country."

Pete Leonard appears to have accepted this assertion despite Aberdeen's failure to return ashes predating the installation of these up to date cremators by many years. No effort was made by anyone at Aberdeen City Council to reconcile whether or not baby ashes exist or whether staff simply did not recover them. Neither was there any probe as to whether the type of cremator equipment or working practices at Aberdeen affected either position. The cremators at Aberdeen referred to by Pete Leonard were also the type most commonly used in Scotland. Other crematoria were using them in such a way as to be able to successfully retrieve remains.

Steven Shaw advised that he was told by Derek Snow that what happened at Mortonhall Crematorium did not apply to Aberdeen,

"I was told 'no not at all because we don't have any remains' and I accepted that explanation from Derek (Snow) at that stage. I knew after speaking with Derek that we didn't give ashes because there were no ashes."

There was no evidence that any effort was made by anyone at Aberdeen City Council to clarify at exactly what age or stage ashes were available. The senior managers did not challenge what they were told despite the information emerging from Mortonhall Crematorium nor did they seek information from Seafield Crematorium, or even closer, Parkgrove Crematorium, to ascertain how these crematoria could have been obtaining ashes despite the Aberdeen position that none existed until the age of eighteen months to two years.

Mark Reilly commented,

"Over that period there was a lot of information coming out. Somebody was saying every time I cremate I can always get ashes, some people were saying oh we don't get ashes, some people say sometimes we do, sometimes we don't and we knew the sort of information coming out varied."

On 3 April 2013 the BBC broadcast a documentary, 'Scotland's Lost Babies' which reported that the issues about the failure to return babies' ashes to families may not be confined to Mortonhall Crematorium. The documentary included an interview with the Superintendent of Seafield Crematorium who said that she always recovered ashes and returned them to parents.

Steven Shaw told the Investigation that,

"it wasn't until I watched the BBC documentary…that I started to question it…I was a bit surprised and a bit horrified because we had always stuck by our statement of no remains.

We stuck with the line that Aberdeen Crematorium did not recover ashes. I was looking for comfort and confirmation from Derek, because to me Derek was my expert and I had no reason to not believe him."

There was of course considerable information emerging to suggest that he should have had reason to test the explanations presented to him by Derek Snow.

Pete Leonard, Director said,

"I did not see the BBC documentary and was not aware that Seafield were using a tray and getting ashes."

Nor did he appear to have been briefed at the time by any of his staff on the content of the documentary.

iv Audit requested by Aberdeen City Council management

Pete Leonard told the Investigation,

"Around about that time we received a letter from Sue Bruce (then Chief Executive of City of Edinburgh Council) with the scope of the inquiry that she had asked Dame Elish to perform and I had a conversation with Valerie Watts then Chief Executive of Aberdeen City Council. I said I'd been to see the crematorium team, they assure me everything is okay but I really think we need to get some objective people in to do an audit and investigation into some of the processes and ask them questions. That led PwC to do an investigation, which was very much process based. At the same time, myself and Mark Reilly went to visit the team, got more behind the scenes.

I think not getting ashes had been for as long as they could remember. Certainly with the new cremators they didn't. With the older ones I don't think they did, but I think they said previously they may have done in the dim and distant past, there might have been something. I think they gave some examples there, but I can't really recall.

I think it pretty much reflected what the guys said and looked at the records. On reflection I think we didn't focus enough on behaviour. When subsequently things changed in terms of what people's story was, my own reflection on myself was perhaps I could have been a bit more challenging around some behaviours.

I drew up the terms of reference for the report and cleared these with the Chief Executive but it was based on what Sue Bruce had sent through, it was very similar terms of reference.

I am asked if the auditors looked at records as opposed to wider processes. Yes, that was the case. I am asked if anyone was examining the actual operational processes of cremation itself. No there was not. I think the years picked for audit were aligned with the different types of cremators from what I can see. I think there were different changes to the record keeping and we kept records up to a certain date. I think somebody had written to say they'd had some issue around 2008 and that they received ashes so on the back of that, we said can you go further back and examine what the practice was then"

An audit by the company PwC LLP was duly commissioned and terms of reference agreed in March 2013. The auditors reported on 9 July 2013. This audit was limited in scope and did not look at the actual cremation operational processes but rather traced a sample of cremations to the supporting records and administrative process in respect of the cremation of stillborn babies and infants under the age of two. The audit report describes its work as to 'undertake a data collection exercise and review the current procedures in operation to better inform the Council Officers' understanding of arrangements and practices.' The report was based on the documentation available but there is no indication of the Council seeking audit of the actual cremation working processes by a suitably qualified cremation industry expert or body such as the FBCA.

The PwC audit report's recommendations and findings included the following:

The policy and communication process should be formalised and written. This section of the report refers to infants under eighteen months old whereas most of the rest of the report refers to infants under two years.

In those cases sampled between 1984-1985 all instances record that ashes of babies were obtained with the majority being dispersed in the Garden of Remembrance but some being taken away for burial or scattering. There were no application forms available to check if the dispersal in the Garden of Remembrance was with the approval of the next of kin.

In those cases sampled from between 1 Aug 1999 to 31 July 2000 when the electric cremators were in use and BACAS ^[11] had been introduced (1998), the records indicate ashes of a stillborn infant were scattered and for the ashes of an eight month baby the application form and the operating sheet said there will be no remains whereas the BACAS recording system states that remains were collected. In three cases the instruction in relation to ashes is either scored out or marked 'not applicable' and BACAS states 'no remains'. In eight cases the form is marked not applicable or no remains and BACAS states 'no remains'. In two cases (eighteen months and twenty months) the application form states 'to be collected' and BACAS records they were collected.

In those cases sampled between 1 April 2007-31 Dec 2012, where a child was two years or older, ashes were recorded as being in existence and were collected by the Funeral Director; where the child was less than two years, in seven out of eight cases looked at, the operating sheets state no ashes remained and this is recorded in the BACAS recording system. In the remaining case the operating sheet stated 'remains to be collected by the Funeral Director if any' and the daily schedule stated there were no ashes. The child was one week old.

The Council should consider the processes in place to ensure data is accurately recorded within BACAS.

As observed above, the auditors were not asked if the cremation processes were any different in those years that they found ashes to have been returned to families. The Investigation is aware that baby trays may have been in use in some of those years. This audit report was apparently relied on by Aberdeen management to support their continuing position. Pete Leonard, Director, told the Investigation,

"There had been a conversation about use of trays and what have you and I was very nervous about health and safety and I guess I placed a lot of reliance on the internal audit which we scoped out in March and it reported in July 2013."

There was no evidence given to the Investigation that after the production of this audit report the Council challenged Derek Snow's assertion that there were no ashes to be obtained from babies less than eighteen months old. At the very least the information provided by PwC should have alerted the Council to the inconsistency between their public position and what the audit disclosed from the past.

There is no evidence of the contents of the report being probed or checked to ascertain the reason for the different outcomes in the sampled cases. This information should have been of particular interest given the Council's public position that ashes did not exist for babies under eighteen months to two years.

As of 10 July 2013 it had therefore been brought to the attention of Aberdeen City Council that during the period 1984-1985 the records reported that ashes did exist at Aberdeen, contrary to the Council's public position. This does not appear to have been taken further. Despite these findings and inconsistencies with what the Council understood to be the position, no further formal investigation was carried out at that time nor was a more probing audit commissioned.

On 15 July 2013 the then Leader of Aberdeen City Council, Councillor Barney Crockett issued a statement on behalf of the Council that stated,

"I hope families here in the North-East will take some comfort from knowing that we have had a close look at our own procedures at Hazlehead Crematorium and found them to be sound. We remain fully confident that our crematorium staff at Hazlehead have carried out their duties with the upmost of professionalism and have always approached their very sensitive work in a caring and considerate manner."

Procedures at Aberdeen continued as they had been until, at the prompting of Lord Bonomy, ^[12] staff visited Seafield Crematorium in Edinburgh in November 2013.

6.3 Policy, Guidance and Training

Some of the Superintendents and Cremator Operators who worked at the crematorium during the period of the remit for this Investigation are deceased and a small number of retired members of staff declined to speak to the Investigation. There were no local written procedures in place during the whole period of the Investigation.

The witnesses interviewed were able to speak to working practices at Aberdeen going back to 1986. The Report therefore focuses on practices from that time to the present day.

i Written Procedures

Operational practice and policy at Aberdeen Crematorium was derived by word of mouth from more experienced peers or Supervisors with very little other than the Operators' manuals produced by manufacturers committed to writing.

Operational staff observed,

"…In relation to written guidance procedures that was available for cremation, there was heaps of things round the walls in the office but the instruction in procedures I used were all by vision on site and word of mouth from other Operators. I never read anything."

Another said,

".…All we got towards the training was a reference card, the Scottish Federation of Cremations and Burial. What you got was a list of about eighteen questions and you read it and then you had a file with stuff like that in it. It was nothing too in-depth and then you just referred to that. But then the new machines went in (2010) that was a totally different story because they came in complete with manuals."

Derek Snow, the Crematorium Manager added,

"When I started in 1986 there was no written procedures or guidance for babies. As far as I know there's still nothing like that at the moment."

Steven Shaw, the current Environmental Manager, said that it was clear to him that,

"we didn't have written up simple guidelines. I pushed for them to write up the procedures."

Pete Leonard said,

"When we started speaking to the guys, it was very clear then that there were no practices which made me nervous. "

Prior to the Mortonhall Investigation, Aberdeen Crematorium had no local written guidance on practice and procedure available for staff members. General written guidance on cremation was provided by the FBCA. This guidance provided the basis for certification of Cremator Operators. The subject of infant and foetal cremation is discussed very briefly in the Scheme. It notes that many cremation authorities use a stainless steel tray when cremating infants in order to contain the tiny bones that may remain after the cremation is completed. The Scheme goes on to state:

"It is usually advisable to perform this type of cremation at the end of the working day as the coffin and tray can be charged into the hot cremator and allowed to cremate using minimal top combustion air. Under these circumstances, top combustion air and the residual temperature may be sufficient to ignite and maintain the cremation. If insufficient, the ignition burner should be used as necessary.

On completion of the cremation, the tray containing the remains should be removed through the charging door and not raked through the ash door. Therefore, the cremator must be switched off and the primary chamber be allowed to cool to a safe temperature to allow the safe withdrawal of the tray the following morning."

Staff also had access to manufacturers' manuals for the cremators they were using. Aberdeen City Council's response noted in the 10 July 2013 PwC LLP internal audit report was that they would be formalising their written policy and would consider any findings that came from the Scottish Government's review.

However, when staff were interviewed by the Investigation in February 2015 there was still no formal written procedure, guidance, instruction or local training manual available to staff at Aberdeen Crematorium despite

• the recommendations of Lord Bonomy in his report of May 2014,
• the Mortonhall Investigation Report April 2014,
• the PwC internal audit recommendation of July 2013,
• interest expressed by the Scottish Parliament,
• press and extensive media coverage of the issues surrounding the cremation of babies throughout the period 2012-2014.

Neither did the receipt of an anonymous letter result in such action. This letter indicated that the reason baby ashes were not being returned to families at Aberdeen was because babies were being cremated alongside the coffins of unrelated adults. Members of staff were still working on drafting the crematorium's first Operational Procedures Booklet in early 2015.

In particular, there were no local written instructions for Cremator Operators about how best to achieve the recovery of ashes for infants or any discussion about what type of ashes should be considered appropriate for recovery.

ii Training

The training of staff at Aberdeen throughout the period has mainly been in-house training on general cremation practice. When it came to the cremation of foetuses and babies, staff learned from their more experienced peers or supervisor. However special training for the cremation of babies was not included.

The longest serving senior member of staff at Aberdeen Crematorium was Derek Snow. He was trained in house but also attended external training. He did his training through what he described as 'the old system' which involved attending a two week training course at Linn Crematorium followed by an examination. Derek Snow stated that over the period of his work there (1986 to 2014) he did not have the opportunity to visit other crematoria after that course apart from a visit to Newcastle when the replacement of the cremation equipment at Aberdeen Crematorium was under consideration before 2010.

Steven Shaw told the Investigation he thought that staff were all trained more or less the same way. He believed that Derek Snow's training was cascaded down from one member of staff to another,

"Derek trained someone else who then trained another and that's how it's been."

It was put to Pete Leonard, Director, that Derek Snow had suggested that he was only really a manager when it suited his line managers to treat him as such, that he was given very little scope to manage and was not given the opportunity to attend training. Pete Leonard replied,

"I couldn't really say. I am asked if he ever made a complaint to me about the way he was being managed. No not at all, he seemed to be happy in his work."

This is in stark contrast to what former Environmental Manager, Sandy Scott said about Derek Snow wanting to leave since 2006. Sandy Scott told the Investigation,

"Derek Snow did not want to be at the Council. He made it quite clear he wanted to leave and I did some investigating and spoke to my Head of Service but we felt we couldn't let him go at that point. It was always a feature of our one to ones as he wanted to bring it up with me."

Both former Environment Manager, Sandy Scott and David Forsyth confirmed that the opportunity to have further training was available. David Forsyth said,

"Part of the appraisal process was an opportunity to ask for training and if it was within budget we could look at that."

Sandy Scott confirmed that,

"If Derek had asked for training (I can't remember if he did) then as long as it was relevant we would look at that. There is still budget for that."

In the late 1990's, in addition to in-house training, Cremator Operators were sent on training courses to Harrogate or Sutton Coldfield. The Harrogate course did not cover the cremation of infants or non-viable foetuses. When the new electric cremators were introduced in 1995 a trainer was brought in from Parkgrove Crematorium (where ashes from the cremation of babies were obtained) to train the Cremator Operators on its use. This training was specific to the functionality of the electric cremator and not about the process of cremation as the Operators were already trained and qualified.

From at least 2001 the cremation training was done in-house at Aberdeen Crematorium. Cremator Operators told the Investigation that there was no specific training given for infant, stillborn or non-viable foetus cremations. An external examiner from the FBCA attended after the Cremator Operator had carried out fifty cremations (one in five of which was recorded) for the practical examination. ^[13] However, what does not appear to have varied was the fact that no part of the examination referred to the cremation of babies.

Cremator Operators told the Investigation,

"…There was no specific training for children or infant cremations."

"…In my test there was never any mention of infant cremations."

As cremation training was done in-house the Cremator Operators had virtually no contact with staff from other crematoria, except Parkgrove, until the enquiries into Mortonhall came to light.

Other training on issues such as manual handling and first aid was available but there was no continuous or developmental training provided in relation to cremation. When new gas cremators were installed in 2010 further training was provided by the manufacturers, Facultatieve, in the use of the new machines.

Facultatieve told the Investigation that it was their role to train in the use of the machines, not the process of cremation. However, part of the training when installing their machines is to go through the Operations Manual and Operators have to sign each section to say they have read and understood it. This would include infant cremations. The Manufacturer's Manual states,

"Infants

For the cremation of infants, a heat resisting infant tray is available. The only rule for its use is: - will it hold the coffin without any overhanging? The coffin is first put on the tray and the two together carefully pushed into the cremator. Such a tray is necessary because the bones of small infants are very tiny and would be easily lost if the usual raking techniques were used. At the end of the cremation, the whole tray complete with cremated remains must be removed through the front charging door.

Usually infants are most conveniently cremated towards the end of the working day when the tray and coffin can be put into a hot cremator and left, with perhaps top air jets only on, to slowly and gently cremate.

Depending on the cause of death, some infants can be difficult to cremate, and if this is the case, then of course the burner may be used as necessary. Before withdrawal of the tray the cremator should be allowed to cool sufficiently to prevent the possibility of injury to the Operator, and it may be best to leave the cremated remains in the cremator until the following morning."

This advice has not fundamentally changed since the first cremators were built by Evans Universal in 1987 when they acquired the cremator manufacturers Dowson and Mason. Earlier records show that baby trays have been manufactured by Dowson and Mason since before 1963.

Sandy Scott, former Environmental Manager told the Investigation,

"In terms of the new building and equipment my involvement was minimal; it was done by the architects. We would have input into making sure that the staff welfare was okay. I think responsibility for setting up training for the staff to use the new equipment would have been with the architects. We didn't have the experience to set up the training."

As with the Mortonhall Investigation, despite the complexities and difficulties of this particular aspect of cremation operations, there has been little by way of any local or national written guidance for Cremator Operators at Aberdeen. The absence of any practical formal training over these years to attempt to support staff in recovering remains from infants or foetuses is a significant concern.

6.4 Cremation Process and Equipment

The process for cremating an adult is described in Chapter 5, Explanatory Notes and Terms .

Cremator Operators at Aberdeen described to the Investigation a number of different cremation processes for babies depending on the year, the type of equipment in use and the availability or otherwise of a tray. These are:

• cremation first thing in the morning when machines were being preheated ready for the first adult cremation of the day
• cremation last thing at night by raking forward the ashes of the last adult to be cremated and placing the infant coffin in the cremator at the same time and leaving overnight
• placing an infant coffin at the side of or on top of an unrelated adult coffin and cremating both bodies together

i Cremation Equipment and How It Affected Cremation Processes

Electric cremators manufactured by Parkgrove were used at Aberdeen from 1995/6 to 2010. During the time period when electric cremators were in operation in Aberdeen Crematorium the staff did not recover ashes of babies or non-viable foetuses. The same electric cremators were used over this period at Parkgrove Crematorium in Friockheim where, even in the absence of baby trays and infant mode, ashes for babies were being recovered by staff there.

Ken Parke, the manufacturer of the electric cremators told the Investigation that baby trays are not required in the Parkgrove cremators as the extract fan is not employed for the cremation of babies. He explained that infant cremations are carried out at the end of the day and, once complete, left in the cremator to cool. Ken Parke explained that,

"The coffin is just placed into the cremator and there's no fans, no extract fan and it's left there overnight and then the next morning it's raked down and processed."

The next morning the ashes are raked out of the cremator, any metal removed and the ashes crushed.

Although Ken Parke was frequently at Aberdeen Crematorium he was never told by Aberdeen staff when he attended there that they were not getting ashes for babies. However, Ken Parke confirmed that he had a telephone conversation with Derek Snow in or about May 2003 when Derek Snow asked about obtaining ashes for babies,

"I said to him at the time, 'you've got exactly the same machine as ours and there's no reason why you shouldn't get ashes'. There will always be ashes there. It might be the coffin that's there but there will always be ash there."

Whereas in Friockheim the ashes were raked out the next day and retained, in Aberdeen crematorium ashes were not looked for as the Operators stated they believed there were no ashes for infants under eighteen months or in some cases two years. Cremator Operators were advised by more senior colleagues that they would not recover ashes from babies. Despite this advice and alleged belief, an examination of the Registers of Cremations between 1981 and 1996 reveal that ashes were in fact recovered on occasion and would be returned to the next-of-kin.

Gas cremators manufactured by Facultatieve were installed in 2010. In April 2013 the Facultatieve cremators were given an additional programme known as 'Infant mode' as part of an upgrade related to the monitoring of emissions. ^[14] Facultatieve described infant mode as,

"The infant profile is set such that very low levels of combustion air are applied; this reduces turbulence and retains more ashes. Also the main or ignition burner is effectively disabled again to reduce the effect of turbulence. We recommend that the infant mode is used on any charges below the age of five years."

Despite the introduction of infant mode, Aberdeen City Council continued to maintain that there were no ashes to be returned to next of kin from the cremation of babies variously up to eighteen months to two years of age until November 2013.

A Cremator Operator who had worked at Aberdeen Crematorium since early 2000, and who had therefore used both the Parkgrove and the Facultatieve cremators, told the Investigation,

"…We would not look for ashes for a child under the age of eighteen months."

No one could give an explanation for this understanding. Others said that whether they looked for ashes or not depended on the size of the coffin.

ii Cremation of babies and non-viable foetuses along with unrelated adults

Several Cremator Operators described the process during the period of the electric cremators between 1995 and 2010. It was explained that an adult cremation would take place and when that cremation was almost complete, the ashes of the adult would be raked forward to the edge of the hearth at the rear of the Cremator. They reported that the baby's coffin would then be placed into the chamber and the cremation would take place there with the adult's ashes still in the cremator. This was often done last thing at night and all the ashes were raked down the following morning. The Investigation was told that the Operators now accepted it was possible that baby ashes were mixed up with the adult ashes when the cremations were carried out this way.

One Cremator Operator explained,

"Going back to the old machines and before we used the trays, the adult cremation was almost finished and we used to rake it down near to the finish, to the ashes compartment and then we would charge in the child's coffin and just let it burn away and then the whole lot was raked down together.

So we'd have the adult's ashes and then the child's ashes. It would be impossible to tell, obviously if a baby's coffin is put into a chamber at one end and there's an adult set of ashes at the other end, in the combustion process itself ashes are going to fly about inside a chamber. I'm guessing it's 100% impossible to keep those ashes completely separate…the same argument could be made for the previous cremation"

Another Operator told the Investigation about a further process they also used,

"If it was a baby under the age of eighteen months then that baby would go in with an adult. No particular adult, just whatever one is going in to the cremator. We always tried to cremate the babies the same day they came in but it could be with any adult that day. Even if it was a private funeral arranged by the parent this is what would happen. This is how we always did it then. This was the new machines and the old machines, all the time I have been here up until 2010. This is what I was trained to do. The person who got the adult's ashes was also actually getting the child's ashes. There were two ways of doing this. I either put the baby's coffin on top of the adult's coffin or, in the older machines, I raked forward the adult's ashes before the cremation was totally finished and then put a baby in as well. The ashes were always raked out all together. For non-viable foetuses in boxes rather than coffins, we put the boxes in the cremator alongside the adult coffin. I am asked when this practice stopped. It was sometime after the new cremators came in and before the issues at Mortonhall came out in the press. I am not sure what the reason was for changing. It might have been the lack of height in the new cremator, it might have been because they had infant profile setting. I am not sure. We stopped cremating them with adults but we still did not look to recover any remains at that point."

This practice was confirmed by seven out of the eight Cremator Operators interviewed for the Investigation, with one Cremator Operator, who had cremated for a period of less than three years, stating that he did not imagine that babies would be cremated with adults. He had not cremated infants but did confirm that individual non-viable foetuses were put into the cremator together. Derek Snow, the Superintendent, also denied being directly involved in any such cremation but stated,

"Although I didn't see non-viable foetuses being put in with adults, I was aware of it. I didn't do anything to stop it until the Mortonhall thing came up… if nothing had come up about Mortonhall I would still have been doing the same thing. We never knew any different. If it turns out that older babies, other than non-viable foetuses were being cremated with an adult, I was not aware of that. If that's being going on I definitely did not know about it,"

Derek Snow's position about his state of knowledge contradicts the evidence of Graham Keith, Performance and Development Manager, who told the Investigation that when he showed Derek Snow the anonymous letter alleging that both viable and non-viable babies were being cremated in with adults Derek Snow responded,

"Yes. There could be some truth in this."

If the raking was carried out before the adult cremation was completely finished, as indicated by some Operators in Aberdeen, this would contravene the FBCA Code of Practice paragraphs 3(a) which states:

"Once a coffin with its contents has been placed in the cremator, it shall not be touched or interfered with until the process of cremation is completed. On completion the whole of the Cremated Remains shall be collected and shall be disposed of in accordance with the instruction received."

It is also contrary to paragraph 5,

"Each coffin given to the care of the Cremation Authority shall be cremated separately."

Another Operator told the Investigation,

"I believe I have seen a time when an adult coffin and a child's coffin were charged together. It was not myself and I cannot honestly tell you who it was who did it but I have seen it myself both with non-viable foetuses and coffins."

A further colleague told the Investigation,

"As far as I know everyone has cremated infants with adults by putting them in at the beginning and by raking the adult forward first. That's the way we were told, that's the way it's always been done. I'm led to believe that that's the way it's always been done from the day it was open. The way I looked at it, this dinnae feel right and that's why when we got the new machines I changed the way I done it.

I suppose we all work different ways, some people might have just done it all the time, I couldn't say how often it was. When you were cremating you was in charge of initially three and then it was four cremators, we was in charge of all of them ourselves. The person who is cremating is in charge.

There is no way of knowing which adult the baby went in with. In the old machines, I don't think it recorded everything. In the new machines now everything gets recorded but for the infant ones under eighteen months, they didn't put in any details. There was nothing recorded, there was nae computers or anything"

Another Operator confirmed this:

"…In the pre-2010 machines information for children under eighteen months was not put on to the computer."

In two of the cases referred to the Investigation it was established that no details whatsoever had been entered into the computer operating system of the cremation equipment.

A Cremator Operator told the Investigation that,

"…Looking first at non-viable foetuses, once we charged an adult coffin, non-viable foetuses were just placed at the side. They were just little cardboard boxes that we had received from the hospital. They were just raked out at the end of the cremation with the adult ashes."

Another former Operator stated,

"When I worked there I just wanted out. I just wanted away from that place and, because I knew that I was going to be going back to the funeral business so therefore I was going to be having more dealings with the Crematorium, I thought go quietly rather than cause a ruckus. It is something that I regret not doing now but I'll have to live with that but that's it."

One factor that may have had a bearing on when non-viable foetuses were cremated was a change in practice at Aberdeen permitting the deceased to be held over for up to twenty-four hours or slightly longer after the funeral service and before the cremation ^[15] . One Cremator Operator told the Investigation that before this practice changed he would pre-heat the cremators in the morning ready for the first cremation of the day and would place non-viable foetuses in the cremator during this pre-heat phase. However, when the practice of holding over was in place, he no longer had a period of waiting for the first funeral of the day to be completed because there was already a body to be cremated from the previous day. That being the case, he placed the non-viable foetuses in with that adult.

"…so then you would put these dozen (boxes containing non-viable foetuses) on the top of an actual coffin, without the tray. So they would all be cremated at the same time."

There was also evidence that joint cremation may also have occurred when someone was working late to ensure they could get home earlier. A Cremator Operator was asked in what circumstances an infant's coffin would be placed in beside an adult and answered,

"I suppose it would just be for example if you were working late. It probably meant the difference in finishing at 7 o'clock as opposed to 8 o'clock.

This (holding over) was a saving for the council because it meant we weren't there working overtime so long. Then you had maybe two bodies kept over - the last two services, one in the east chapel and one in the west chapel. So you had two coffins when you went in, in the morning with a half past eight start. You would check your machines; and you maybe had a dozen foetuses. You were going to operate the machines properly this time because you had the two adult coffins from the previous day; there wasn't much clearance if it was a large coffin, but if it was a smaller coffin you maybe had about nine inches' clearance."

This evidence about the cremation of non-viable foetuses and babies is clearly deeply shocking and offends against not just the FBCA Code of Practice but against any sense of human decency. The resulting distress to the parents of the babies cremated at Aberdeen, to the next of kin of any adult who was cremated at Aberdeen during the period of these practices and to the wider community will be profound.

The PwC LLP audit report dated 10 July 2013 stated that,

'Following each cremation we were informed the chamber is checked by the cremation staff'.

The auditors had clearly not been given the correct information about the processes in place at Aberdeen Crematorium.

It was also clear that Lord Bonomy had been misled by the Aberdeen staff who met with him and his team during the Infant Cremation Commission's visit to Aberdeen Crematorium.

iii The Anonymous Letter

The above set of circumstances was raised in an anonymous letter dated 28 May 2014 received by Aberdeen Council. The letter stated,

"I have been very upset at the enquiry into the way infant cremations have been handled in certain crematoria over Scotland. As a past employee at Aberdeen Crematorium we were trained in a procedure that we thought to be correct, after reading the report in the media I have been very upset and stressed to think the procedure at Aberdeen Crematorium was wrong and now wait for an enquiry into this. For many years the procedure to cremate babies/infants was to cremate in with an adult be it viable or non-viable, this was carried out as far as I know up until the enquiry came to light. I think it's wrong that you sit on this and nothing has been said. This must be a very difficult situation not only for Aberdeen City Council but for the staff past and present that now know this procedure was very wrong. This is why there were never any remains recovered from children less than two years, they were never cremated on their own, they always went into the cremator with an adult. I am appalled that I myself have been part of this and think the responsibility lies with Aberdeen City Council for allowing this to happen. This needs to be rectified!"

The practices referred to in the letter have been borne out by the evidence obtained in this Investigation.

In response to receipt of the letter interim Chief Executive, Angela Scott, issued a press statement on 9 June 2014 that stated,

"I have received a serious allegation regarding practices at Hazlehead Crematorium. The allegation relates to the joint cremation of babies and adults.

In light of the allegation I now have to reconsider the findings of our independent audit which were published last year and I have advised Lord Bonomy's Infant Cremation Commission of this development."

The Investigation was told by Steven Shaw that,

"Going back to the anonymous letter, I just couldn't believe that would actually happen. I don't know that much about the crematorium and the processes and how it all works but I know that you don't put two bodies in together."

The Investigation was informed that Council Management interviewed Derek Snow about this matter and Mark Reilly said,

"The only thing I did gather from Derek when I asked if they were still doing this practice, he said 'No, we stopped when Mortonhall came out and we only did it when we were busy'."

Pete Leonard, Director of Communities Housing and Infrastructure said,

"I guess I felt really let down and right from the word go, what we'd said to the guys was 'we're not going to judge you on what's happened, when you're in an industry and you follow historic practices, sometimes you might find yourself doing something that culture accepted before. Something which might look horrific but you're caught up in the middle of that and you're just doing what you've always been told. So this is about understanding what's going on'. We had said, 'if there's anything, anything at all, now's the time to get it out, you've got our full support'. We couldn't have emphasised that more and so to then find out that the guys were lying and they'd been so convincing …I was bloody angry to be honest but really upset. Then I was really upset because of the impact on families. I've got young children myself and you can empathise. So then we had to move into trying to figure what happened and I wasn't looking at punishing anybody, I just wanted to figure out what had been going on and we don't really know. I mean, having gone through the experience of believing what they said before, to be honest, anything they said, I took with a pinch of salt. Could be true, it maybe isn't true and there was no real way I got that mechanism to get to the truth. The investigation may have more success."

Neil Carnegie, Senior Service Manager for Housing Management was requested by Mark Reilly, Head of Services, to undertake an investigation into whether or not staff members at Aberdeen Crematorium had been truthful to Lord Bonomy's Infant Cremation Commission and to senior management about processes and whether they had withheld information that they were required to disclose about the cremation of babies with adults. In relation to that practice he told the Investigation,

"I am satisfied that there was malpractice in terms of they were putting more than one coffin in at the same time as well. In terms of exactly what was happening, I am still not sure. There was malpractice. I think it would have been a fairly regular routine arrangement but I was told different versions of events."

These practices may also explain the apparent lack of enthusiasm for exploring other options to enhance the prospect of recovering ashes, such as finding safe working practices to reintroduce a baby tray, the failure to make use of the infant mode profile following its introduction in 2013, manual intervention to moderate the heat and air within the chamber of the cremator or just simply looking to find ashes.

iv Baby Trays ^[16]

The operating manuals present in the crematorium for the Facultatieve gas cremators bought by Aberdeen City Council in 2010 recommended the use of baby trays for infant cremations. This issue was raised by a Cremator Operator with the then Superintendent, Derek Snow. Derek Snow advised the Operator that trays had been used previously and did not work. A Cremator Operator told the Investigation that,

"…I went to Derek (Snow, former superintendent Aberdeen Crematorium) and I says please just tell us how to do it. All I got was 'we had the baby trays in here years ago, it doesn't work, we'll just do this normal'. And that was basically that.

I think basically that Derek was adamant that trays were not the answer because it was so dangerous."

Another Cremator Operator told the Investigation,

"I probably did see when reading the Facultatieve manual that there was something about how to cremate babies, but it didn't resonate with me because we did it differently. In particular, I think it mentioned baby trays and we didn't use one so I thought it didn't apply to us."

It is worth noting however that baby trays were used in Aberdeen in earlier periods. Staff members interviewed by the Investigation were unable to confirm the dates of use of a baby tray with any certainty. The records for the period 1984-85 examined for the internal audit report by PwC show that ashes were recovered at that time. Further sampling by this Investigation found ashes being recovered and returned to families on occasions up to 1996 although it is not known whether this was with the assistance of a baby tray. Derek Snow recalls a tray being used when he began working at Aberdeen Crematorium in 1986. He said it was considered a health and safety risk and he understood it was withdrawn around 1989 until they were reintroduced in November 2013 (for stillborn babies and infants) and July 2014 (for non-viable foetuses) following the visit of Lord Bonomy and the publication of the Mortonhall Investigation Report.

A Cremator Operator who worked at Aberdeen Crematorium between 1997 and 2005 however recalled using a tray when he worked there. When speaking about the cremation of non-viable foetuses he told the Investigation,

"…The Cremator Operator had discretion as to whether he used the tray or not and whether they put the coffin in the tray or without the tray."

He explained that during the time when a baby tray was used there were visors and gloves and other protective gear. It is clear that trays and protective clothing were available at some point. He did however say that there was nothing at all left in the tray. This explanation begs the question of why they used the tray at all. He highlighted that the tray was difficult to get out of the cremator and that information in relation to children less than eighteen months was not fed into the computer when the electric machines were used at least between 1997 and 2005.

The Cremator Operators who began working in Aberdeen in 2001 do not recall a tray in use then.

The questionnaire completed for the Infant Cremation Commission by Aberdeen City Council in 2013 states in response to the question,

"'Does the manufacturer's operation manual give guidance/instructions on best practice for cremating babies/infants. If so, please provide details'

Answer: 'Yes the use of metal trays is recommended but this was not implemented due to the health and safety issues surrounding the handling of these trays'."

In relation to trays Pete Leonard said,

"There had been a conversation about the use of trays and what have you and I was very nervous about health and safety and I guess I placed a lot of reliance on the internal audit which we scoped out in March and it reported in July 2013."

The audit report by PwC did not make any mention of baby tray equipment.

There is no evidence to show that any attempt was made to find alternative methods or to introduce safer working methods to allow the use of a tray. There is also irreconcilable inconsistency between the expression of an absolute belief that there were no ashes to be obtained from babies because of the physiology of their skeletal development and the stated position that ashes could be collected with the use of a baby tray which was not used because of health and safety issues.

The possibility of using a tray was raised by Gordon Bruce, now deceased, Head of Aberdeen Funeral Directors in 2003. Mr Bruce offered to pay for a tray for Aberdeen Crematorium or to donate one. This was also referred to by another Funeral Director who said,

"When I was at Aberdeen Funeral Directors the owner, Mr Bruce, who has now passed away asked questions a few times about the fact that Friockheim had the same machines and could get back ashes…Aberdeen Crematorium refused to give us anything. I am certain that Mr Bruce offered to purchase a tray at one point if that was the stumbling block at Aberdeen Crematorium…The offer was never taken up."

The Investigation was shown a letter from Facultatieve, the manufacturers of the gas cremators to the former Crematorium Manager, Derek Snow, dated 30 January 2002, in response to a telephone call from Derek Snow. The letter begins,

"Further to your telephone conversation today with our [name] concerning baby trays, tools and storage racks, we have pleasure in enclosing the price list of the goods requested together with the information sheets relating to the ancillary equipment as discussed."

v First Recovery of Remains

Shortly after the media publicity about the practices at Mortonhall Crematorium in December 2012, the Cremation Manager Derek Snow was away from work when two concerned members of staff decided to cremate a non-viable foetus of seventeen weeks' gestation and check to see if there was anything left. This was without the use of a baby tray. Both Operators thought that they saw little bones. It was the first time they had ever checked for remains after carrying out a cremation of a non-viable foetus. They showed the remains to other staff members who saw what they described as "like tiny little bones."

This cremation was carried out by placing the non-viable foetus on the hearth of the cremator. While they acknowledged that there is always the possibility of something being in the chamber of the cremator from a previous cremation after the dust settles, both Operators thought they saw tiny bones. They reported this to the Assistant Superintendent as the Cremation Manager was absent. They were never told what happened to these remains. Some staff members reported that they were told that 'an executive decision' had been made in relation to the ashes. Nobody was able to confirm to the Investigation what action had been taken with regard to these ashes.

The Investigation was provided with a note prepared by Graham Keith about the episode which stated,

"As you are aware Scottish Government guidelines advise that there will be no cremated remains from non-viable foetuses. This ash was buried along with recovered metals and residue from machines in the Garden of Remembrance."

Steven Shaw said of this:

"I recall hearing something from Graham (Keith) but I am not sure if it is the same conversation. I'm not sure if the parents in that case were made aware, they should have been, I would have expected that but that's something I'm not 100% sure of."

No one has been able to confirm further what happened to the ashes or confirm the identity of the foetus. No further action was instructed by management to explore in an official manner what had been reported from staff about this informal trial cremation.

The Investigation found that in spite of the publication of the Mortonhall Investigation Report and the Infant Cremation Commission Report ^[17] in 2014, members of staff at the time of this Investigation's interviews in early 2015 had different understandings of the definition of ashes and remains though they all shared the view that it would be comforting for families to get something back. The staff clearly had not been briefed on the findings in either Report to enable them to understand the physiology of baby cremation and that it is possible to recover bones from cremated foetuses as early as seventeen weeks' gestation.

The Cremator Operators confirmed that since the introduction of the new process of using a baby tray in 2014 they have seen bone remains from a non-viable foetus of eighteen weeks' gestation and have been recovering ashes from foetuses and infants.

Cremator Operators questioned why, if remains were being recovered in other crematoria, this information was not fed back through the FBCA to Aberdeen. ^[16] This is of particular concern when a representative of FBCA, George Bell, then Bereavement Services Manager at Mortonhall Crematorium, was involved as examiner for many years and when the Crematorium Manager Derek Snow was in attendance at FBCA meetings. One Cremator Operator told the Investigation,

"…I feel a bit gutted to be in this situation when it could have been done years ago"

6.5 Administration and Record Keeping

The Investigation understands that the administration and record keeping systems at Aberdeen Crematorium have been changed since the time of the interviews for this Investigation.

There are two areas to consider,

• Bereavement Services at Aberdeen City Council headquarters who receive and process all the required forms to allow a cremation to take place and where the Registrar is based.
• Computer operating system records on site at the crematorium.

i Bereavement Services

Official administration and record keeping for Aberdeen Crematorium is handled by the Bereavement Services team based at Aberdeen City Council headquarters at Marischal College.

There are two key officials in charge of the processes - the Assistant Registrar and the Authorised Officer.

Funeral bookings are made by Funeral Directors or the hospital with the crematorium directly and the crematorium enters the booking into a daily schedule. The crematorium faxes the daily schedule of funerals to Marischal College when the services for that day are all booked. For adults, stillborn babies and infants the unique identification cremation number is included in this daily schedule. Although the number is generated by BACAS (the database system), to which crematorium staff do not have access, the cremation numbers are consecutive, allowing the crematorium staff to allocate numbers following on from the previous day's schedule. Non-viable foetuses, however , are not cremated on a daily basis so the crematorium staff cannot so readily check the previous number. The crematorium staff therefore write the letter F (to denote foetus) on the daily schedule instead of a number, and the administrative team at Marischal College allocate the unique number to the non-viable foetus cremation when the schedule arrives with them. The administrative staff input the data from the daily schedules to BACAS. These daily schedules are then returned to the crematorium with the unique numbers and the Medical Referee's Authority to Cremate confirmed to allow that day's cremations to go ahead.

At the time of the Investigation interviews, Funeral Directors delivered the required paperwork to the Assistant Registrar's office at Marischal College rather than to the crematorium. ^[18]

On arrival all paperwork is checked and details are entered onto BACAS by the support assistant.

Staff interviewed were adamant that the information input to BACAS was taken directly from the Form A (Application for Cremation). However, they conceded that 'no remains' was not an option on the Form A and yet they entered these words into BACAS once that option had been added to the software's options. The explanation offered was that perhaps the options for the ashes had been scored through and that this had been interpreted as 'no remains'. The PwC Audit Report of 10 July 2013 had recommended the Council should consider the processes in place to ensure data is accurately recorded within BACAS.

The first computerised database system to be installed was called IONA in 1996. It was replaced soon after by BACAS which was introduced in 1997. At that time there was no option provided in the system for disposal of ashes in the drop down menu for a category of 'no remains'. Martin Caxton, General Manager of Clear Skies Software which supplies the BACAS programme, explained that the flexibility to add disposal options came with an upgrade to the system originally installed.

The BACAS system produces the cremation card, known in Aberdeen as the 'yellow ticket'. The yellow ticket is the identification method for the deceased as the coffin arrives at the crematorium and when it is cremated after the service. This Yellow ticket should remain with the coffin until the cremation takes place. The yellow ticket was to be returned to Marischal College from the crematorium once the cremation was complete and the details entered onto the yellow ticket at the Crematorium regarding disposal of the ashes should have been updated on BACAS at Marischal College. The Investigation found that this usually happened but that there did not appear to be a system in place for chasing up any yellow tickets that did not come back to Marischal College. Until recently the yellow tickets were then destroyed. Now they are stapled and kept on file with cremation papers.

"The first entry that we put in for disposal is the intention. That's the instruction that we're getting from the Funeral Director on behalf of the family about what would happen to the ashes.

After the cremation has taken place and after the remains have been picked up, the yellow card is returned to us. It's got signatures on it and what actually happened to the ashes. It could change completely. The intention could be 'dispersal when attending' but they change their mind and it's changed to 'being picked up by' - so we've got all that written on the yellow card."

If the disposal outcome was 'no remains', the ticket would be returned to Marischal College with only the date and a signature on it.

Cremation papers are delivered to the Medical Referee by hand and are left at the crematorium overnight. In the morning the authorisation form known as Form F is collected from the Medical Referee and a summary of the Form F is sent to the crematorium by fax. If one or more cases on the summary have not been cleared by the Medical Referee the cremation cannot take place until the Medical Referee phones the crematorium directly to authorise the cremation to proceed.

Paperwork is delivered to the crematorium by hand by a member of the administrative staff including the yellow tickets (cremation cards), floral tribute cards and cremation certificates.

Non-viable foetuses are given a separate number beginning with an F. This is generated by BACAS. For shared cremations of more than one foetus every foetus is given its own number and a yellow ticket is generated for each one. The paperwork for shared cremations comes directly from the hospital and the foetuses are identified by a reference number only.

There was a manual Register kept for non-viable foetuses before BACAS was introduced. There is no statutory obligation to maintain a register for these cremations. The register did not have a column for recording the disposal of ashes in common with other such registers in other crematoria.

ii Records maintained on cremator operating system at crematorium

There should be cremation reports of all cremations carried out at Aberdeen since 2010 when Facultatieve machines were installed. The computer records the whole cremation in terms of temperature, air, which mode has been used, which Cremator Operator carried out the cremation and the unique cremation number of the deceased as entered by the Cremator Operator. It also records any manual interventions made by the Cremator Operator. The prime purpose of these reports is for emissions monitoring by the Scottish Environmental Protection Agency ( SEPA).

For two cases referred to the Investigation with funeral services on separate dates, there are no cremation reports. This means that the unique cremation number for those two babies was not entered into the computer's operating system. Given the evidence of the Cremator Operators about the practice of cremating babies with unrelated adults, it can be inferred that each of these two babies was cremated along with an unrelated adult. Unfortunately, it is not possible to tell from the cremation reports or any other monitoring data held by Aberdeen or Facultatieve the identity of the adults with whom the babies were cremated. This is because the small size of the baby coffin would not cause a different level of emissions to be recorded from that expected of an adult being cremated alone.

The fact of physical separation of Bereavement Services from the crematorium was identified as an arrangement that could have been improved if the two teams were brought together. David Forsyth, former Environmental Manager (2006-2008), told the Investigation,

"I think it would have been better to bring Bereavement Services and the crematorium teams together and we did speak about that and about digitalising the records."

His successor, Sandy Scott, said

"I really wanted Bereavement Services and crematorium to come closer together so we did a review. They very much worked in silos and I found that strange. We did a few brainstorming sessions together but it was more difficult than I anticipated. I think there had been entrenched views for a long time about whose job should be whose. The previous Assistant Registrar was quite a strong character and so was Derek. I think they each thought their own job was the more important."

iii Sampling of registers

Registers of Cremation from the period before the introduction of the computerised system BACAS were sampled for the years 1981, 1988, 1992, 1993, 1994 and 1995 by this Investigation.

Sampling of these Registers showed that there were entries in 1981, 1988 and 1992 recording that ashes from babies had been collected and taken away. These entries are dated and it can be inferred from this that the Register was updated with the actual date of collection. This included cases of stillborn babies and, if the Register is accurate, reveals, as also found by PwC that ashes were indeed available from Aberdeen Crematorium in the past, contrary to their stated position.

However, the words 'no remains' or 'no ashes' do not appear in any of these Registers.

The Authorised Officer for Bereavement Services told the Investigation

"I am informed that it seems no‑one has ever written 'no remains' in a cremation ledger before the computer came. I was not aware of that. I can't understand that. That's an interesting one. We've always put it as 'dispersed in the Garden of Rest. I don't know why she would never have written no remains. Thinking back nearly twenty odd years, we weren't giving out remains but yet we were putting dispersals in the Garden of Rest in the Register. I probably didn't even realise it."

It would appear that an entry of 'Dispersed in the Garden of Rest' without the later addition of a date might in fact be the instruction received for the ashes rather than the actual outcome. Evidence from the administrative staff at Aberdeen City Council revealed that, as at Mortonhall, the outcome of cremations had been entered on the Register prior to the cremations taking place meaning that the Register commonly consisted of a predicted outcome rather than a record of the actual outcome.

This practice continued when the Registers of Cremation were changed from the manual to a computerised system. However, shortly after installing the BACAS record keeping system, Aberdeen City Council requested from the software supplier that an option of 'no remains' be added to the list of possible options for recording the disposal of ashes. From March 1997 until 25 November 2013 (when a baby tray was introduced) almost all Register entries for babies are recorded as 'no remains'.

An issue with the accuracy of recording in BACAS was raised in the PwC LLP audit report dated 10 July 2013. The Council response was,

"The Council will review how records are documented and look to put in place validation checks to verify the accuracy of the documentation recorded on the Daily operating Sheets and BACAS."

As at Mortonhall the Investigation found that from one day to the next the outcomes for disposal of ashes changed from 'dispersed in the garden of rest' to 'no remains' without any change in the actual outcome having taken place. This means that the statutory Registers of Cremation, so far as it relates to stillborn babies neonates and infants at Aberdeen are wholly unreliable.

6.6 Communication

i Communication between families and NHS staff

Many parents interviewed for the Investigation recalled that they were in a state of acute distress at the loss of their child and felt that they had little time to make decisions about the final act of care for their baby before leaving the hospital,

A Specialist Midwife for Pregnancy Loss acknowledged,

"It could be quite quickly after delivery when these options are discussed, very definitely on discharge from the ward…It could be two or three hours, six hours, could be overnight between delivery and discharge, it just depends"

One family suggested,

"There's actually no rush. I don't understand what this rush is with them. They're on this conveyer belt. We've got to get you out and through and we can't just take time."

A significant number of parents interviewed felt that they did not have all the options clearly explained to them and made decisions they later came to regret. A number of parents had difficulty remembering who had told them what, what forms they saw or signed, what was on forms that they signed and how decisions were reached.

One mother told the Investigation,

"The funeral arrangements were made with the hospital chaplain. He just spoke to me about it and then organised it all. We did fill in forms that night (the night the baby died), we signed forms that night. But I can't remember what the forms were for."

Another said,

"It was just before we were leaving the hospital. I'm talking about a few hours after she was delivered. I think at the time anything was overwhelming. The chaplain was a very nice man and he came across very helpful and he offered us his condolences. I would rather have had a little bit longer to think about things before having to make a decision."

Sometimes arrangements began to be discussed before the baby had actually been delivered. Another parent, who was only seventeen at the time said,

"It wasn't long after I had been told [name] wasn't going to survive that they spoke about the funeral. It's really painful, it was just hours after. I didn't feel able to talk about that kind of thing at that point in time."

Many mothers described being in physical pain or on strong medication at the time of these conversations. The Investigation was told by the acting Specialist Midwife for Pregnancy Loss at NHS Grampian, Myra Kinnaird, that

"They've got up to seven days to actually change their mind on what they have signed or come back and let us know. If they don't then it defaults to hospital collective cremation"

The Investigation did not find evidence of families knowing they could have asked for more time.

Midwives or the Hospital Chaplains informed parents verbally that there would be no ashes recoverable from the cremation of the baby. This was received wisdom among nursing staff. A written information leaflet produced in 2008 was provided to the Investigation by NHS staff. The leaflet, entitled 'Information for Parents Whose Baby Has Died' states

"Please note that when babies are cremated, because of their size, there are no ashes."

The leaflet does not point out that remains may be recoverable at crematoria other than Aberdeen Crematorium. It is difficult to reconcile the contents of this leaflet with a letter sent to the Chaplain at Aberdeen Royal Infirmary on 27 May 2003. The Hospital Chaplain, Fred Coutts, wrote to Ken Parke of Parkgrove Crematorium on 20 May 2003. This letter stated,

"I have heard form Aberdeen Funeral Directors that you recently cremated the body of a stillborn for them and that you returned the ashes to the family in a casket. I am writing to you to seeking confirmation of this. I have been advised by Aberdeen Crematorium, which has been confirmed by other crematoria in Scotland and the Federation, that no ashes remain after the cremation of such a small baby and consequently none can be given to families. Can you confirm now that you are able to give ashes back to families when stillborn babies are cremated? This is important for us to know in our work in the Maternity Hospital so that parents can be advised accordingly."

Derek Craig of Parkgrove replied on 27 May 2003,

"The use of Electric Cremators at high temperature allows the cremation to take a slow and gentle burn with no internal or external fans used. The coffin is placed in the end of the machine as the last cremation of the day. After the last flame has diminished the remains are raked forward into the cooling tray then withdrawn from the cremator and allowed to cook in the cremulating room. All cremations of this kind have resulted in a small amount of remains left."

A Midwife told the Investigation,

"We were told up until I think 2012, that there wasn't any ashes that can be retrieved from Aberdeen Crematorium because of the method of cremations, because it had a more up to date burner, whereas Friockheim and Buckie had older burners and sometimes the hospital Chaplains would arrange for the parents to go to either of these and they would receive ashes.

If parents asked us if they would get ashes we would say no because our understanding was that - we were told by both the City Council and the hospital Chaplains that there's no ashes before age two because the bones are so soft, so we wouldn't actually get ashes from a baby at that stage. The information we gave to parents was that there wouldn't be any ashes available."

The Mortuary Manager at Foresterhill NHS Grampian Site told the Investigation,

"Up until the beginning of this year [2015] I used to complete the A Form (Application for Cremation) on behalf of the family for pre-twenty-four week foetuses...We've been told that it should in as many cases as possible be the mother who is the Applicant. Only in exceptional cases will NHS Grampian be allowed to apply on behalf of the family and that would generally mean something like ill health or unable to sign the form.... So the midwife goes through it... and then the mother signs it and now the midwife signs it."

If the parent opted for a private cremation or burial, they were put in touch with the Chaplaincy Service. Gordon and Watson Funeral Directors was the firm chosen to carry out services organised by the hospital. Parents could also choose to make arrangements through their own Funeral Directors.

ii Communication between Funeral Directors and families

Gordon and Watson are the Funeral Directors used by NHS Grampian to organise hospital arranged funerals. A formal contract was entered into between NHS Grampian and Aberdeen City Council dated 14 September 2015 for the sensitive disposal of pregnancy losses up to 23 weeks and 6 days. It provides for the options of shared cremation, individual cremation or burial. It further provides a duty on NHS Grampian to ensure that mothers are aware of their rights in relation to giving instructions and of how ashes will be dealt with. It contains a duty on behalf of NHS Grampian of

"Ensuring that mothers are informed that there may not be ashes/cremated remains... and that Aberdeen City Council as the Cremation Authority are unable to guarantee that recovered ashes contain human remains."

The Investigation was shown a paper which was presented to Aberdeen City Council's Communities Housing and Infrastructure Committee dated 18 March 2015 entitled 'Infant Cremation Commission Report and Recommendations'. It provides an update of actions carried out by Aberdeen City Council following the Infant Cremation Commission report.

Action on the majority of recommendations which were for Aberdeen City Council to action were noted as complete or in progress.

Where the hospital is arranging the funeral, the role of the parents would be to agree a date and time for cremation, express any wishes concerning the service, inclusion of any toys or photographs in the coffin with the baby and any arrangements to see the baby in the funeral home before the service. It is the role of the parents also to give an instruction for the disposal of any ashes, but they were usually told that there would be none and were not asked for an instruction.

Like the hospital staff, Funeral Directors believed there would be no remains from the cremation of a non-viable foetus or stillborn baby or infant. A parent told the Investigation,

"Then pretty much as soon as we met (the Funeral Director) and we said cremation she was saying 'You do know there will be no ashes' and we had to have quite a pause in the meeting at that point just because we hadn't considered that, that's not what we had read and that was another sort of hurdle to get over. We actually asked her to double check that. She double checked that with Hazlehead and came back to us and we were told that it was because do the age of [name] and the equipment they were using...They said that the reason there would be ashes elsewhere in Scotland is because they didn't use the same equipment that they used there. It was to do with temperature or something. This was 2012."

Another said,

"The Undertaker said 'if you get a cremation there is no fee and there would be no remains'"

In examining the available Forms A in the Investigation it was observed that in many of the forms the disposal section was scored through, particularly those completed by hospital staff. Others varied stating 'no ashes', 'scatter if any' or' retain if any'. Where parents organised the funeral of their child directly they choose their own Funeral Director. Some parents did not recall the question of ashes being discussed and others expressed surprise that an instruction in relation to ashes had been given when they had been told that there were no ashes for babies. A parent told the Investigation,

"Looking now at the part of the form that deals with disposal of ashes, having been told there were no ashes it makes no sense to see that on the form the instruction is for the ashes to be scattered in the Garden of Remembrance and that the relatives do not wish to be present at the scattering. We've asked the question about the ashes and they have told us you don't get ashes back from a baby. So if they're going to say how do you wish to deal with the ashes, do you want them scattered in the Garden of Remembrance? If we had said yes, then that would have begged the question but you've just told us there aren't any ashes. And it says 'do the relatives wish to be present at the scattering?' If they had said there are no ashes and now they are telling us this - it doesn't make any sense. We would have wanted to be present"

Many parents did not recall seeing the Form A which is often signed at a time when they are dazed or heavily sedated and unable to fully understand any explanations given and to fully understand what was being asked albeit some recognised their signatures on the form. The Investigation was told,

"We don't recall seeing it (Form A) but I can absolutely confirm that's my signature. I don't recall reading any of those questions or providing answers to any of them…There are crosses on the places for us to sign which indicates perhaps that we were given a form and asked to sign it. It's possible that the form was blank when I signed it. We said what about the ashes and were told you don't get any ashes back from a baby. At that point in time you're taking everything that that's the way it is so you don't question."

Another parent said,

"We were told there was the possibility we might not get any ashes back, but that if there were ashes the Funeral Director or the crematorium would be in touch with us. We were not given any options of other places to go. There was no mention of Friockheim…We were very clear we wanted the ashes back. We never heard from the Funeral Director or the crematorium. We assumed therefore that there were no ashes…On the Form A, Application for cremation, the signature is mine. The form was completed by the Funeral Director. In the section on what to do with the ashes, all of the options have been scored through. However, there was a bit of a form we were given that said would you want the ashes back and we circled yes. That may have been the Funeral Director's own form. It was made quite plain to them that if there were ashes that that was something that we wanted to have."

Yet another said,

"I cannot remember that form but my signature is on it but the rest of the writing is not mine"

However, parents were not always warned that there may not be ashes,

"I think looking back had we gone fifty, sixty miles up the road (according to the papers at the time) we might have got ashes back there and I think had I known that at the time, it might not have changed our minds but I think it would have given me something else to think about, because that was my way of moving forward at the time."

Others felt that they had not been given any or clear information about ashes with a parent saying of the Funeral Directors,

"They actually never mentioned anything about ashes. I still regret it and I thought that if I had been told earlier (that there would not be ashes) I wouldn't have done it

We went into the Funeral Director's office. We don't remember being asked about ashes. We don't remember seeing the Form A ...but it is our signatures on the form.

So when the Funeral Director came to collect him and I had asked when I would be able to pick up the ashes and he says he didn't think that there would be any. His exact words were 'I'll try my best. I'll see what I can do' ...but I never ever heard from him again to ask him about it."

Another told the Investigation,

"… we didn't know before the funeral that there weren't going to be any ashes, we wouldn't have done it (cremation) otherwise"

None of the parents reported being given the option of travelling to another crematorium where ashes were returned. A parent stated,

"I don't remember being offered a different crematorium either"

However, a Funeral Director told the Investigation,

"…It was the common understanding in the business which is why sometimes we would refer families that wanted cremations for their children to go to Parkgrove Crematorium if they wanted something back or go for burial."

This is a curious position given the stated belief that there were no ashes. Funeral Directors had been told that there were no ashes because of the physical nature of the bones. Some families were simply told there would not be ashes,

"I was told 'there will be no ashes and that was it' by the Undertaker.

The decision to have cremation was taken because most of the family had been cremated. At that point the Undertaker mentioned ashes. He just says there wouldn't be ashes because [name] was a baby. I didn't really appreciate what it meant at the time. You're very trusting and you'd assume that what you're being told was accurate."

Other families told the Investigation that on occasion the Funeral Directors checked with the crematorium whether or not there would be ashes,

"We both asked at the same time 'Why will there be no ashes?' and it we just because anything under the age of eighteen months has no ashes because their bones are just not formed. That was relayed to us by the Undertaker who was on the phone to Hazlehead at that point."

Another parent said,

"But the Funeral Director went and she asked again for us to confirm and I just feel as though they were doing what they had been told...I just think the Undertakers were amazing."

It would appear that on occasion parents were not warned that there may not be remains, that they were not given other options and that they were not always given a full and proper explanation of the choices on the Form A.

6.7 impact of Mortonhall Investigation and the Infant Cremation Commission

Only after Lord Bonomy's invitation to visit Seafield Crematorium in November 2013 was a programme commenced to draw up Operational Procedures. All staff contributed to the final version in conjunction with the manufacturers and a Health and Safety representative.

In March 2015 the Aberdeen Crematorium's Operational Procedure Version 1.0 (the Operation Procedure) was produced. This was a draft version. Cremator Operators told the Investigation that,

"…Since the changes we've made now using the trays we have written our own procedures.

…Technically the procedures were only put in a book quite recently. Going back to when I first started (2005) there wasn't actually a procedure book."

Baby trays were used for the cremation of stillborn babies and infants from 25 November 2013, a mere four days after the visit to Seafield Crematorium. Even then, baby trays were not used for non-viable foetuses which were still placed on the hearth until July 2014 when they were also placed in baby trays. This is because, despite the evidence of their own experience that ashes could be obtained from baby cremation, Aberdeen City Council decided to wait for a clear instruction from the Scottish Government or the Infant Cremation Commission on how to proceed with the cremation of non-viable foetuses.

The current procedure for infants, stillborn babies and non-viable foetuses is that they are placed on the baby tray by the Cremator Operator and the machines are set to infant profile. The resulting ashes of infants, stillborn babies and individual non-viable foetuses are now either scattered or retained for collection by next of kin depending on the instruction received. Ashes from shared cremations of non-viable foetuses are scattered in the Garden of Remembrance.

Since the reintroduction of the tray in 2013 there has been a 100% success rate in obtaining ashes from babies, where ashes have been requested. Staff members at Aberdeen described their distress at the realisation that they could have been recovering ashes over many years.

"Since the Mortonhall Report came out I've have been asking myself questions. If it comes out that we were doing that and there could have been ashes given back….

It doesn't help because we've been taught to do things and clearly it wasn't accurate. The information we were told was not accurate and for us as cremators to have followed what we were told to do and then now it's been deemed inappropriate - you would have to be a really hard person not to be affected by the consequences of what we effectively were told in training to do."

6.8 Findings for individual cases

Thirty-seven babies cremated at Aberdeen were referred to this Investigation. With the exception of one case in 1987, ashes were not returned to the families of these babies. In the 1987 case, it was discovered that the baby's ashes had, at the request of the family, been posted to another crematorium to be interred with the baby's brother.

Twenty-three cases are recorded at Aberdeen as having 'no remains'. All of these cremations took place following the introduction of the computerised recording system BACAS, the earliest cremation taking place in 1997.

For two cases no cremation report was produced from the cremation equipment. With the cremators installed in June 2010 only, such reports were normally automatically produced by the Cremator software following cremations. It can be inferred from the absence of these reports and the evidence of the Cremator Operators about cremation practices at Aberdeen that these babies were not cremated alone but in separate instances with an unrelated adult on each occasion. This took place without the consent or knowledge of the next of kin of both the babies and the adults concerned. It is not possible to say which adult these babies were cremated with because of the manner in which this was done. This practice of cremating along with an unrelated adult was commonplace at Aberdeen but it is only in these two cases that the absence of documentary evidence demonstrates that the babies were not placed in the cremator for individual cremation. The other cases predate the installation of this equipment.

In a further two of the twenty-three cases, both of which took place in a later year, a report was produced by the cremator software suggesting that the babies were cremated individually. However, the ashes were not returned to the families. Evidence from Cremator Operators in Aberdeen about their practices in such cases leads to the inference that it is probable that their ashes were not looked for or recovered from the equipment at the end of the cremation and that they were therefore left in the cremator and raked out with the ashes of the next adult cremation.

Nine cases are recorded as 'dispersed in the Garden of Rest' but with no date of dispersal recorded.

Two cases are recorded in the Register of Non-Viable Foetuses. The register has no column to record the disposal of ashes. One of these cases was a stillborn baby whose cremation should have been registered in the Statutory Register of Cremations.

One case from 1997 is recorded as, 'scatter no relatives'. This is identical to the instruction for ashes given on the Form A.

One case from 1995 has no disposal recorded but has a date in the disposal column identical to the date of cremation. This is unusual as the practice in the Crematorium at that time was to scatter ashes one week after cremation.

It cannot be ascertained with any certainty where any of the babies' ashes have been disposed of by Aberdeen Crematorium. Neither can it be determined whether the ashes were in fact dispersed as suggested in the records. This is due to the failure to look for and recover ashes and the practice of raking down the cremator into the cooling tray together with ashes of a previous or a subsequent cremation that had been left at the end of the cremator containing another individual's ashes.

Some will have been scattered in the Garden of Remembrance without the parents' knowledge where the instruction on the Form A has been completed as 'disperse'. However, those families on many occasions were told there would be no remains by hospital staff and/or Funeral Directors and therefore gave no instruction.

Other baby remains will be wherever the ashes of an unrelated adult cremated at the same time has been interred, scattered or retained. Some others may have been interred at the tree line at the bottom of the Garden of Remembrance along with residue and metals from other cremations.

This is a deeply shocking outcome for so many parents who entrusted their baby to professionals as many members of the community do at a time when we are all are at our most vulnerable and burdened with grief. These families have been failed.

A paper which was presented to Aberdeen City Council's Communities Housing and Infrastructure Committee dated 18 March 2015 entitled "Infant Cremation Commission Report and Recommendations" indicated an intention to "commence discussions with affected parents on their wishes for an appropriate local memorial" Aberdeen City Council met with representatives from SANDS Aberdeen to discuss how best to take this forward and it was agreed that discussions with parents should commence after the National Cremation Investigation has published their report. This will allow all parents affected by the cremation of babies at Aberdeen Crematorium to discuss a potential memorial.

6.9 Conclusions

1. Like Mortonhall this was a section of the City Council working in almost complete isolation without any strategic direction, development or quality control of the service, so far as it related to babies, infants and non-viable foetuses. There was little knowledge by Senior Management of the service provided to the families of these babies. There was insufficient interest taken or leadership shown by management.

2. As with Mortonhall, much of what was learned by Cremator Operators at Aberdeen was received wisdom from more experienced peers. The extraordinary belief that there would be no recovered ashes from babies up to the age of eighteen months or two years was contradicted by what was known to be recovered in many other crematoria as well as in Aberdeen itself in earlier years. It is also clearly contradicted by the evidence of the Forensic Anthropologist, Dr Julie Roberts, who states that bones in cremated foetuses from as young as 17 weeks' gestation can and do survive the cremation process. She stated in her report,

"My previous report prepared for Dame Elish provided evidence that the skeletal remains of foetuses as young as 17 weeks can and do survive the cremation process (City of Edinburgh Council, 2014). Taking that into consideration alongside the data presented in this report, it is inconceivable that there would be nothing left of newborn babies and infants aged up to two years following cremation. The 'no ashes' or 'no remains' policies at the Crematoria of concern must therefore be related to issues surrounding recovery processes, the ability to recognize burnt skeletal remains, and/or individual or corporate management decisions. The same applies to the reasoning that the remains of infants and adults could not be distinguished and separated in instances where they had been cremated together."

3. Training was largely carried out in-house and there was no appetite to look beyond and seek best practice from other crematoria, professional organisations or manufacturers of equipment. There was no evidence of any joint training with Funeral Directors or NHS midwives working in this area. The inter agency Bereavement Services Group did not address the issues of baby cremation until after the Mortonhall Investigation. It is incumbent on all those professional agencies involved in the cremation of these babies to ensure that they communicate effectively with each other and have appropriate joint training and joint understanding of their obligations to the parents of these babies.

This inertia allowed unacceptable practices to develop across all the relevant agencies in Aberdeen.

The cremation of babies along with unknown adults is an unethical and abhorrent practice which will offend the sensibilities of the wider community and cause great distress to those whose babies were cremated there. It will also cause profound concern to the next of kin of unrelated adults who may have collected and continue to retain ashes of loved ones cremated at Aberdeen which also contain the ashes of a baby or one or even several non-viable foetuses.

4. The understanding that there were no ashes or that they could not be recovered was not explained and is inexplicable. The nature of the processes and the expedient way this was done, without any recording to this effect, means that it is not possible to identify those adults and babies who were cremated with each other.

5. An additional practice carried out at Aberdeen was described to the Investigation. This involved raking adult ashes forward at the completion of a cremation and inserting into the same chamber an infant to be cremated while the adult ashes were still present. The entire contents of the chamber were then raked into the ash pan to cool. For obvious reasons this process was not recorded. It is therefore not possible to identify those unrelated adults and babies to whom this happened.

6. When obliged to consider this issue with the commencement of the Mortonhall Investigation and during the separate opportunity to explain their position to Lord Bonomy and his team the true picture at Aberdeen Crematorium was not disclosed. The Infant Cremation Commission was misled about the practices taking place.

7. It was clear from the interviews of staff in early 2015 that despite the passage of time since the Mortonhall Report, the report of the Infant Cremation Commission and extensive media coverage of the circumstances at Mortonhall Crematorium that staff had not yet been properly briefed or briefed at all to allow them to have an accurate understanding of the physiology of the bones of foetuses, stillborn babies and infants.

8. The most senior level of management at Aberdeen must provide strong leadership and now take full responsibility for the effective management of the crematorium. It must also ensure that immediate and appropriate training takes place and that effective and ethical practices are maintained. This relates not only to a change of working practices but to an assurance that the culture of the organisation and the knowledge and understanding is such as to prevent any future abuse of the trust of those families who have placed the remains of their loved ones in their care.

9. It is of serious concern that some of the mothers of the babies referred to this Investigation were unable to give informed consent to the cremation of their child because of the persistent effects of sedating medication or strong pain relief. Some were recovering from surgery and all were suffering considerable grief. Steps should be taken to ensure that any form to be completed by any patient after a foetal loss, stillbirth or infant death is fully explained to the mother at a time when they are fully able to understand that to which they are consenting. Likewise, for those suffering the unexpected loss of an infant baby must be given adequate time and consideration to make a decision about the cremation of their child.

10. As with other crematoria there was a total absence of any local written instruction or guidance. This remained the case even in 2015 after an audit report of 2013 which highlighted the lack of written procedure. This meant that the actual practices employed in the crematoria were not documented and available for inspection by normal quality assurance procedures. Had such written guidance been available it may have alerted Cremator Operators to the deviant nature of their practices.

11. By allowing the predicted outcome rather than the actual outcome to remain in the disposal column Aberdeen City Council created a situation where the inaccurate information was allowed to remain on the Register. Although the inaccuracy was identified no steps had been to correct the accuracy of the Register. This casual and careless approach to a statutory obligation is of considerable concern.