Report of the Infant Cremation Commission

Footnotes

1. Mortonhall Investigation Report, Background Section:
http://www.edinburgh.gov.uk/downloads/file/2673/mortonhall_report_-_0_contents_and_background_p1-14

2. http://www.edinburgh.gov.uk/news/article/1125/independent_investigation_into_mortonhall_crematorium. The Mortonhall Investigation commenced worked in early 2013 with the following remit:

• To assess and review the initial findings of the City of Edinburgh Council report prepared by Mike Rosendale, Head of Schools and Community Services dated 11 January 2013 ('CEC report')
• To assess and comment on the arrangements to review current policy and practice recommended in the CEC Report
• To review any Mortonhall Crematorium records (together with the outcome of the PwC data collation exercise) and to carry out further interviews of staff and others relevant to the investigation, in each case as you consider necessary
• To assess and comment on the historic practices of management and staff at Mortonhall crematorium
• To establish the rationale that underpinned practices at Mortonhall, and to confirm where practices may have departed from Council policy
• To assess and comment on the communication process between Mortonhall, NHS Lothian, Funeral Directors and bereaved parents

3. BBC news: http://www.bbc.co.uk/news/uk-scotland-22003573

4. Aberdeen City Council website: http://www.aberdeencity.gov.uk/CouncilNews/ci_cns/pr_hazlehead_040413.asp

5. Aberdeen City Council website: http://www.aberdeencity.gov.uk/CouncilNews/ci_cns/pr_pwcaudit_150713.asp and http://www.aberdeencity.gov.uk/nmsruntime/saveasdialog.asp?lID=51442&sID=666

6. BBC news: http://www.bbc.co.uk/news/uk-scotland-22114517

7. Glasgow City Council website: http://www.glasgow.gov.uk/index.aspx?articleid=9859

8. BBC news: http://www.bbc.co.uk/news/uk-scotland-glasgow-west-22556955 and Herald Newspaper: http://www.heraldscotland.com/news/home-news/glasgow-city-council-apologises-for-disposing-of-baby-ashes-against-parents-wishes.1368718352

9. Scottish Government website: http://www.scotland.gov.uk/News/Releases/2013/05/lordbonomy02052013

10. See 'The Laws of Scotland: Stair Memorial Encyclopaedia', Edinburgh: Butterworths, 1987

11. Cremation Act 1902 http://www.legislation.gov.uk/ukpga/Edw7/2/8/contents; Cremation Act 1952 http://www.legislation.gov.uk/ukpga/Geo6and1Eliz2/15-16/31/contents; Cremation (Scotland) Amendment Regulations 2003 Amendments http://www.legislation.gov.uk/ssi/2003/301/contents/made

12. Cremation Act 1902, Section 2: http://www.legislation.gov.uk/ukpga/Edw7/2/8/section/2

13. Cremation (Scotland) Amendment Regulations 1967: http://www.legislation.gov.uk/uksi/1967/398/contents/made

14. The Registration of Births, Still-births, Deaths and Marriages (Prescription of Forms) (Scotland) Regulations 1997: http://www.legislation.gov.uk/uksi/1997/2348/contents/made

15. ICCM Charter for the Bereaved: http://www.iccm-uk.com/iccm/library/Reference%20Charter%20Review%202012.doc

16. National Records of Scotland 'Vital Events Reference Tables' Stillbirths 2002-2012 Table 4.4: http://www.gro-scotland.gov.uk/statistics/theme/vital-events/general/ref-tables/2012/section-4-stillbirths-and-infant-deaths.html

17. Figures provided by National Records of Scotland Senior Statistician in response to a Commission request on 30 October 2013. See also Annex Q

18. All Burial and Cremation Authorities (most usually the 32 Scottish Local Authorities) include relevant charges on their respective websites.

19. Disposal of Pregnancy Loss Up to and Including 23 Weeks and 6 Days Gestation: http://www.sehd.scot.nhs.uk/cmo/CMO(2012)07.pdf

20. NHS National Services Scotland, Information Services Division: Abortion Statistics Report 2012, Page 4: http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/2013-05-28/2013-05-28-Abortions-Report.pdf

21. NHS National Institute for Health and Clinical Excellence 'Ectopic Pregnancy and Miscarriage: NICE Clinical Guideline 154' Published December 2012: http://www.nice.org.uk/nicemedia/live/14000/61854/61854.pdf

22. See Annex O, crematoria questionnaire summary, questions 15,16 and 17

23. See Annex O for summary information, and full breakdown of data is available on the Commission webpages at: http://www.scotland.gov.uk/Topics/Health/Policy/BurialsCremation/CremationCommission

24. See Report paragraph 8.21

25. Mortonhall Investigation Report, Section 2, Page 32:
http://www.edinburgh.gov.uk/downloads/file/2676/mortonhall_report_-_2_p21-77

26. Mortonhall Investigation Report, Section 2, Page 21 onwards:
http://www.edinburgh.gov.uk/downloads/file/2676/mortonhall_report_-_2_p21-77

27. The Cremation (Scotland) Regulations 1935, Regulation 1:
'1. Every crematorium shall be-
(a) maintained in good working order;
(b) provided with a sufficient number of attendants; and
(c) kept constantly in a clean and orderly condition:
Provided that a crematorium may be closed by order of the Cremation Authority if not less than one month's notice be given by advertisement in two papers circulating in the locality and by written notice fixed at the entrance to the crematorium. The Cremation Authority shall give notice in writing to the Secretary of State and to the Department of the opening or closing of any crematorium.'

28. The Cremation (Scotland) regulations 1935, Regulation 2:
'2. Every crematorium shall be open to inspection at any reasonable time by the person appointed for that purpose by the Secretary of State or by the Department.'

29. The Cremation Act 1952, Section 1: http://www.legislation.gov.uk/ukpga/Geo6and1Eliz2/15-16/31/section/1

30. SEPA: http://www.sepa.org.uk/air/process_industry_regulation/pollution_prevention__control.aspx

31. MIR, p60: 1. There may not be a minimum gas residence time of 2 seconds in the secondary chamber at 850 ^oC or 800 ^oC, the temperature being below either 800 ^oC or 850 ^oC. 2. There may not be a minimum oxygen content of 3% by volume in the secondary chamber since the equipment controlling the air flow is switched off. 3. There may not be negative chamber pressure in the secondary chamber which is partly achieved by the use of ventilation and temperature in the primary chamber. 4. There may be no spot sampling or continuous monitoring of emissions. While there may be spot sampling of cremations more generally there may be none for the cremation of young babies and the continuous sampling equipment will be switched off at night. 5. The alarm may not operate if the temperature in the secondary chamber falls below the required temperature because the relevant equipment is switched off at night. 6. There is no way of knowing, when the remains are removed in the morning, whether cremation is complete and , if not, how that might be remedied. The only option at present Mortonhall would be to either wait until the next night and use the overnight method or cremate using the full adult process. Normally, with an adult cremation an operator will observe the process and remove the remains only after the last flame has died meaning that there is nothing left to burn but since no observation is possible overnight, there can be no way of knowing if cremation, or "calcination" as it is called in the permit, is complete.

32. 'Baby and Infant Funerals', ICCM, Published June 2011, Page 3:
http://www.iccm-uk.com/iccm/library/BabyInfantFuneralsPolicyFINAL2011.pdf

33. Report paragraph 5.6

34. Letter from FBCA to Lord Bonomy, 6 May 2014

35. Letter from FBCA to Lord Bonomy, 6 May 2014

36. Report paragraph 5.11

37. MIR, Section 6, p531

38. See, however, the updated position in Glasgow City Council as set out in Report paragraph 8.5

39. Annex E, Section 6 'Skeletal Development in the Foetus and Infant'

40. Annex E, Section 8, The Cremation Process: Survival of Foetal and Infant Remains, page 21 of 24

41. ICCM Metal recycling scheme: http://www.iccm-uk.com/iccm/?pagename=recyclingmetal and APCC (Association of Private Crematoria and Cemeteries): http://www.apcandc.co.uk/index.html

42. FBCA/ICCM Crematoria Managers Conference, Glasgow, 24/10/13;

43. Glasgow City Council 11/11/13 (plus subsequent meeting 29/04/14) and Aberdeen City Council 15/11/13 (plus subsequent meeting 02/05/2014)

44. It is perhaps significant to view this difference in practice in the context of the numbers of cremations conducted. Figures provided to the Commission by Edinburgh Crematoria Ltd on 28/04/2014 show that Seafield had conducted 56 individual cremations of non-viable babies, the earliest in 1993 and only 3 prior to 2000. Similarly, Warriston had conducted 49 such cremations, the earliest in 1996 with the next not until 2004.

45. MIR, Section 4, p125

46. Annex E, Supplementary Anthropology Report, Section 1

47. MIR Section 4, p121

48. Annex E report of Dr Julie Ann Roberts, 8.2.2 "This process…is extremely detrimental to delicate foetal and infant bones… Further fragmentation…could lead to destruction of the bone altogether or loss amongst any accompanying burnt material"

49. JM Dunlop, 'Cremation of Body Parts and Fetuses', Journal of Obstetrics and Gynaecology Vol 24 No 4, June 2004 and C Howlett, 'The Cremation of Fetal Remains: Procedure and Practice', IBCA (now the ICCM) Conference Paper, 16 February 1997

50. The hearth construction is an assembly of blocks laid in place with mortar, but with use, the hearth blocks wear and become uneven, with 'valleys' between blocks into which (especially fine) ash accumulates and cannot be raked out. Typically, hearth blocks must be replaced every 2000 to 3000 cremations.

51. In June 2013, 16 crematoria advised they were using baby trays, including eg Craigton, Falkirk, Clydebank, Inverness, Masonhill, Roucan Loch, Seafield and Cardross.

52. MIR, Annex G 'Cremation of Babies Safe Working Procedure and Protocol', The City of Edinburgh council December 2013: http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CCYQFjAA&url=http%3A%2F%2Fwww.edinburgh.gov.uk%2Fdownload%2Fdownloads%2Fid%2F2689%2Fmortonhall_report_annex_g_-_safe_working_procedure_and_protocol&ei=176RUOxIsSM7AbBw4GADQ&usg=AFQjCNFAnPL8PgEBU02rGqGUHZ0CJ_gTGw

53. 'Turned off' can be described as when the computer controlling the cremator has been switched off, which means that the gas supply, burners, airflow, extraction fan and monitor.

54. ELVs are 'emission limit values' which are set for processes regulated under the Pollution Prevention and Control (Scotland) Regulations 2012 - the PPC Regulations.

55. Annex G, Letter from Dr Chamberlain to SEPA, 13 May

56. See Annex H, PG Note page 32, paragraph 5.28 onwards

57. MIR, Section 4, page 152

58. On 22 May 2014, at 11:07, Donnelly, Norman wrote:
'Dear Lord Bonomy,

When considering the development of any Process Guidance Note it is common for the obligated sector to provide access to and information on sites which the sector consider would constitute BAT for the particular activity which the Process Guidance Note applies to. From discussions with my colleague who developed Process Guidance Note 5/2 (12) I can confirm that no monitoring or process information was provided for small scale cremators and no small scale cremators were visited as part of the BAT development process. Further I can advise that overnight cremations which occur when the cremator is in cool down with all process and monitoring controls switched off was never identified as an activity for consideration and consequently the polluting impacts and the controls that may be required to mitigate any impacts from this activity was not considered. SEPA are still discussing the regulation of the Mortonhall site and I can offer no further comment on the progress of these discussions at this time.

Four agencies Technical Advisor'

59. Scottish Government 'What to Do in the Event of a Death': http://www.scotland.gov.uk/Publications/2006/04/12094440/0

60. MIR, Section 6, p527

61. Burial and Cremation Review Group: Report and Recommendations, 04/04/2008. Recommendation 12: 'The right to instruct the disposal of bodies on death should be vested in the nearest relative as defined in section 50 of the Human Tissue (Scotland) Act 2006 (asp 4). (paragraph 12)' http://scotland.gov.uk/Publications/2008/03/25113621/2

62. The statutory role of the Crematoria Medical Referee will come to an end when the Certification of Death (Scotland) Act 2011 comes fully into force, projected for April 2015. Further information can be found at: http://www.scotland.gov.uk/Topics/Health/Policy/BurialsCremation/Death-Certificate

63. The Cremation (Scotland) Regulations 1935, regulation 16:
'16. Notwithstanding anything in the foregoing Regulations, the Medical Referee may authorise the cremation of the remains of a still-born child if there has been produced-
(a) a certificate of registration under the hand of the Registrar of Births, Deaths and Marriages in the form of Schedule 8 appended to the Registration of Births, Still-births, Deaths and Marriages (Prescription of Forms) (Scotland) Regulations 1965; and
(b) a certificate that the child was still-born given by the registered medical practitioner who attended at the confinement of the mother or by a registered medical practitioner after post-mortem examination of the body; and if the Medical Referee after such inquiries as he may think necessary is satisfied that it was still-born.'

64. The Cremation (England and Wales) Regulations 2008:
'2.-(1) In these Regulations-
"the 1953 Act" means the Births and Deaths Registration Act 1953(b); "the 1988 Act" means the Coroners Act 1988(c); "the 2004 Act" means the Human Tissue Act 2004(d); "applicant" means the person making an application for cremation in accordance with regulation 15; "body parts" means material which consists of, or includes, human cells from-
(a) a deceased person, whether or not separation from the body occurred before or after death; or
(b) a stillborn child;'

65. The Cremation (England and Wales) Regulations 2008 - Guidance to cremation authorities and crematorium managers. Page 3 paragraph 6
http://www.justice.gov.uk/downloads/burials-and-coroners/cremations/cremation-crematorium-guidance.pdf

66. The FBCA statistical return for 2013 indicated 6824 such cremations, as per Report paragraph 5.10

67. The Commission considered that possible categories of information were: Reference Number; Crematorium Name & Cremation Authority Name; Cremation Date & Time; Applicant Name; Name of Non-Viable Baby or individual NHS ID; Location of Supporting Documentation (eg relevant Health Board); Applicant's Ashes Instructions; Ashes Outcome; Ashes Location; Confirmation of Outcome / Location Issued to Applicant.

68. See Annex K: CMO & CNO Guidance, Annex D

69. Annex H

70. FBCA 'Test And Examination Scheme For Crematorium Technicians'
http://www.fbca.org.uk/support-1.asp

71. ICCM website:
http://www.iccm-uk.com/iccm/index.php?pagename=training

72. Edexcel website:
http://www.edexcel.com/Pages/Home.aspx

73. ie in the FBCA courses set out in Report paragraphs 11.3 and 11.4

74. British Institute of Funeral Directors:
http://www.bifd.org.uk/

75. National Society of Associated Independent Funeral Directors:
http://www.saif.org.uk/

76. See also the analysis of implementation at Annex L

77. MIR, Section 3, p105

78. MIR, Section 3, page 93

79. The main providers of pamphlets are SANDS UK and the Miscarriage Association, but it should be noted that there are many other charities and organisations working in this field. Some of these, but by no means all, are SIMBA (Simpson's Memory Box Appeal), Child Bereavement UK, The Scottish Cot Death Trust, Cruse Bereavement Care, Bliss, Sands Lothians, Forget-Me-Not Care and Counselling, TAMBA (Twins and Multiple Births Association) and Tommy's.

80. The Cremation (Scotland) Regulations 1935, Regulation 2:
'2. Every crematorium shall be open to inspection at any reasonable time by the person appointed for that purpose by the Secretary of State or by the Department.'