Report of the Infant Cremation Commission

Annex L - Scottish Government Analysis of CMO & CNO Guidance Implementation

IMPLEMENTATION OF CHIEF MEDICAL OFFICER GUIDANCE ON THE DISPOSAL OF PREGNANCY LOSSES UP TO AND INCLUDING 23 WEEKS AND 6 DAYS GESTATION

Scottish Government Analysis of CMO & CNO Guidance Implementation

Responses Received - 23 October 2013

Summary

• Ten of the fourteen territorial Health Boards in Scotland report that they are now meeting the minimum standards set out in the July 2012 CMO Guidance.
• Of the remaining four, two expect to be meeting the standards by the first quarter of 2014 and Scottish Government officials will follow up with all four in the next few weeks in order to ascertain progress, any on-going issues and any assistance that they might find useful.
• Boards identified key benefits of consistency and standardisation leading to improved record keeping for audit trail purposes. They also highlighted improved transparency, through improved communication and information for patients, which accorded with the underpinning principle of respect and dignity for all concerned, within the Guidance.
• Key challenges reported included implementation costs; storage and transportation issues; the change-over to new documentation and staff training.
• As far as can be ascertained from the responses received, seven crematoria are already providing the new collective cremation service to Health Boards, and more may follow. Health Boards are free to make arrangements with crematoria outside their geographic area, or can use burial as an alternative arrangement. Several are utilising both of these options.
• There are two private hospitals in Scotland offering services relevant to the Guidance. Both replied to confirm they were also meeting the new minimum standards.

Background

Guidance Development

1. The need for new guidance was identified by the 2005-2008 Burial and Cremations Review Group, led by Sheriff Brodie. Following Scottish Government's acceptance of the Review Group's main recommendations in 2010, the new guidance was developed during 2010-12 via a Scottish Government established short life working group comprised of key stakeholders and experts in this area.

2. This included representation from the Royal Colleges of Nursing, Midwifery, Obstetricians and Pathologists; the Institute of Cemetery and Crematorium Management; the Miscarriage Association, the Stillbirth and Neonatal Death Society; the Association of Early Pregnancy Units; and the Association of Anatomical Pathology Technology. Also included was a Director of Women and Child Health; a consultant paediatric pathologist; a consultant obstetrician and staff members from both the SG Chief Medical Officer Directorate and the SG Chief Nursing Officer Directorate.

Guidance Key Points

3. The new guidance makes clear that the disposal of any pregnancy losses by way of incineration or clinical waste (which was technically possible under the earlier 1992 guidance) is no longer acceptable. Instead, a new minimum standard is introduced of collective disposal in a crematorium. In circumstances where such disposal is not available, disposal by collective burial is acceptable. In either situation, "collective" is defined as a number of pregnancy losses, in individual sealed containers, collected together into a larger sealed container. Women may opt out if they wish to make their own arrangements.

4. Fundamental to the Guidance is the requirement that all involved are treated with dignity and respect.

Guidance Issued

5. The Guidance on The Disposal of Pregnancy Losses up to and including 23 weeks and 6 days gestation was issued from the Scottish Government's Chief Medical Officer on 19 July 2012. It was sent to all Chief Executives, Medical Directors and Directors of Nursing and Midwifery of the NHS Boards in Scotland. It was also issued, for information and awareness, to the two private hospitals in Scotland where the Guidance might prove relevant. It was also made available via the SHOW website: http://www.sehd.scot.nhs.uk/cmo/CMO(2012)07.pdf

6. At the time of issuing, the Chief Medical Officer signalled that compliance with the new guidance would be audited by Scottish Government after a period of twelve months.

Situation at time of Issuing

7. When the guidance was issued, it was unknown how many health boards were already offering services that met or exceeded the new minimum standard. Anecdotally, Scottish Government was aware that good practice existed, but it was unclear whether this was universally available across the entirety of any health board area, or was limited to particular institutions.

Checking / Auditing Compliance

Request for Updates

8. Scottish Government lettered all Health Boards on 7 August 2013 seeking an update on their implementation of the Guidance, by 28 August 2013. A separate letter requesting similar information was also issued to the two private hospitals. The letters additionally provided a template for responses, based around six questions.

Summary of Responses Received

1 a) Can you confirm that all applicable NHS services in your NHS board area are currently delivering a service that meets or exceeds the minimum standards as set out in the Guidance?

1 b) Can you confirm that all applicable NHS services in your NHS board area are not disposing of pregnancy losses by way of incineration or clinical waste?

9. Ten of the 14 territorial health boards confirmed they were meeting the minimum standards, and additionally confirmed they were not utilising incineration or clinical waste routes. These were: Ayrshire and Arran; Borders; Fife; Forth Valley; Grampian; Greater Glasgow and Clyde; Highland; Shetland; Tayside and Western Isles.

10. Of the remaining four health boards, Orkney advised that although they were not yet meeting the minimum standards, they were not utilising incineration or clinical waste routes for disposal. Lothian reported it was meeting the minimum standards everywhere except for first trimester pregnancy loss. Dumfries and Galloway provided no additional information at this stage in the questions. Lanarkshire advised the reason implementation was delayed was due to a difficulty in procuring the services of a crematorium.

11. Both private hospitals, Spire Murrayfield in Edinburgh and BMI Ross Hall in Glasgow, confirmed they were meeting the minimum standards and were not utilising incineration or clinical waste routes for disposal of pregnancy loss.

2 a) If your answer to 1a) or b) was no, when will you be able to meet the revised minimum standards ?

2 b) If your answer to 1a) or b) was no, what steps are being taken to meet the revised minimum standards by the date identified in 2a)?

12. These two questions were only applicable to the four health boards identified in question 1b.

13. Dumfries and Galloway indicated January 2014 as the date by which they would be meeting the standards, and that they had established a group which was taking forward the work, including drafting local pathways and developing a business case.

14. Orkney indicated April 2014 as the date by which they would be meeting the standards in order to negotiate local burial arrangements or mainland cremation via Aberdeen or Inverness. No additional information or breakdown was provided as to how the April 2014 date had been determined.

15. Lothian response indicated end of September 2013 as the date they would be meeting the minimum standards, once arrangements were in place for the collective cremation of first trimester (< 12 weeks gestation) pregnancy losses. Their additional text on steps being taken, however, seemed to indicate that this date might not be achievable, for reasons which could usefully be explored further by and with officials if they are continuing to delay implementation. They note a particular issue as being staff concerns over the ethics of discussing end of care arrangements with women who may understandably not wish to enter into such a discussion. Although discussion must be attempted, the Guidance does not in any way suggest it should be continued if the patient is clearly unwilling to participate, and measures are suggested within the Guidance to deal with this circumstance. Lothian also appears to suggest in its response that moving to the new minimum standards will cost more than the higher standards they are already delivering, which requires some clarification.

16. Lanarkshire provided no definite date, as this was dependent on a successful second tender exercise to identify a crematorium that they could work with. We understand anecdotally that this situation has now been resolved, but are awaiting an official update from the health board on this question.

3. If all applicable NHS services in your NHS board area are currently meeting or exceeding the minimum standards, what benefits have already been seen or are expected to be seen over time?

17. Although it is still early days in terms of implementation for most areas, several health boards cited the benefit of having standardised and consistent arrangements, which linked with a closely associated benefit of improved record keeping and audit trails.

18. Other key benefits cited were improved transparency for patients, through the provision of improved and clearer information and advice. This was also seen to accord with the underpinning principles of respect and dignity for those involved, as set out in the Guidance.

19. One health board explicitly referenced strengthened working relationships with the funeral industry and bereavement charities as a result of undertaking the implementation activity.

4. What challenges, if any, require/d to be overcome in order for your NHS Board to meet or exceed the minimum standards?

20. The reported challenges varied significantly in nature, quantity and in level of provided detail, depending on the Board, but tended to be most apparent in areas where the most work was required to meet the standards and/or the Board was serving a significantly higher population. Forth Valley and Grampian in particular appear, from their responses, to have conducted a great deal of challenging but successful work in order to successfully implement the Guidance within a year.

21. The main recurring challenges noted in responses were implementation costs; the practical co-ordination of a change-over to new leaflets and documentation; some storage and transport issues and staff training.

22. There was no substantive difference in the challenges reported by rural versus urban board areas. Western Isles and Orkney have arrangements with mainland crematoria, if required, and Shetland utilises the alternative burial option set out in the Guidance where a crematorium is not available.

5. Has your NHS Board identified any areas of the revised guidance that might need to be re-considered in the light of any planning, implementation or other issues that may have arisen? Which areas and why?

23. Whilst some points were raised in this section, most were tangential to the Guidance wording ie they related to the processes being put in place to meet the Guidance requirements rather than signalling changes to the Guidance itself. None were raised with any degree of urgency or identified as being of particular significance.

24. Forth Valley mentioned a need for clarity over the question of whether there would or would not be any ashes following cremation, and we are already aware that a very minor amendment to a Guidance annex might be required in this respect. We will, however, await the findings of Dame Angiolini's Mortonhall Investigation and the report of the Infant Cremation Commission, both due by the end of this year / early next year, in case more substantive changes are recommended by them and require to be considered.

6. Which crematorium / crematoria does your NHS board work with in respect of the collective cremation of pregnancy losses (or for any alternative pregnancy loss / infant cremation arrangements)?

25. Of the 27 crematoria in Scotland, 14 are already working with the health boards either to provide the new collective cremation service or for NHS arranged private or individual cremations.

26. Seven crematoria appear to be specifically providing (or have agreed to provide when or if required) the new collective cremation service. These are: Masonhill Crematorium (Ayrshire), Mortonhall Crematorium (Edinburgh), Kirkcaldy Crematorium, Falkirk Crematorium, Hazlehead Crematorium (Aberdeen), Craigton Crematorium (Glasgow) and Perth Crematorium.