Report of the Infant Cremation Commission

Annex S - Infant Cremation Commission Approved Meeting Minutes

Infant Cremation Commission Approved Meeting Minutes

Infant Cremation Commission
Minute of Meeting 1- May 21, 2013

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
James Blackburn
Donald Henderson
Ian Kearns
Helena McLaren
Ann McMurray
Dr Mini Mishra
Tim Morris
Gillian Morton
Rick Powell
Garrick Smyth
Gavin Stevenson

Apologies:
Gareth Brown (represented by Donald Henderson)

1. Welcome and Introductions

1.1 Lord Bonomy welcomed members to the first meeting of the Infant Cremation Commission. Round the table introductions were carried out, after which Lord Bonomy noted the wealth of experience and knowledge represented in the membership and thanked everyone for their willingness to undertake this work.

2. Remit

2.1 A draft of the proposed remit was tabled. Use of the terms 'recoverable remains', 'ashes', 'cremated remains' 'babies' and 'infants' were discussed at length in order to ensure that the terminology used was clear and relevant to the public eg what might be understood by the term 'cremated remains' as opposed to 'ashes' and also that it did not exclude any areas which the Commission intended to examine eg bereavements as a result of pregnancy loss. Mr Henderson confirmed that the draft, as revised, was acceptable to the Scottish Government.

2.2 Decision Point: The remit was accepted and is attached at Annex A.

2.3 Action Point: The accepted remit will be published on the Scottish Government website on Wednesday May 22, 2013.

4. Local Investigations (agenda order changed)

4.1 There was some consensus that it would be appropriate to issue local investigations guidance but that the current wording would benefit from revision and reflection as to whether any key points may have been omitted. Commission members raised some concern that issuing such guidance could be inferred as an expectation that every cremation authority should undertake a formal investigation, which was neither the Commission's role nor its intent.

4.2 Action Point: To consider further the wording and timing of publication as an agenda item at the second meeting on May 28, 2013

4.3 Action Point: Secretariatto make agreed minor amendments to the document, following on from changes to the remit, prior to re-circulating with papers for the next meeting.

3. Plan of Activity

3.1 Lord Bonomy noted that the plan of activity was likely to be shaped by the level of individual knowledge and access to relevant information that each Commission member held. For this reason, he was likely to benefit from one to one meetings with each member and he would consider this in due course.

3.2 It was stressed that members should not publicly discuss or air personal views on the work of the Commission. When discussing any necessary topics or requests with their respective organisations, they should ensure communication does not go extend beyond what is required.

3.3 Members briefly discussed the format and publication of minutes. There was no desire for verbatim or detailed recording of discussions, and some concern that publishing minutes where issues had not yet been resolved could cause unnecessary public concern.

3.4 Decision Point: Concise minutes, focused on action points, will be produced.

3.5 Decision Point: Minutes will be published at the completion of the Committees work

5a&d. Current Landscape and Sources of Evidence

5.1 There was lengthy discussion on current practice, the various documentation available and what might be obtainable. The following actions were agreed.

5.2 Action Point: All members to send a note of their name, role of their organisation, their own role and experience within that organisation and their experience relevant to the remit. Added to this each member should indicate areas or aspects of the current system which they already know or believe should be improved. By close of Monday May 27, 2013.

5.3 Action Point: Rick Powell (FBCA) and Tim Morris (ICCM) to formulate a joint draft list of questions around how to maximise the recovery of ashes/cremated remains. These questions, for all crematoria in Scotland, should cover such aspects as: local technical, policy and guidance documents; local practice and techniques (eg use of baby trays, placement within cremator etc); operational instructions within the manufacturers' cremator manuals; type (ie individual or collective) and number of cremations across the country. Also to set out the usual costs/charges that apply when a child's cremation is involved. By close of Monday May 27, 2013.

5.4 Action Point: at the suggestion of Rick Powell and, following agreement on the draft questions above, similar questions are to be put to the member organisations of International Cremation Federation with a view to obtaining a picture of practices adopted in other countries.

5.5 Action Point: Tim Morris to provide draft ICCM guidance on operational techniques. By close of Monday May 27, 2013.

5.6 Action Point: Ian Kearns (Local Authority)to provide local authority fees information from 2012. By close of Monday May 27, 2013.

5.7 Action Point: James Blackburn (NAFD)to set out in writing the types of circumstances in which NAFD members do or do not have contact with family members and what, in practice, members do or should advise parents. Also to set out the costs/charges that are usually applied by funeral directors for a child's funeral. By close of Monday May 27, 2013.

5.8 Action Point: Gillian Morton (NHS) to request from all territorial Health Boards the policy manuals for staff and leaflets for parents and relatives that cover these matters. John Birrell (NHS bereavement co-ordinators) may be able to assist. Also to cover the costs/charges that apply in cases of collective or individual cremation organised by NHS institutions. By close of Monday May 27, 2013.

5.9 All members should be clear to frame their requests for information on behalf of the Infant Cremation Commission.

5b. Call for Written Submissions

5.10 The deadline for submissions (July 19, 2013) was discussed and a follow up meeting of Tuesday August 20, 2013 was tentatively identified, to allow time for analysis of the responses.

5.11 There was consensus across members that the current system was not satisfactory and that improvements were needed. With that in mind, Lord Bonomy asked members to ensure that their organisations sent in their own formal written submissions in response to the call.

5.12 The wording of the Call for Written Submissions, which will be published on Wednesday May 22, 2013 alongside the accepted remit, was also discussed. A minor amendment to the final paragraph of the draft, replacing 'is comfortable that…' with 'will welcome', was agreed. Ensuring it was clear that the submissions be in writing was also agreed. The opening of the call was also to be amended in the light of earlier revisions to the remit wording.

5.13 Decision Point: the wording of Call for Written Submissions was agreed subject to the above discussed amendments and is attached at Annex B.

5.16 Action Point: to publish the agreed Call for Submissions on the SG website on Wednesday May 22, 2013.

5.17 Action Point: members to ensure their organisations send their own written submission to the cremationcommission@scotland.gsi.gov.uk mailbox by July 19, 2013.

5 Open Meeting

5.18 It was agreed the possibility of holding an open meeting for affected parents and relatives would be considered further at the next meeting.

5.19 Action Point: this will be an agenda item for May 28, 2013 meeting.

6. Any Other Business

6.1 Action Point: The link to the SG news release and dedicated webpage will be issued to all members once available on May 22, 2013.

7. Dates of Future Meetings

7.1 The next meeting will be held on May 28, 2013, 2pm to 5 pm.

7.2 Possible next meeting dates of June 18 or 26 and also August 20, 2013 have been very tentatively identified.

Infant Cremation Commission
Minute of Meeting 2 - May 28, 2013

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
James Blackburn
Gareth Brown
Ian Kearns
Helena McLaren
Ann McMurray
Dr Mini Mishra
Tim Morris
Gillian Morton
Rick Powell
Garrick Smyth

Apologies:
Gavin Stevenson

1. Welcome and Introductions

1.1 Lord Bonomy welcomed members to the second meeting of the Infant Cremation Commission. Lord Bonomy noted that the first meeting of the Commission had been fruitful and provided a clear focus for progress.

2. Minutes

2.1 Decision Point: The minute of the first meeting was agreed with no changes and will be published at the completion of the Commission's work.

3. Matters Arising

3.1 The Commission discussed the publication of the remit and call for written submissions and the resulting press attention. The Commission noted that some local groups and charities were unhappy not to be invited as members of the Commission but the Commission is clear that it must maintain a national perspective and, in accordance with its remit, cannot investigate specific incidents. The perspectives of individuals and organisations, in addition to the views provided by Commission members, will be useful and will be secured through the invitation for submissions.

3.2 Decision Point: The views of local groups and charities across the country are welcome but best considered in the form of a written submission.

3.3 Decision Point: Although the remit was amended prior to being accepted at the first meeting on May 21, 2013, the Commission agreed that there will be no change to the formal name of the commission, which will remain 'Infant Cremation Commission'.

4. Open Meeting

4.1 The idea of holding an open meeting with parents was discussed at length. It was generally felt, however, that such a meeting might not meet the needs of all parents as effectively as the existing option to make a submission privately in writing, given the personal and sensitive nature of the issues involved.

4.2 Decision Point: The Commission agreed that there would not be an open meeting at this stage, though it may be considered again at a later stage of the process.

4.3. The views of those most directly affected will be captured via the call for written submissions.

4.4 Decision Point: The Commission agreed that it was entirely appropriate for members to feed into discussion any issues raised personally with them by bereaved families or other members of the public.

5. Local Investigations

5.1 Lord Bonomy reminded members of the concerns from the first meeting that issuing guidance on local investigations may in fact prompt investigations to be launched which otherwise wouldn't be required, but on balance it was agreed that guidance would be beneficial. The Commission discussed and refined the wording of the guidance to ensure its purpose was clear, and to address other issues raised by the Commission members.

5.2 Decision Point: The Commission agreed the wording of the guidance for local investigations subject to revisal in light of para 5.4.

5.4 Action Point: Gavin Stevenson to circulate a revised draft of the guidance to local authority Chief Executives for comment prior to publication.

5.5 Action Point: Commission Secretariat to circulate a revised draft of the guidance to Commission members for final comments prior to publication. The finalised guidance will then be published on the Scottish Government website as well as circulated to all Cremation Authorities.

6. Questions for Crematoria

6.1 Lord Bonomy offered his thanks to Tim Morris and Rick Powell for compiling the questionnaire for crematoria which was tabled as a paper on the day.

6.2. The Commission discussed and agreed amendments to the questions to ensure terminology, language and definitions were accurate including how crematoria would interpret 'baby' or 'infant' within the questions.

6.3 Action Point: Commission Secretariat to amend the questionnaire based on the discussion and circulate to members for any further comment prior to issue.

6.4 Action Point: Commission Secretariat to issue the questionnaire to Local Authority Chief Executives and Managing Directors of private crematoria, once signed off by the Commission as per Action Point 6.3, with a request for responses within one month of date of issue.

7. Update on Information Received Following Last Meeting

7.1 Lord Bonomy thanked the Commission members for providing the information requested at the previous meeting and looked forward to receiving the remainder of the requested information as soon as was possible.

7.2 Action Point: Those members still to submit previously requested information to do so as soon as is possible.

8. Any Other Business

8.1 The group discussed a draft of proposed additional guidance for those considering making written submissions, particularly in relation to reassuring the public as to how sensitive and personal information would be handled.

8.2 Decision Point: The Commission agreed that responses to the call for written submissions will not be actively published, although an anonymised analysis of key themes would be published in due course.

8.3 Decision Point: The guidance on written submission will make clear that there is no expectation that any personal or sensitive information will be released in the event of any requests made to Scottish Government under the Freedom of Information (Scotland) Act 2002 or the Data Protection Act 1998.

8.4 Action Point: Commission Secretariat to make the required amendments and issue to the Commission for any further comment prior to publication on the Scottish Government website.

9. Dates of Future Meetings

9.1 The next meeting of the Commission will take place on August 20, 2013 from 2pm - 5pm

9.2 Decision Point: Lord Bonomy indicated that a major source of material for the commission's work would be the wealth of experience and knowledge possessed by Commission members and indicated that he wished to meet with each member of the Commission individually over the period of the next month to expand his own understanding of the issues involved and explore their ideas for the improvement of current policies, practice, guidance and legislation.

9.3 Action Point: Commission Secretariat to make the required arrangements for individual meetings on June 13, 17, 18 and 21, 2013, and notify each Commission member of the time of their meeting.

Infant Cremation Commission
Minute of Meeting 3 - August 20, 2013

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
James Blackburn
Gareth Brown
Ian Kearns
Helena MacLaren
Ann McMurray
Dr Mini Mishra
Tim Morris
Gillian Morton
Rick Powell

Apologies:
Gavin Stevenson
Garrick Smyth

1. Welcome and Introductions

1.1 Lord Bonomy welcomed members to the third meeting of the Infant Cremation Commission. Lord Bonomy noted he was grateful for the effort and dedication of all Commission members.

2. Minutes

2.1 Decision Point: The minute of the second meeting had previously been agreed by members with no changes and had been published on the Commission webpage.

3. Matters Arising

3.1 It was agreed that all matters arising were covered by the agenda.

4. Update Paper (Paper 1)

4.1 The paper updated the Commission on matters of interest and progress made since the last meeting.

4.2 Lord Bonomy highlighted to members the request made by parents to join the membership of the Commission, and his subsequent decision to not change membership. Lord Bonomy confirmed that, following the input from Commission members and the opportunity to further reflect on this issue, he is confident that the right decision has been made. Lord Bonomy reiterated his belief that the Commission members were best placed to provide the expertise required to enable the Commission to deliver on its remit. He also made the Commission members aware of his commitment to share the Commission's draft report with bereaved parents for comment prior to publication. Members indicated they were content with this commitment.

5. Update for Website

5.1 Commission members were provided with a draft update for publication on the Commission's web pages.

5.2 Action Point: Commission members are asked to contact the Commission Secretariat within the week with any comments on the draft update.

6. Submissions Analysis (Paper 2)

6.1 Commission members had received a paper prepared by the Commission Secretary which provided an anonymised summary of the submissions the Commission had received. Lord Bonomy noted that the analysis indicated a fair degree of consensus amongst respondents' views on the areas for improvement. The Commission noted that the majority of submissions agreed that parents should be offered whatever is left following the cremation of their baby if they wish, and that good quality communication with parents was paramount.

6.2 The Commission discussed the guidance provided by the two industry bodies, the Institute of Cemetery and Crematoria Management (ICCM) and the Federation of Burial and Cremation Authorities (FBCA) and the technical processes involved in the cremation of infants in contrast to the cremation of adults.

6.3 Commission members agreed that bereaved parents should be given time to consider their options in relation to cremation or burial of their child, without the pressure to make a decision quickly. There was concern that bereaved parents might be 'falling through the net' as a result of lack of continuity of care, after leaving hospital. However it was recognised that there are often external pressures that cause parents to make decisions as quickly as possible, such as family or social pressure to have a quick funeral.

6.4 Commission members recognised that while not all parents want detailed information about the process of infant cremation all staff, across each partner organisation, should be able to provide full, clear and consistent information to the parents who do. All parents should have the opportunity and the ability to access information if they want it. It was highlighted that all professional partners should be clear on their role in the process.

6.5 Decision Point: The Commission agree that there is a need for standardisation across professional guidance to ensure consistent advice and information is given to staff and parents.

6.6 Action Point: Commission Secretariat to circulate ICCM and FBCA guidance to Commission members for information.

6.7 Commission members considered the differences in legislation and guidance regarding foetuses, still births and infants, including eg the current requirements of Waste Management Regulations. The detail and retention of records was also discussed. These issues will all be relevant to the Commissions conclusions and recommendations.

6.8 Decision Point: Commission members agree that crematoria should keep a record of all cremations. The non-statutory register, where the cremation of pre - 24 week fetuses are recorded, should be standardised and made statutory.

6.9 Commission members discussed the impact of CMO guidance on the sensitive disposal of pregnancy loss up to and including 23 weeks and 6 days, issued in 2012. The Scottish Government is currently conducting an audit on the implementation of this guidance across NHS Boards.

6.10 Commission members considered the contract arrangements in place between hospitals and selected funeral directors. The Commission discussed the impact on, and the benefits for, bereaved parents, as well as problems associated with, these sorts of arrangements by the NHS.

6.11 The Commission discussed the potential value of a national memorial for those affected by this issue. Such a memorial could provide a place for bereaved parents to grieve and remember their child. Members supported this idea but also saw benefits in local memorials which would provide more accessible focal points for parents and relatives.

7. Crematoria Questionnaire Analysis (Paper 3)

7.1 The Commission considered changes in cremator technology and techniques, Scottish Environmental Protection Agency (SEPA) requirements, training schemes and the legal requirements crematoria must meet in order to be able to operate.

7.2 The Commission discussed concerns regarding the accuracy of the information received from crematoria. Lord Bonomy noted his intention to review responses critically and to investigate further any anomalies or concerns. It was agreed that as a first step the FBCA and the ICCM would consider the responses in detail and provide views to Lord Bonomy.

7.3 Action Point: Commission Secretariat to send questionnaire responses to Rick Powell and Tim Morris for consideration. Rick Powell and Tim Morris to return comments to Lord Bonomy by early September

7.4 Lord Bonomy made Commission members aware that he would be meeting with Dame Elish Angiolini of the Mortonhall Investigation immediately following the Commission meeting.

8. Dates of Future Meetings

8.1 The next meeting of the Commission will take place on 29 October 2013 at 10.30 am in Glasgow. Commission Secretariat will announce the venue as soon as possible.

Infant Cremation Commission
Minute of Meeting 4 - 6 November 2013

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
James Blackburn
Gareth Brown
Helena MacLaren
Ann McMurray
Dr Mini Mishra
Tim Morris
Gillian Morton
Rick Powell
Gavin Stevenson
Garrick Smyth
Norman Dowie

Apologies:
Ian Kearns

1. Welcome and Introductions

1.1 Lord Bonomy welcomed members to the fourth meeting of the Infant Cremation Commission, and introduced Commission members to Norman Dowie, a retired Deputy Principal Clerk of Justiciary in the High Court in Edinburgh. Lord Bonomy outlined Norman's role as including further investigation of cremators and cremation techniques employed by crematoria; current electronic record keeping and reviewing statements for consistency. He also reported Norman would be attending his meetings with Glasgow and Aberdeen City Councils.

2. Minutes and Matters Arising - Paper 1

2.1 Decision / Action Point: The minute of the third meeting was agreed with no changes and will be published on the Commission webpages. There were no matters arising.

3. Update on Progress - Paper 2

3.1 Lord Bonomy updated the Commission on a meeting held with ICCM and FBCA members on 24 October 2013. Lord Bonomy noted unanimous support from those in attendance that the Commission finds a clear and workable definition of the word 'ashes'. A similar meeting with members of the NAFD has also been arranged. Lord Bonomy also updated members on his meeting with Dame Elish and reiterated his intention to share a draft of the report with parents.

4. Report Chapter 1 Draft - Paper 3

4.1 Lord Bonomy sought opinions from Commission members on the first draft of the introductory chapter one of the report setting out the background. A number of minor amendments and changes to terminology were discussed, as was including and verifying different statistical information and facts.

4.2 Decision Point: Lord Bonomy will take these views into account as drafting of the report proceeds.

4.3 Gavin Stevenson indicated that the willingness and support of Commission members towards this work should be conveyed within the first chapter of the report.

4.4 Lord Bonomy noted that only 4 of the submissions received from affected parents related to cremations within the last 5 years and also that some cremation authorities have made changes to their practice over that period. He indicated that these were factors that should be acknowledged within the report.

4.5 Lord Bonomy confirmed his current intention to refer to the development of the cremation process within the report. John Birrell suggested Edinburgh academic, the Reverend Peter Jupp, as a possible source for this information.

4.6 Action Point: Secretariat to follow up with John Birrell regarding sources of information.

4.7 Lord Bonomy revisited the suggestion of whether the report should include discussion of a possible national memorial. Members agreed that a national memorial would have significance and status. However there were differing views as to its purpose ie would this be a memorial for all who had lost a child, which might be seen as beyond the remit of the Commission.

4.9 Decision Point: Members agreed that that a national memorial could be explored within the report.

4.10 Members discussed how the report might best acknowledge the distress and pain experienced by affected parents and families, without apportioning blame unfairly e.g. where some practices in the past were consistent with attitudes at that time, even if they were now viewed as unacceptable. Lord Bonomy noted that the findings of the Mortonhall Investigation will have a bearing on this, and therefore on the Commission's report.

4.11 Decision Point: Members agreed that recognition and acknowledgement as well as discussion of a national memorial should feature in the report.

4.12 Action Point: Helena MacLaren and Ann McMurray to develop a draft expression of recognition and acknowledgement for possible inclusion in the report.

4.13 Action Point: John Birrell to identify existing memorials and memorial services and advise on examples of best practice.

4.14 Action Point: Secretariat to review submissions to identify whether and how many parents believed they were deliberately misled by the cremation authority, funeral director, NHS or these groups in any combination.

5. Issues for Discussion (Paper 4)

5.1 Lord Bonomy identified a need for a clear set of guiding principles and reflected on the use of legal language to ensure clarity and consistency. He requested views from the group as the sorts of terms that would be useful to include within any such guiding principles.

5.2 Suggestions and points raised included: that the guiding principles should focus on the needs of those left behind and that any core principles should contribute to the way people construct guidance or process in the future and that therefore the inclusion of empathy was important. Other specific terms discussed included respect, dignity, openness, honesty, transparency and responsiveness (to take account of individual needs).

5.3 A concern was raised that guiding principles predicated on parents being in distress about the loss of a child would require to have regard for the wide variety of different situations that parents may be in. Wording would therefore need to accommodate the different choices, situations and sensitivities involved.

5.4 A further concern discussed at length by members was whether such guiding principles should or could be applied consistently across the country and across the various sectors involved. It was noted that there were existing precedents and mechanisms for this which could be utilised later on if required, and that this need not affect any recommendation made by the Commission.

5.5 Lord Bonomy updated the group in the progress being made in obtaining the opinion of Counsel on the interpretation of regulation 17 of the 1935 cremation regulations and advised of his intention to contact the Vice - Dean of the Faculty of Advocates. He stressed the need to define 'ashes' in a way which would meet both public and professional requirements and asked if the group agreed a suggested definition of ashes as being 'what has been left following the conclusion of the cremation process'.

5.6 Whilst no one dissented from this definition, discussion followed immediately as to whether the 'conclusion' of the cremation process also required to be clarified. A suggestion offered was not to use the phrase 'after the last flicker of flame expires' as this may not be applicable. Another point raised was that the definition could be supplemented with 'which may or may not contain human remains'. Lord Bonomy considered that some further advice may be required on these matters and additionally noted that expert reports, commissioned by Dame Elish, were expected in due course regarding the effect of the cremation process on the human body.

5.7 Members discussed how to explain the content of ashes to the public and sought to find a positive message whilst maintaining factual honesty. Lord Bonomy noted that from discussions with crematoria it is clear that in some cases it is possible that nothing at all is left in the cremator. There was consensus that whilst parents clearly want whatever is left following the cremation process, regardless of what that may be, their initial decision on whether to opt for cremation or burial must be an informed one.

5.8 It was noted that although the Scottish Government CMO pregnancy loss guidance contains no reference to the availability or otherwise of ashes, it already accepted that a minor revision to an annex within the guidance was required. This annex includes the statement that individual ashes cannot be provided due to an absence of formed bone, when in fact individual ashes cannot be provided because these are collective cremations. Lord Bonomy noted a preference for the term 'shared' rather than 'collective' cremation; however there was no consensus on this amongst Commission members.

5.9 It was additionally confirmed that SEPA had previously advised it was content with arrangements under the 2012 CMO Guidance on the Disposal of Pregnancy Loss, provided the terminology 'disposal at a crematorium' was officially used, rather than 'cremation'. It was noted that, the Commission could recommend that Scottish Government liaise with SEPA on the use of language if it felt this was appropriate.

5.10 Action Point: Lord Bonomy to request a copy of crematoria permit / license from Ian Kearns.

5.11 The meeting moved on to discuss records and record keeping and whether a statutory register for Non viable fetal (NVF) cremations, as agreed in principle previously by the Commission, would conflict with the current arrangements for collective cremation of NVFs, whereby the main record (the mother's relevant medical record) is retained by the health board and a unique reference number only is retained by the cremation authority, which does not have access to the identity of the parent.

5.12 Mini Mishra and Gillian Morton both highlighted the critical importance of maintaining anonymity and patient confidentiality. It was confirmed that the crematorium record would be kept indefinitely and the health board records are now retained for a minimum of thirty years, with fifty years recommended as best practice.

6. Cremation Forms (Paper 5 + Annex of Forms)

6.1 Lord Bonomy indicated that assistance in improving current forms may be found in the style and content of cremation forms used in England and Wales, and suggested that all forms including the stillbirth form should be revised and supplemented. It was highlighted that some changes to these will be made under the new death certification system, due to be implemented in 2015.

6.2 Members also discussed the issue of recording information electronically, James Blackburn confirmed that this is not currently common practice with funeral directors. Lord Bonomy highlighted the benefits of being able to retain and access records more easily, but also recognised that until appropriate systems for electronic signatures are developed, hard copy application forms must continue in use. Gareth Brown acknowledged the benefits of electronic storage as this would mean that all records, not just the register, could be retained for an indefinite period of time.

7. Note of Meeting 1 October 2013 (Paper 6)

7.1 Members had no comments on the minute of the sub meeting of 1 October 2013, to discuss submissions.

8. Next Steps

8.1 Action Point: Lord Bonomy proposed producing a brief update on timescales, following an update from the Mortonhall Investigations Team, to be shared with the Minister for Public Health.

9. Next Meeting Date

9.1 Lord Bonomy decided that the next meeting date should not be set yet as work will be underway to produce a draft report and exchanges can take place via email in the interim.

Infant Cremation Commission
Minute of Meeting 5 - 21 March 2014

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
Paul Cuthell (Deputising for James Blackburn)
Ian Kearns
Helena MacLaren
Ann McMurray
Dr Mini Mishra
Tim Morris
Rick Powell
Gavin Stevenson
Garrick Smyth
Norman Dowie

Apologies:
James Blackburn
Gareth Brown
Gillian Morton

1. Welcome and Introductions

1.1 Lord Bonomy welcomed members to the fifth meeting of the Infant Cremation Commission, particularly Paul Cuthell, who deputised for James Blackburn.

Apologies were noted from James Blackburn, Gareth Brown and Gillian Morton.

2. Minutes and Matters Arising - Paper 1

2.1 Decision / Action Point: The minute of the fourth meeting was agreed with no changes and will be published on the Commission webpages. Some sensitivities were noted regarding the timing of publishing the minutes, therefore it was agreed secretariat would reflect and publish at an appropriate time. There were no matters arising.

3. Update

3.1 Lord Bonomy offered his apologies to the group for cancelling the last agreed meeting date and rescheduling Meeting 5 at short notice.

3.2 He made the Commission aware of the delay to the Mortonhall Investigation Report and made clear this was due to information uncovered by the investigation requiring further enquiry. It is clear that the Commission cannot complete its report until it has had the opportunity to consider the findings and conclusions sight of the Mortonhall report.

3.3 Lord Bonomy noted that the structure of the Commission's report is now beginning to take shape but highlighted his awareness of the existence of factual errors and terminology issues at this early drafting stage. It was noted that the Commission must be mindful of its remit when drafting the report, however, Commission members were encouraged to share their views about the structure and the content of the report in a frank and open manner.

4. Language and Terminology

4.1 The Commission discussed Lord Bonomy's preference for the term 'shared cremation' rather than 'collective cremation' which was in the 2012 CMO Guidance. John Birrell noted that the term 'collective' is used in the 2012 CMO guidance to describe the process to be carried out by the hospital. It was noted that whilst consistency is critical, the CMO Guidance is for healthcare professionals not parents .

4.2 Decision / Action Point: Lord Bonomy concluded that the report narrative should at least in the interim refer to 'collective or shared cremation'. The report could, if necessary, explain that the majority of the Commission preferred 'shared' but recognised the use of the word 'collective' to describe the NHS process. Secretariat

4.3 The Commission had a short discussion regarding terminology including 'pregnancy loss', 'Non-Viable Fetus' and 'Pre-Viable Baby', on which there was no clear consensus. It was proposed that there may need to be a glossary within the report in order to ensure language and terminology is fully explained.

4.4 Commission members provided initial feedback on the draft report, which was generally positive. Some concern was, however, expressed at the quantity of complex legal language, particularly in the 'Introduction' section, which could be a barrier for the report's general audience.

4.5 Decision / Action Point: It was agreed that an executive summary should be included at the start of the report. This should be concise and cover all the key points. It was also agreed that there would be a collated list of recommendations included in the report.

4.6 Lord Bonomy noted a number of environmental issues which are being followed up with SEPA relating to abatement legislation and the current practice in crematoria.

4.7 Lord Bonomy noted that, during the work of the group in the last year, practice in some areas has already changed for the better, which should be highlighted in the report.

4.8 There was a short technical discussion with some Commission members regarding the use of infant cremators.

4.9 Lord Bonomy noted Health Boards had very different experiences when implementing the 2012 CMO guidance. He suggested there should be an opportunity for Health Boards to learn from one another. Multi-disciplinary groups involved in education and training were also highlighted a potential good practice.

5. Draft Report Sections 1 - 8

5.1 The group discussed the content and detail of the report.

5.2 There was some discussion around inspections currently carried out by SEPA, the ICCM, FBCA and NAFD. It was noted that Funeral Directors do not have to be members of any association and are able to operate without any form of licence. It was confirmed that in cremation authorities only crematorium technicians require to have a prescribed qualification.

5.3 The group noted that the 2012 CMO guidance was put in place following Sherriff Brodie's review in 2010. Sherriff Brodie's group were very clear that they were not content with the existing arrangements and that guidance should be reviewed.

5.4 Action Point: Sherriff Brodie's Report should be checked to ensure the wording in the report, and subsequent consultation, are accurately represented. Secretariat

5.5 The Commission had further discussion around the terminology of 'ashes' and 'cremated remains'.

5.6 Decision Point: The Commission agreed that transparency is necessary, and parents should be completely clear on what has happened to their baby. Therefore, Commission members agreed the phrase 'It is not possible to say to what extent these ashes contain the remains of the baby' The Commission did not reach a conclusion as to whether the words 'if any' should be added to this statement.

5.7 Decision Point: It was unanimously agreed by attendees that parents should receive everything that is left in the cremator following cremation.

5.8 It was noted that each cremation authority makes its own decision regarding carrying out collective cremation or not.

5.9 Action Point: ICCM and FBCA to set out historical and current position on the collective cremation of NVF in the crematoria in Scotland. This should include a letter sent by the FBCA to members in August 2001. Tim Morris and Rick Powell

5.10 It was noted that if the Commission were to recommend that all Health Boards should offer hospital arranged individual cremations, the Commission should be mindful of the cost implications for Boards.

5.11 Action Point: Collate information on which hospitals currently offer individual cremation and what the cost implications are. Secretariat

5.12 The Commission discussed in-house training and technical training in detail. These discussions included the potential for revising or amending the training documents used by the ICCM and the FBCA. It was proposed that training on compassion and communication may also be appropriate for inclusion in training documentation for technical staff, as most staff have interchangeable roles. It was noted that some Cremation Authorities already share good practice, share training opportunities where possible and benchmark against one another.

5.13 It was noted that any statutory register for NVFs should number each NVF separately. This information should be kept separately from the cremation register as this is linked to national statistics. The information required on a NVF register will also be different from that required by the cremation register.

5.14 Action Point: Draft a form to show what should be on a statutory register of cremation for NVF. Secretariat

5.15 Action Point: The Commission discussed the applicant for the registration of a birth or death where the mother and/or father is under 16. National Records of Scotland should be contacted for further advice. Secretariat

5.16 Decision / Action Point: The Commission agreed that, on draft forms, the statement of truth could be brought forward to ensure parents read the complete form, and are not merely handed the back page to sign, or wording should be changed so the individual is aware they are signing to confirm the accuracy of the preceding 5 pages. Forms to be amended and recirculated ahead of the next meeting. Secretariat

5.17 Lord Bonomy noted that in order for a statutory register of NVFs to have credence it would be necessary for some sort of confirmation that in each case the fetus was below 24 weeks and showed no signs of life. It was noted that if doctors were requested to provide formal certification for the purposes of cremation, there could be a cost to parents as this would fall outwith the services provided by the NHS.

5.18 Action Point: The Commission discussed the issue of a memorial. Submissions should be reviewed to ascertain the views of parents, or others, regarding memorials. Secretariat

5.19 Action Point: The Commission noted annual International baby loss day on 15 October, and a new initiative called 'To Absent Friends' John Birrell to provide further information on 'To Absent Friends'.

6. Next Meeting

6.1 Decision / Action Point: Next meeting to be early to mid-Aril. Availability to be provided. Secretariat

Infant Cremation Commission
Minute of Meeting 6 - 9 May 2014

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
James Blackburn
Gareth Brown
Ian Kearns
Helena MacLaren
Ann McMurray
Dr Mini Mishra
Gillian Morton
Tim Morris
Rick Powell
Garrick Smyth
Norman Dowie

Apologies:
Gavin Stevenson

1. Welcome and Introductions

1.1 Lord Bonomy welcomed the Commission members and noted the publication of the Mortonhall Investigation Report (MIR) on 30 April 2014.

2. Minutes and Matters Arising - Paper 1

2.1 Decision / Action Point: The minute of the fifth meeting was agreed with no changes and will be published on the Commission webpages. It was agreed that the minutes would not be published until after the publication of the report to avoid any confusion.

2.2 Lord Bonomy noted again his intention to share the report with parents prior to publication and highlighted that he would be requesting the report be treated confidentially, however, the logistics of this were still to be finalised.

3. Points Arising from Mortonhall Investigation Report (MIR)

3.1 Lord Bonomy noted that the ICCM and FBCA had provided their response to the MIR, this has been circulated to Commission members. He then invited comments from Commission members on the MIR findings and recommendations.

3.2 Some concern was expressed as to how those working in bereavement services would react to some aspects of the MIR, because it is possible to infer from its wording that these staff were providing advice to the bereaved that was based solely on received wisdom and which did not give due regard to the feelings of the bereaved, which was not the case for the vast majority of dedicated people working and volunteering in this area.

3.3 Lord Bonomy noted that Seafield crematorium was highlighted in the MIR as using best practice when carrying out infant cremations. However it should be noted that they carry out low numbers of infant cremations.

3.4 The Commission discussed the MIR recommendation on national research. The Commission considered this to mean commissioning an independent piece of research to ascertain the best way to maximise retrieval of ashes. However it was agreed that this may not add much more to current understanding. The Commission considered that a better approach may be to ensure industry colleagues form a working group to agree best practice guidelines.

3.5 It was suggested that any working group should report in to Scottish Government and should incorporate the view of bereaved parents. The group should also include cremator manufacturers and representatives from SEPA.

3.6 Lord Bonomy noted that he had received positive feedback from SEPA and highlighted that their interest is purely from an environmental perspective.

3.7 Lord Bonomy noted that in regard to shared cremation it was his understanding that some Health Boards retained non-viable babies for extended periods before sending for cremation. The Commission agreed that this was unacceptable. It was noted that some crematoria designate a specific day each week or month to carry out shared cremations.

3.8 Lord Bonomy raised an ethical question regarding overnight cremations and it was recognised that some parents don't like the thought of their baby being left alone in the dark. However it was understood that if this was the way to ensure there would be ashes then parents were likely to accept the process, provided it is carried out with dignity and respect.

3.9 Lord Bonomy noted that the baby cremator is now in place in Mortonhall and that SEPA have been informed. It is understood that Mortonhall will set out exactly how they will proceed which will be shared with Lord Bonomy.

3.10 Action point - Clarify how many hospitals offer individual cremations and who incurs the cost - Secretariat / Gillian Morton

3.11 James Blackburn noted that the NAFD are currently reviewing their professional code of practice and would be looking to improve their guidance on infant cremations. It was also noted that 10% of funeral directors in Scotland do not belong to any professional body at all.

3.12 The Commission considered that an overarching code of practice (to cover healthcare providers, the funeral industry and all Cremation Authorities) could include a flow chart to highlight the points at which the organisations should be talking to one another. The Commission also considered that interactive training for all, possibly developed by NHS Education Scotland, could be made available on a webportal.

3.13 It was acknowledged that parents are already having to discuss difficult questions regarding post mortems and that, for many parents, making the funeral arrangements is part of the process of coming to terms with the death.

3.14 Action point - Draft an outline on the proposed overarching group to identify a code of practice, best practice etc. _ Secretariat

3.15 The Commission discussed whether or not non-viable babies should be classed as the mother's tissue / body part and it was agreed that this required further thought.

3.16 Lord Bonomy discussed the role of SEPA and the potential to allow for overnight cremations. He noted this was a complex area and will require further work.

3.17 The Commission noted the recommendations on page 530 of the MIR and discussed body parts and tissues noting an understanding that tissues on slides could be kept without authorisation.

3.18 Seek view from SGLD on the recommendations contained on page 530 of the MIR relating to body parts - Gareth Brown

3.19 The Commission discussed the registration of the cremation of non-viable babies, noting that this could only practically involve those situations where the mother presented at a hospital (or GP), and where they would therefore be able to obtain medical confirmation that the non-viable baby showed no signs of life. It was discussed whether a doctor or midwife would have to be present at the point of miscarriage in order to provide confirmation, and the possible implications of this for Health Boards.

3.20 Action Point - Draft of the proposed register for the cremation of NVFs to be shared with group - Secretariat

3.21 The Commission discussed the recommendation in the MIR that representative bodies review their policies and practices. Rick Powell noted that the FBCA Executive Committee met the day following the publication of the MIR. The Executive Committee agreed to wait until after the Commission has reported, then the Technical Committee will carry out a review based on the recommendations offered by the Commission. Tim Morris noted that the ICCM have already begun a review of their policies and procedures including a draft Unit for technicians, however, the ICCM intends to wait until the Commission reports before releasing any new or revised documents. Rick Powell also noted that the FBCA have met with Edinburgh City Council in order to move forward with joint working. This is likely to include support from the ICCM, though it is noted the ICCM have not yet been contacted by the council. Rick Powell highlighted that Edinburgh City Council have indicated an intention to review their operational procedures in order to maximise the recovery of ashes. It was noted that to date the FBCA and ICCM have not had any discussions outwith Commission meetings.

3.22 Tim Morris noted that irrespective of membership every crematorium technician is required by law to be appropriately qualified before they work unsupervised. Some operate with just the manufacturer training but the ICCM's training programme is much broader than this.

3.23 After discussion the Commission members agreed that all guidance should flow from one central source to ensure consistency. This could be a single set of guidelines that all partners sign up to. Lord Bonomy noted the possibility of a recommendation that both organisations (ICCM and FBCA) to apply the same guidance.

3.24 The possibility of an Inspector of Crematoria was also discussed and it was noted that the ICCM has recommended this in the past. Any Inspector could broadly be expected to ensure the standards set by the code of practice are met, carry out random inspections across the country and provide a commentary on crematoria meeting standards. Lord Bonomy noted that the service provided by crematoria is in effect a public service that it may be appropriate to regulate. However he considered that the Commission did not have the scope to say whether it should be regulated.

3.25 The Commission discussed the balance to be struck between transparency and sensitivity when discussing the recovery of ashes with parents and if parents should be informed that any ashes recovered may or may not be predominantly coffin ash. Some Commission members felt that as it is not explained following an adult cremation that some of the ash would be coffin ash it was not necessary to clarify the point for infant cremations. However others highlighted that the difference was that in the case of infants it was possible the ash could be comprised purely of coffin ash and therefor it was important to be clear with parents to enable them to make informed decisions.

3.26 Decision point - Consensus was reached that parents should be provided with full information regarding the make-up of ashes, however this should be done using sensitive and appropriate language.

3.27 The Commission also noted the use of a ceramic disc as carried out by some crematoria in England.

3.28 The Commission discussed the recovery of any metals following cremation. Tim Morris noted that the environment agency state metals are classed as ashes until they are removed at which point they should be disposed of or recycled, approximately 20% of crematoria in Scotland recycle. Every family is asked for their consent prior to any recycling taking place. It was noted that future medical advancements could mean that this would be a relevant consideration in the cremation of infants.

3.29 The Commission discussed the fact crematoria currently carry out infant cremations for free. It was suggested that if it were made clear overnight cremations were not permitted to take place then some cremation authorities may need to recover costs.

3.30 The Commission discussed the conversation hospital staff are required to have with parents regarding the potential burial and cremation options and the importance of ensuring that these options are fully discussed and understood.

3.31 It was noted that the draft report suggested a formal contract be in place between Health Boards, funeral directors and crematoria. It was acknowledged that the ICCM already provides some guidance on the terms that should be included in these contracts. The suggestion of a template for these contracts was welcomed, however it was also noted that some cremation authorities may be uncomfortable with this and fear a potential increase in the number of cremations they are asked to carry out.

3.32 Decision point - The qualifications of crematoria management staff was discussed. It was agreed that crematoria managers should hold a technician qualification, this was agreed as best practice but not mandatory. The Manager would be described as the individual with responsibility for the day to day running of the crematoria. It was also recognised that the ICCM offer a manager qualification which highlights the cremation process.

3.33 Decision point - It was agreed that the CMO guidance on the disposal of pregnancy loss up to and including 23 weeks and 6 days should remain as guidance and should not be made statutory. This was agreed as compliance had been achieved without legislation and to more easily allow for any amendments in the future.

3.34 It is noted that there is no current legal requirement for crematoria to be members of a trade body though this could be recommended for the future. It is noted that currently only 1 crematorium in Scotland, Friockheim in Angus, is neither a member of the FBCA nor a member of the ICCM.

3.35 The Commission discussed the recording of information and it was noted that in the case of shared cremation each non-viable baby is recorded individually.

3.36 The issue of unclaimed ashes was raised and discussed. It was noted that currently funeral directors are not able to return ashes to crematoria for dispersal without signature authorisation from the original applicant, this has caused issues where the original applicant cannot be contacted. It was acknowledged that the retention of ashes would be encompassed in the pending broad burial and cremations legislation.

3.37 Further training for crematoria staff to enable them to better explain ashes composition following cremation was proposed with the intention that this further knowledge would encourage a more educated, responsible and caring approach. However it was noted that parents should receive everything regardless of content.

4. Draft Commission Report / Meeting with Parents

4.1 Lord Bonomy noted his intention to complete the report by the end of May. He noted that comments would be sought from Commission members on the draft during the week of 12 May 2014 and asked that members devote as much time as possible to this.

5. Next Meeting

5.1 The next meeting was agreed for 22 May 2014 with the final meeting of the Commission on 28 May 2014.

Infant Cremation Commission
Minute of Meeting 7 - 22 May 2014

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
James Blackburn
Gareth Brown
Ian Kearns
Helena MacLaren
Ann McMurray
Dr Mini Mishra
Tim Morris (by telephone)
Rick Powell (by telephone)
Gavin Stevenson (by telephone)
Norman Dowie
Sarah Dillon (secretariat)
Alison Kerr (secretariat)

Apologies
Gillian Morton
Garrick Smyth

1. Welcome and Introductions

1.1 Lord Bonomy welcomed everyone to the meeting, and thanked them for finding the time to attend at such notice. He also advised that although originally scheduled as a one hour meeting, there were a number of matters to discuss and it was likely more time would be needed.

2. Issues for Discussion

2.1 The Commission discussed the 23 matters which had been circulated for views and comment. Key points discussed and / or agreed included the following.

2.2 It was agreed that: applications for the cremation of babies up to the age of 6 months would continue to be encompassed within the standard (but revised) Form A; that the definition of ashes should include reference to the fact that this excluded any metal; that parents' views would be sought on 'overnight' / residual heat cremation, given that this is the best means to recover ashes; that recommending individual cremations for all non-viable babies would not be advisable as it may result in Health Boards having to introduce charges for families where currently there were none; that there were no objections to a new Inspector of Crematoria, particularly as powers already existed for this under the 1935 Regulations; that electronic record keeping may be preferable to hard copy records; that although further legal opinion would be required, the wording of the Cremation Act 1902 in respect of a crematorium being a place for the burning of 'human remains' could possibly already encompass non-viable babies; and that the question of some form of memorial should be raised with parents.

2.3 It was discussed: that tighter or statutory regulation of the funeral industry might not be required if the proposed National Committee can achieve the same ends; whether and how to frame the message that ashes may not contain any elements of the child, depending on its stage of development and what other material eg a wooden coffin was included during the cremation; what extra training modules might be useful for crematoria staff; whether there was potential to allow parents extra time to make decisions and complete paperwork given the possible impact this may have on funeral timescales and the role of healthcare providers, other than the NHS, in Scotland.

3. Other Issues

3.1 Lord Bonomy provided some approximate timescales for completion of the Report, but that these may need to be re-considered depending on the views of the parents to whom he would be speaking next week.

3.2 Commission members were asked to continue sending any feedback on the draft Report sections.

4. Next Meeting

4.1 The next meeting date was re-confirmed as 28 May 2014 in Glasgow, circa 1.30pm.

Infant Cremation Commission
Minute of Meeting 8 - 28 May 2014

Attendees:
The Rt Hon Lord Bonomy (Chair)
John Birrell
James Blackburn
Gareth Brown
Ian Kearns
Helena MacLaren
Ann McMurray
Dr Mini Mishra
Gillian Morton
Tim Morris
Rick Powell
Garrick Smyth
Gavin Stevenson
Norman Dowie
Alison Kerr (secretariat)
Rebekah Carton (secretariat)

Apologies:
Sarah Dillon (secretariat)

1 Welcome and introductions.

1.1 Lord Bonomy welcomed the Commission members and noted that this was the last meeting of the Commission. Only significant changes, if there are any, will be circulated by email after today. Lord Bonomy thanked the group for their willing participation in the Commission's work and their speed of responses. He particularly thanked the secretariat, Alison Kerr and Sarah Dillon, for all their assistance.

1.2 Lord Bonomy noted that a positive meeting with the parents had preceded this meeting and also that he would be meeting with Minister the following day (29^th May) to update him on progress.

1.3 Lord Bonomy outlined the timetable following this meeting. He noted that work on finalising the main report text would continue over the next few days, followed by subsequent secretariat work to add in necessary references, endnotes and annexes. His intention was to then review and submit the completed Report to Ministers on or around 13 June, and expected that it would be published by Scottish Government sometime during the week beginning 16^th June.

2 Changes to the Report.

2.1 The Commission discussed the draft recommendations. Lord Bonomy noted that the order of these will be updated to reflect where they appear in the main Report narrative. A number of amendments were discussed including those noted below.

2.2 The group discussed the retention of the cremation register and whether it was more secure in its original form (ie. hard copy) or electronically. It was noted that the burial register is electronic and has been for some time. It was agreed that the working group who are looking at software could add this to their remit.

2.3 The group discussed the recommendation regarding an independent examiner visiting each crematoria to assess trainee technicians undertaking infant cremations as concerns were raised by some regarding the logistics of this. It was agreed that an alternative approach could be a training course in a centralised location. The recommendation will be revised to reflect this.

2.4 The group discussed whether crematoria should be licenced in general, noting that SEPA regulate the environmental impact but there is no regulation of general or ethical practice. This is the same for cemeteries. It was noted that this was possibly beyond the remit of the Commission, which has to confine itself to matters of baby and infant cremations, but that it could be mentioned within the Report as a possible issue for fuller consideration in due course.

2.5 The Commission discussed the need to ensure that bereaved parents are supported in reading through the cremation application forms and other such paperwork. To aid this, it was agreed that consistency of terminology was important. Clear and consistent definitions of terms should be part of the proposed code of practice and included in information for parents.

2.6 Some had noted that the figures around shared cremations in 2010, 2011 and 212 were overly complicated. It was agreed to revise these in order to present them more clearly.

2.7 The Commission revisited the question of whether each non-viable baby within a shared cremation should be registered separately (under its unique case reference id) in the proposed cremation register for these babies. The Commission agreed that this would have no adverse impact on the anonymity of the mother and was the more respectful and sensitive approach to take.

3 Issues emerging from the meetings with parents

3.1 Lord Bonomy set out the points raised by, and the suggestions received from, the parents who had attended the meetings on 26 and 28 May. He noted that the meetings had been helpful and informative for him, and he hoped the parents had found them equally useful.

3.2 Topics discussed included regulation of crematoria and funeral directors; bereavement training; greater transparency and access to information; an independent crematorium inspectorate; notification whether ashes were or were not recovered; how the application forms for cremation could be improved; the definition of ashes and what should be made available to bereaved parents; the ethics of 'overnight' cremation and shared cremation and also views on any local and/or national memorials.

3.3 Members considered and discussed the suggestions which had arisen from these topics, which resulted in several being agreed for inclusion within the Report's narrative and/or the Report's recommendations.

4 Other Issues

4.1 The Commission discussed and agreed minor edits to the executive summary.

4.2 The Commission discussed a section of additional wording tabled at the meeting regarding an Inspector of Crematoria and Funeral Directors. In the light of previous discussions on regulation, and also taking into account the views of parents, it was agreed that an additional recommendation should also be added regarding the appointment of an independent Inspector who could be accountable to Ministers.

4.3 Secretariat confirmed they would circulate the draft Minutes from Meeting 6 (9 May), Meeting 7 (22 May) and Meeting 8 (today 28 May) for approval prior to publishing on the Commission's webpages at the time of the Report's publication.

5 Close

5.1 Lord Bonomy thanked all Commission members again for their willingness over the past year in giving their time, advice and knowledge, as well as putting any professional differences aside, in order to produce a Report that will help ensure changes for the better in infant cremation practice in Scotland.