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

10 Dundee Crematorium

10.1 Introduction

A total of two cremations of infants or babies conducted at Dundee Crematorium were referred to the Investigation. The earlier of those cremations took place in 1975 and the more recent in 2009.

Dundee Crematorium was opened in 1936. It is situated on McAlpine Road, Dundee in a woodland setting. It has a chapel and is surrounded by Gardens of Remembrance. The Crematorium carried out 1,453 adult cremations in 2013. In the same year there was one child cremation, two cremations of stillborn babies and two individual cremations of non-viable foetuses. There are no shared cremations of non-viable foetuses cremated with other non-viable foetuses carried out at Dundee Crematorium. Any non-viable foetus cremated at Dundee is received from the Funeral Director who has a contract with the hospital. The crematorium does not have a contract for baby cremations with either the hospital or any Funeral Director.

The crematorium has a dedicated baby memorial area with private gardens, plaques and rose beds.

10.2 Management

Dundee Crematorium is managed by Dignity Funerals Ltd.

The Investigation was provided with a chart setting out the structure of the management team as of January 2006. At the head of the organisation was the Chief Executive, Mike McCollum and reporting to him, the Crematoria General Manager, Steve Gant. Immediately below him was the Regional Manager for Scotland and the North of England, David Baxter, the line manager to the Dundee Crematorium Manager, Geoff Dickerson. David Baxter told the Investigation he has been Regional Manager for 12 years, one of four Regional Managers who report to Steve Gant. Prior to taking up this role David Baxter was Area Manager. He started as a Cremator Operator at a different crematorium some 33 years previously.

The operational team consisted of one Cremator Operator, a Handyman who also works as a relief Cremator Operator, carrying out three or four cremations a week, and two office staff.

10.3 Policy, Guidance and Training

Witnesses interviewed for the Investigation were able to speak to policies and practices at Dundee Crematorium going back to the mid 1980s. Therefore, the Report focuses on practices from that time to the present day and cannot comment on working practices employed before then. One of the cases referred to the Investigation dates back to 1975 and there are no staff who can speak to this period from an operations perspective. Furthermore, cremation records are only kept for 15 years, in line with statutory requirements, meaning only limited records are available.

Crematorium staff explained that it has always been usual for there to be remains following infant cremations at Dundee Crematorium. Although they do not guarantee the return of ashes, the crematorium's policy is for the Cremator Operator to do his very best to recover remains from foetal or infant cremations whenever possible.

David Baxter, Dignity's Regional Manager for Scotland and the North of England, told the Investigation that his understanding was that with the older cremators it was harder to retrieve remains from non-viable foetus cremations. However, since new cremators were installed in the late 1990s, he understood the crematorium was able to obtain remains from the majority of non-viable foetuses. He also confirmed that in the 15 years he has been based in Dundee he has always understood that there would be remains for stillborn babies and infants. These remains would be disposed of in accordance with the instructions of the family, as communicated to the crematorium by the Funeral Director.

His understanding that there were always remains for stillborn babies and infants is not evident from samples of the Registers of Cremation for Dundee from 1975, 2008 and 2009 examined by the Investigation. These showed that the number of occasions when the crematorium did not return ashes from stillborn babies and infants was greater than the number when ashes were returned. Moreover, there were examples where the entry on the register specifically recorded there being 'no remains' for stillborn babies and infants.

According to the crematorium staff, they have always informed Funeral Directors that they should let the family know that ashes cannot be guaranteed, just in case there are none in a particular case. However, a local Funeral Director from Robert Samson Ltd who was interviewed by the Investigation disagreed. He told the Investigation,

"The understanding and what we were told, many years ago to be fair, was we should not ever expect any cremated remains from Dundee Crematorium."

David Baxter, Dignity's Regional Manager, told the Investigation that the crematorium did not pass this message to Funeral Directors.

Asked whether Dundee Crematorium has written guidance on cremation procedures a Cremator Operator told the Investigation there is a,

"general guide that we're to follow. That's a Code of Practice and that's just one page."

According to the other Cremator Operator there is guidance in the cremator room, especially about cremation temperatures.

David Baxter, Dignity's Regional Manager, told the Investigation that the crematorium has a specific written procedure for the cremation of non-viable foetuses as well as one for all other cremations. They follow also FBCA and ICCM guidance.

On the procedure for carrying out the cremation of babies or non-viable foetuses one of the Cremator Operators said,

"it's word of mouth really and it's just a case of picking the right profile."

The other Cremator Operator explained that a lot of the ashes come from the wooden coffin but that there are small bones to be found. Commenting from personal experience he told the Investigation,

"I've seen the small bones in the ash with the stillborns."

Asked what is returned to families one of the Cremator Operators said that regardless of the presence of visible skeletal remains,

"They get the whole lot. It's the same with adult cremation. They get whatever comes through the cremulator. ^[38] I was taught that when we do get ashes we put them in the wee urns."

This was confirmed by his colleague who said his understanding of ashes was all " the remains that come out the cremator."

10.4 Cremation Process and Equipment

Geoff Dickerson, who has been the Crematorium Manager at Dundee since December 2005, described his role as,

"Running the site and everything that goes on there and making sure everything in the office runs smoothly… also over in the chapel making sure the services run smoothly, that everything is fine; and the same with the cremating side of it… making sure that it is run smoothly and the cremator is working ... Really I oversee every person's job",

As well as being the manager, Geoff Dickerson is a Cremator Operator. He told the Investigation that he cremates at least once a week. As is common practice, Geoff Dickerson's cremation training was conducted in-house and resulted in his obtaining FBCA certification.

One of the two Cremator Operators, who is also FBCA qualified, said he received his certificate in 1994. Since then his only further training had been when there was a new machine, at which time the commissioning engineer would take Operators through " the basics". Describing his role, he told the Investigation,

"My job essentially is doing the cremation; getting the ashes back to the office; and then the office deals with getting them to the Funeral Director or to the family. Once I've left the ashes, and signed them in, I'm done with them unless they're coming back to me to be scattered in the grounds or something like that. So if the ashes are to be scattered then they either come back to me or the other Cremator Operator. We do both the cremation and the scattering."

The second Cremator Operator, who is also the crematorium's gardener and handyman, passed the FBCA test in May 2007. He too said he had received no further training other than updates on any procedural changes. His role involves taking over from his colleague when he goes home at night and taking his place when he's on holiday. He said he had some limited experience of cremating non-viable foetuses, " maybe half a dozen".

He explained that there has been a profile for a baby (infant mode) since 2013 that slows down the cremation process. The cremation is completed before the Cremator Operator leaves for the night and the tray is left in the cremator overnight to cool.

The Investigation was told that some boxes containing non-viable foetuses are only the size of a matchbox. Speaking of his experience cremating non-viable foetuses the full time Cremator Operator said,

"I have been in a situation where I've not managed to recover ashes from NVFs. It's hard to say how often that happens, I've done that many over the years. I'd say it depends on the size of them I think. When there's nothing left there is absolutely nothing left in the tray."

The crematorium staff were asked by the Investigation whether they had ever cremated more than one body at a time in the cremators at Dundee. Although it is lawful to cremate non-viable foetuses with other non-viable foetuses through shared cremation, this did not take place at Dundee and there was no contract with the NHS for cremation of non-viable foetuses. The Investigation was told that no non-viable foetus or baby had ever been cremated with an unrelated adult. The only shared cremation of which anyone was aware had been for a mother and her baby.

At Dundee, unlike in other crematoria visited by this Investigation, the Cremator Operators do not rotate duties and work in the chapel. Instead the chapel work is done by the Verger and one of the administrative officers is trained to be a relief Verger. Across Dignity-run crematoria there is uniformity of practice and policy in both the cremation and the administration so that staff can move around to other crematoria if required.

i Impact of Cremation Equipment

The Investigation explored the impact working practices and policies had on the services delivered at Dundee, particularly in relation to equipment including the use of baby trays.

Most of the cremations that take place at Dundee Crematorium are of adults and many of the features of an adult cremation are replicated during the course of a baby cremation ^[39] .

ii Cremators

At the time of the Investigation Dundee Crematorium was equipped with two Joule Furnace Construction single-ended gas-fired cremators with a spyhole through which Operators can see into the chamber. The cremators were installed in 1997 and 1998 respectively and replaced two single-ended Dowson and Mason models. David Baxter told the Investigation that although the current cremators are Furnace Construction, their operating system is software provided by Facultatieve and the cremators are to be replaced in the next two years by new Facultatieve cremators. Infant mode ^[40] would have been added in 2013 as part of the same upgrade for emissions reporting as elsewhere in Scotland.

The cremators were primarily designed for adult cremations with the coffin charged (inserted) at one end through a large door. After the cremation the ashes are raked into a cooling chamber. However, in relation to non-viable foetuses and babies,

"The infants and the NVFs are in a tray. They just come out in the tray so there is no risk of them going into the cooling chamber or into the ash pan."

iii Baby Trays ^[41]

A baby's small coffin, or box containing a non-viable foetus, may be placed on a steel tray inside the cremator to contain any ashes and prevent them being dispersed throughout the cremator by the force of the air jets and lost. At Dundee Crematorium baby trays have been in used for non-viable foetus and baby cremations since at least 1997. A tray is used for every infant cremation, unless the coffin is too large to fit inside it.

The use of a tray is not without risk if it is removed while still at a very high temperature through the charging door. Dr Clive Chamberlain, a Chartered Engineer, member of the Council of the Combustion Engineering Association and expert witness to the Mortonhall Investigation ^[42] identified the risks of using a tray. Describing its removal at the end of the cremation he explained,

"If this has to be done with the cremator at working temperature… this is more difficult and more risky than the usual raking operation into the 'ashing chamber' of the cremator."

At Dundee the risk is managed by conducting infant cremations at the end of the day's cremation schedule. The full time Cremator Operator described how he would cremate a non-viable foetus or stillborn baby,

"last thing at night. We've got a metal tray and you put the baby tray in the cremator. I did used to take the trays out but we were finding …. It was too dangerous because of where we are. We are in basement and it's all wood… it spits metal out as it's cooling down so we thought we leave it in the cremator as it is safer till the morning."

The Investigation was not informed of any operational difficulties in the use of the baby tray.

iv Dispersal of Ashes

At Dundee Crematorium the options for disposal of ashes are: scattering the ashes un-witnessed (without family present) in the Garden of Remembrance; scattering of the ashes witnessed (with the family present); allowing the ashes to be collected by a Funeral Director; or holding them indefinitely pending a decision.

The Cremator Operators explained to the Investigation that where there is an instruction to scatter with no family in attendance, they scatter the remains in the woodland area and don't record the exact location.

David Baxter, Dignity's Regional Manager, further explained that baby ashes are scattered at the baby memorial next to the woodland area and confirmed that the exact location is not recorded. This practice is the same whether or not the scattering is witnessed by family members. Explaining that the baby memorial has been in place for at least 20 years, David Baxter confirmed that a family may request a different location where, for example, they wish to use a location used previously by another family member. Where a family selects a specific area such as a family plot or plaque to scatter the ashes, that would be recorded.

One Cremator Operator said he had no experience of scattering a child's ashes because the families always want to collect them.

A member of the office staff also confirmed that the precise location is not recorded. She said that if families want to know where ashes were scattered in their absence,

"I can take them to the area but I can't take them to a certain spot because it's not marked."

The same administrator told the Investigation the list of ashes for scattering is always double checked to make sure instructions have not changed. She would also, where the ashes were those of an adult, phone the applicant to make sure the instructions are correct and inform the family when the Funeral Director has collected the ashes. She would not however make a phone call to the bereaved family if the cremation was that of a child or baby. This is because crematorium staff are not permitted by their management to contact bereaved families of children, including babies, for reasons of sensitivity.

10.5 Administration and Record Keeping

It is the role of the office staff to receive and process the forms required for a cremation to take place at Dundee Crematorium and to complete Form G, the Register of Cremations. Maintaining a Register is a statutory obligation involving the recording of the cremation number, date of cremation, date and place of birth, age and gender of the baby, applicant for cremation and disposal method/ final resting place. There is, however no statutory requirement to maintain a Register of non-viable foetus cremations.

From 1936 until 1996 all records were kept in manual Registers. This changed in 1996 with the introduction of the computerised Gower system. In 2002 the present Compass System was installed. This system permits the location of the dispersal of ashes to be recorded. The system is updated when ashes have been collected or dispersed.

Funeral bookings are made by Funeral Directors, or the hospital, directly with the office staff. The crematorium deals with all the local Funeral Directors as well as some from outside the area. Ninewells Hospital is the main hospital that Dundee Crematorium deals with for babies and non-viable foetuses. The crematorium has no formal contracts with any Funeral Director or hospital.

A member of the crematorium office staff, who has been in post for 12 years, told the Investigation she had received a variety of on-site training including updates on handling the paperwork. Usually Geoff Dickerson, the manager, would go on a training course and, on his return, he would go through this with the staff.

i Findings on Record Keeping

As with Mortonhall, the Investigation found Form A, the statutory Application for Cremation, to be the most significant of the cremation paperwork in informing all other records and as the basis for all arrangements made.

A Dundee Funeral Director from Robert Samson Ltd told the Investigation how he would complete the section on the back of Form A that sets out the Instructions for Ashes. This,

"would be done in conjunction with the parents either over the phone - they would have had to have signed both sides of it in the hospital - or in the office."

He would, he said, put 'N/A' because the instructions for ashes are 'not applicable'. He had always understood that Dundee did not return cremated remains from babies. He also said he had never encountered a situation where the crematorium had phoned to say they had remains and to ask what was to be done with them.

The Funeral Director's understanding that Dundee Crematorium did not obtain ashes from babies was contradicted by the Crematorium Manager, Geoff Dickerson. He considered the Funeral Director to be,

"one of those we would have said to, when the cremation was booked, that there's no guarantee but we'll do our best."

However, referring to the same firm, Geoff Dickerson told the Investigation,

"I know that between 2003-06 that Funeral Director had a contract with the hospital to deal with NVFs and brought them here, and according to the paperwork there were no remains ever given out to the Funeral Director. They always put on the Form A there was no remains between those dates for those NVFs, and that was for their contract with the hospitals. I couldn't tell you if there were actually ashes or not."

This suggests that while the crematorium staff maintained they were successful at retaining ashes, there appears to have been no policy of querying with Funeral Directors any ashes instructions that assumed there would not be ashes.

One of the Cremator Operators confirmed that in his experience there are occasions when ashes are not requested. He said,

"I was taught that when we do get ashes we put them in the wee urns. The paperwork tells me what's to happen to the ashes once they've been retrieved. But 9 times out of 10 anything like that gets delivered back to the family. You get the odd occasion that they don't ask for them. Some people just don't want to know. I'll get instructions to say disperse, scatter or return but 9 times out of 10 it's normally return."

An Administrator with responsibility for maintaining the crematorium records told the Investigation,

"when I'm adding the information from the Form A to the computer, if the Form A says to scatter then I always put down a message - there may not be any remains. I call the Funeral Director to advise that if this is for a child there may not be any and then if there wasn't I'd go back in and update the record. If the unfortunate position comes about that there are no ashes then I put down 'no remains' on the system. There is an option on it that says 'no remains' and I just go into there and put in a note that says I have spoken to [the Cremator Operator] and unfortunately in this case there weren't any remains for the baby.

Under no circumstances would our records show that ashes had been scattered in the Garden of Remembrance if in fact there were no ashes to scatter. This is because our records also show when we scattered; who scattered; what time they were scattered; what day they were scattered etc.

Until I know that we've got ashes from the child the instructions for the return of ashes is not completed. I can't guarantee that I'm going to have them so it's only completed when we've got ashes."

In common with crematoria in other parts of Scotland the entry 'no remains' does not appear in Dundee Crematorium's manual register. For example, the manual register dating from 1975 showed there were twenty-two infant cremations, of which nineteen were 'dispersed in garden' and three 'delivered to applicant' .

However, David Baxter's understanding (shared by other crematorium staff) that there had always been ashes from infants and stillborn babies was not evident from this Investigation's review of the computerised Register of Cremations. This revealed that in 2008 and 2009 there were nine infant cremations of which six were recorded as having 'no remains', two were 'collected' or 'removed by the Funeral Director' and one was 'scattered not witnessed'. Of those described as having 'no remains', only one cremation was specifically described as being a non-viable foetus. Of the other five, four were stillborn and a fifth, though not recorded as stillborn, was specifically referred to as being '40 weeks' gestation'.

The earlier of the two Dundee cases referred to the Investigation, from 1975, involved a baby girl who was stillborn at 40 weeks' gestation. The mother recalled,

"Nobody at the hospital talked to me at all about what would happen to her. [The baby's father] was told that she would be incinerated. Over the years I have never known where she was or had a place to go to remember her. I heard stories about stillborn babies being buried in corners of churchyards and wondered if she was there but I didn't know anything until three years ago.

When the story about baby ashes came out in the news, I contacted Dundee Crematorium to ask if they had any record of my daughter. They were able to find a copy of the Register of Cremations which showed she had been cremated there all those years ago without our knowledge.

Nobody from [Ninewells] Hospital or Dundee Crematorium ever told us what happened to our daughter. We were not informed of the date or location of the cremation and nobody contacted us afterwards about ashes."

According to the Register of Cremations, this baby's ashes were 'dispersed in the garden' at Dundee. There is also a Certificate for Burial of the Ashes, which incorrectly gives the father's name and not that of his daughter.

On discovering this information almost 40 years after the loss of her child the mother said,

"I cannot understand why we were not informed of this or offered these ashes. I am grateful to the crematorium for providing me with the Register of Cremations so now I know where she is and in the future I might go there."

The second Dundee case referred to the Investigation involved a baby who was stillborn in 2009 at about 27 weeks' gestation, the cremation took place in early 2010. The mother was told by the midwife at Ninewells Hospital,

"if you have a cremation with a stillborn you won't get any ashes back."

When she queried this with the Funeral Director referred to above, he agreed with the Midwife. Speaking of her experience the mother said,

"The midwives were really good with us. They spoke to me before I'd given birth, when I was in labour, about funerals, if it was going to be a cremation, if it was going to be burial. That was the midwives that done that."

Asked about the circumstances in which the discussion took place, the mother thought she was fit enough to respond. However, she could not remember signing the Form A even though,

"I signed it on the day I gave birth and it was the hospital that gave me the form not the Undertaker."

In the Instructions for Ashes section, 'N/A' had been recorded. Commenting on this page the mother said it,

"doesn't look like my signature on the second page and I can't remember signing this."

When the news of Mortonhall came to light the mother phoned Dundee Crematorium in case there had been ashes from her baby's cremation. She was told,

"yes, we've got the ashes and they're scattered."

The entry on the Register of Cremations was 'scatter (not witnessed) ' and a date. This was not an outcome to which the mother had agreed.

Dundee Crematorium has suggested that the instruction for the ashes to be scattered came from the Funeral Director. The Funeral Director doubted this suggestion. He told the Investigation,

"If such a phone call had been made [requesting instructions for the ashes] or such contacts have been made from the crematorium, my first port of call would have been to the parents to say, 'unbeknown to me there are cremated remains. What would you like done with them?'."

David Baxter, Dignity's Regional Manager, declined to comment because there has been a legal agreement between Dignity and the mother and both parties have signed a confidentiality agreement. The absence of a continuous audit trail in this case means it is not possible for the Investigation to determine who was responsible for the instruction to scatter this baby's ashes.

10.6 Communication

In the Dundee case referred to immediately above, the mother was told by both NHS staff and the Funeral Director that Dundee Crematorium would not return ashes from a baby.

The Funeral Director from Robert Samson Ltd was adamant that at some time his firm was told,

"we should not ever expect any cremated remains from Dundee Crematorium."

Nor, according to him, had this message ever been withdrawn or updated.

"I have never been officially or unofficially told to ever expect cremated remains…Nobody's ever come back to me when filling in a cremation form for a baby and said you might get cremated remains."

As a result, until recently, this Funeral Director considered it his duty to tell families that in respect of babies cremated at Dundee there were no remains. Nor was he aware that elsewhere some crematoria did obtain remains.

He described communication with the crematorium as " not great." This is supported by the Investigation's finding that the information given to the parents by Midwives and Funeral Directors was at odds with the crematorium staff's account of the availability of ashes. There is no obvious explanation for this.

Contact between the crematorium staff and outside agencies was limited. Neither the Crematorium Manager nor the Cremator Operators had much if any contact with NHS staff. One of the Cremator Operators said of Health professionals,

"They come here sometimes for educational purposes, you get a doctor. It just gives them a wee insight into what actually goes on at a crematorium."

The Crematorium Manager was surprised at the inaccurate information that had come from a hospital and Funeral Director. On learning, in the specific case referred to that,

"the hospital had said that Dundee Crematorium does not supply ashes, I said that I find that very hard to believe when we have never had any contact with them. I have never spoken to the hospital and said that there are never any remains or anything and I was a bit amazed that they had said that. I don't know where they got their information from but it was not from us."

Nor did the Crematorium Manager,

"actually know what [Funeral Directors] say to families about ashes."

He had, he said, explained to Funeral Directors if they had phoned the crematorium that whether there are ashes depends on the cremator but that they would do their best to recover ashes. He was certain that when Funeral Directors book cremations they are always reminded that there might not be any ashes and they need to let the family know that.

In relation to communication with other crematoria, it seems that some contact took place. The Manager, Geoff Dickerson, helped out at another crematorium (Moray) and the Administrator sometimes provided cover at other Dignity managed crematoria. They included Holytown, Moray and Holmsford Bridge.

Contact between the crematorium and the families of non-viable foetuses, stillborn babies and infants prior to the cremation was very limited and did not tend to involve any discussion about ashes. After the cremation it would be a matter for the families whether they made contact.

10.7 Impact of Mortonhall Investigation and the Infant Cremation Commission

The Cremator Operators did not give the impression that they had been briefed on the evidence of Dr Julie Roberts, Forensic Anthropologist and expert witness to this and the Mortonhall Investigation ^[43] who identified that skeletal elements are recognisable " from as early as 17 weeks' gestation".

10.8 Conclusions

1. The Cremator Operators told the Investigation that very few non-viable foetuses or babies are cremated at Dundee Crematorium. This was confirmed by the figures quoted at the start of this section which show that in 2013 only two stillborn babies and two non-viable foetuses were cremated. When cremating babies and non-viable foetuses the policy of the crematorium was to give back to families everything that came out of the cremator. No distinction was made between any ash from the coffin and skeletal remains. Unlike some other crematoria in Scotland there was no suggestion that the FBCA Guidance, which distinguished between skeletal remains and other ashes, influenced the crematorium's policy.

2. The Investigation revealed an absence of meaningful communication between the crematorium, hospital staff and Funeral Directors about the availability of ashes for non-viable foetuses, stillborn babies and infants cremated at Dundee Crematorium. Given that the hospital and Funeral Directors were advising families that ashes would not be available at Dundee many parents may have failed to request ashes based on this misinformation. There is a clear need for vastly improved communication among these three agencies and for clear protocols to prevent such misunderstanding in the future.

3. Only two cases were referred to the Investigation from Dundee Crematorium and one of those dated back to 1975, making it difficult to investigate fully due to the passage of time and the absence of witnesses who could speak with any authority on the practices then. The records suggest there were ashes from the earlier cremation which were dispersed in the Garden of Remembrance.

4. The later case is comparatively recent, referring to a cremation in 2010. In this case the Investigation was struck by the conflicting information emanating from the crematorium, Funeral Director and NHS staff in relation to the availability of ashes. For a parent to discover that there were ashes and that they were scattered or interred in the crematorium grounds without her knowledge or consent has caused deep distress.

5. An examination of Dundee's Register of Cremations entries revealed that the return of ashes following cremation did not happen to the extent that staff suggested. Despite a tray being used for the cremation of non-viable foetuses, stillborn babies and infants the register entry 'no remains' was not uncommon. One possible explanation for this is a failure to control the cremator so as to maximise ashes retention. As Dr Julie Roberts, Forensic Anthropologist and Archaeologist explained,

"My previous report prepared for Dame Elish provided evidence that the skeletal remains of foetuses as young as 17 weeks can and do survive the cremation process (City of Edinburgh Council, 2014). Taking that into consideration alongside the data presented in this report, it is inconceivable that there would be nothing left of new born babies and infants aged up to two years following cremation. The "no ashes" or "no remains" policies at the Crematoria of concern must therefore be related to issues surrounding recovery processes, the ability to recognise burnt skeletal remains, and / or individual or corporate management decisions."

6. Since June 2015, all crematoria in Scotland have been obliged to report any incidence of failure to recover ashes from an infant or non-viable foetus to the Inspector of Crematoria. No such incidence has been reported from Dundee or any other crematorium in Scotland.