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

11 Dunfermline Crematorium

11.1 Introduction

A total of five cremations of infants or babies conducted at Dunfermline Crematorium were referred to the Investigation. The earliest of those cremations was 1973 and the most recent in 1989. None of these families had ashes returned to them following cremation of their baby.

Dunfermline Crematorium was opened in 1973. It is one of two crematoria managed by Fife Council. The Crematorium is set within mature woodland. A large chapel of modern design has views over the woodland grounds. In addition to the Gardens of Remembrance there are commemorative granite walls. An area of the gardens is provided for the scattering of ashes for babies. There is a large memorial provided in the baby area in conjunction with the charity Sands and a separate wall plaque in the baby area of the gardens. While the adult areas of the garden are divided into discrete sections the baby area is not. There is a Baby Book of Remembrance.

Generally, cremated remains can be either collected by next of kin or Funeral Directors on their behalf or they are scattered at the wall in the baby area in the Garden of Remembrance. They are scattered one month after the cremation takes place. The crematorium has a relatively small number of infant, stillborn and non-viable foetus cremations. One infant, two stillborn babies and seventeen non-viable foetuses were cremated at Dunfermline Crematorium in 2013.

Two other Crematoria are situated in the area; Kirkcaldy Crematorium which is also managed by Fife Council and Perth Crematorium which is managed by Perth and Kinross Council. Perth Crematorium is situated approximately 28 miles from Dunfermline.

Dunfermline Crematorium is equipped with two Evans Footnote Universal 300/2 double-ended, gas-fired cremators. The Evans Universal cremators were installed in 1998.

11.2 Management

i Structure

Since 2010 Dunfermline Crematorium has been part of Fife Council's Directorate of Communities. The Director of Communities manages a Head of Service. A Bereavement Services Manager reports to the Head of Service.

The post of Bereavement Services Manager has overall responsibility for management of the administration and operation of all the crematoria and cemeteries in Fife, Kirkcaldy and Dunfermline. A Bereavement Services Officer reported to the Bereavement Services Manager. That role had been supported by a Support and Development Officer since 2011. The Bereavement Services Officer left in 2015 and has not been replaced.

ii Approach

Senior management receive information through Service Plans or stand-alone reports which are compiled by Heads of Service. The Chief Executive of Fife Council, Steve Grimmond, told the Investigation,

"In the pre-Mortonhall Inquiry period I had no specific information around the kind of technical operation of the crematoria and nor would I have sought that."

The Head of Service, Grant Ward, said,

"My contact with the crematoria has largely been through Liz (Murphy) (Bereavement Services Manager), so I wouldn't profess to have an intimate detailed technical knowledge of the crematoria or their operation.

It's obviously become an area of much greater focus for us but I wouldn't want to profess that it was a sort of hands-on day to day involvement. I've got a range of responsibilities and I very much rely on Liz and I have every confidence in Liz"

Liz Murphy is Bereavement Services Manager and has direct responsibility for the running of Dunfermline and Kirkcaldy crematoria. She said,

"My job is at a strategic level. It's ensuring the day to day operation and helping and developing processes. It's my job to make sure the processes are in place and staff know what they are doing as far as day to day administration and that they have the training to do the job. I also oversee the maintenance of cemeteries. I deal with any issues that arise within overall administration in the work we do - the cemeteries and the crematoria and also the strategic side of identifying our capacities in the cemeteries and looking forward - what do we need and ensuring everything's running smoothly"

Until 2015, she was assisted in this role by a Bereavement Services Officer, William Greig, who was based mainly at Dunfermline.

When asked why issues in relation to ashes were not raised with management, one Cremator Operator said,

"It was not that type of management."

11.3 Response to Mortonhall Investigation and Infant Cremation Commission

On 1 May 2013 after the issues at Mortonhall Crematorium came to light, a Briefing Note was produced by Liz Murphy, Bereavement Services Manager, for senior management and elected members. The note set out the Council's procedures for dealing with the cremation of babies. It stated that,

"Any ashes present after a cremation will always be offered back to a family via the Funeral Director...If cremation is chosen instead of burial, bereaved families are advised that more often than not there will be no ashes/cremated remains left for return. This reflects the national guidance via the Federation of Burial and Cremation Authorities ( FBCA ^[44] )"

This is contradicted by a Cremator Operator who told the Investigation that there were ashes but they were not wanted by Funeral Directors. The Briefing Note goes on to say,

"The Bereavement Services Manager is also actively involved in discussion at a national level with both local authority and private crematoria Operators via the FBCA. Establishing a common policy/approach to the issue of baby ashes is a key area of focus."

Despite this position there was no recognition that other crematoria were returning remains with the use of a baby tray ^[45] . Fife Council's former Bereavement Services Officer, William Greig, who now works at Perth Crematorium, approximately 28 miles away informed the Investigation,

"In Perth...they've always used a tray there"

The Chief Executive told the Investigation that after the Briefing Note was received,

"From recollection there was no internal audit undertaken at the time. Effectively we acted in response to the information that was emerging. We immediately took action to amend the practice. One of those amendments was by the use of a tray (baby tray)."

At the time of the briefing the baby tray had been taken out of circulation and was not re-introduced until May 2014.

11.4 Policy, Guidance and Training

i Written Policy

Cremator Operators said that there was very little other than the Operators' manuals produced by manufacturers and the FBCA Code of Cremation Practice committed to writing. One Cremator Operator said,

"We have a Facultatieve Operator's manual. We don't refer to it much because we are just doing them on a regular basis."

After media coverage of the issues at Mortonhall Crematorium flow charts documenting the processes at the crematorium were produced. John Swan, Corporate Development Lead Officer told the Investigation,

"I was asked to go to a meeting I remember a few years back and discuss the issues at Mortonhall and the babies' ashes. I produced various flowcharts based on what the staff should be doing and since the guys on the ground are the technicians and the managers are in charge my role was co-ordinating it more than anything else and then I think we got a few various issues."

He also referred to older written procedures,

"The old written procedures probably don't even exist anymore as documents are kept for five years and we have had the flow charts for a bit more than five years."

The Flowcharts shown to the Investigation that were issued in March 2010 do not set out any specific steps for non-viable foetus, stillborn or infant cremations. A draft flowchart for Baby Cremations was provided dated December 2014 which shows the use of a baby tray.

Liz Murphy, Bereavement Services Manager, referred to a folder of FBCA training notes. ^[46] However, she confirmed,

"There are not specifically local instructions on the cremation process. It's not written down to the level of detail of how each individual does the cremation."

A Cremator Operator told the Investigation,

"There was stuff in the Operator's manual about cremating infants. Cremating infants you take care always - at that time we were actually using a metal tray. Everything was put on a metal tray, if we got instructions to return ashes."

He provided the Investigation with an extract from a Facultatieve manual which stated,

"Where Infants are to be cremated a special purpose Infant Tray should be used and is available from Facultatieve Technologies Ltd."

Facultatieve advised the Investigation that this recommendation has been in their manual since 1987.

The BSI (the British Standards Institution) carries out annual assessments of Dunfermline to determine the effectiveness of its quality management system. The assessments provided to the Investigation did not raise any issue in relation to infant or non-viable foetus cremations until the November 2014 assessment which stated,

"The recent improvements to the system regarding cremation of babies was explained and a clear understanding of this was demonstrated by the cremator operatives."

The Bereavement Services Manager has confirmed that there is no further reference to infant cremation in any other BSI Assessment Reports.

A report by the FBCA dated 6 November 2012 after an inspection visit does not mention infant cremations or baby trays. That was at a time when there was no baby tray in use in Dunfermline. John Swan, Corporate Development Lead Officer, confirmed that a flowchart was drawn up for the process of using the baby tray purchased in December 2012 after it was reintroduced in May 2014 having been removed from use in April 2013 following health and safety concerns.

ii Training

One Cremator Operator at Dunfermline had been trained in Linn Crematorium in Glasgow. He had obtained a Scotvec (Scottish Vocational) certificate. He also took the FBCA examination. Another Cremator Operator had been trained by a Cremator Operator who worked and carried out training at Kirkcaldy. There was no specific training for cremation of infants, stillborn babies or non-viable foetuses.

When the machines were installed in 1998 Facultatieve provided a five day training course. A Cremator Operator said,

"When the new machines were installed we got training on their use from Facultatieve. It was a 5 days' course when the boys were installing the machines. It's the full intensive course where they train you on the air burners and everything on the machine you have to know. They show you how to do the cremations, raking out and the process, computer, the whole process... The Facultatieve training did not cover things like different types of cremation. The only cremations you got was the 'standard', 'cancerous' and 'large'. We never got trained on babies or anything like that."

He went on to say,

"We didn't have to do any further training to keep our certificates up to date."

The Cremator Operators confirmed that they had, unusually, visited other crematoria at Perth, Seafield and Warriston but that these visits did not involve consideration of infant cremations. Seafield and Warriston obtain and have always obtained ashes for infants, stillborn babies and non-viable foetuses. The Investigation was advised that Perth Crematorium used a baby tray and retrieved ashes also.

11.5 Cremation Equipment

i Equipment

The two Evans Universal 300 cremators used in Dunfermline Crematorium were upgraded in 2010 with mercury abatement software and then with software designed to improve monitoring and reporting of emissions in 2013. This upgrade also provided a new programme called infant mode. Facultatieve described infant mode as:

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

Prior to the Evans Universal 300 cremators in 1998, Dunfermline Crematorium had 2 double-ended Dowson and Mason Cremators with honeycomb hearths.

A baby tray was first introduced in 1991. In response to the questionnaire issued by the Investigation Dunfermline Crematorium stated,

"The tray was first introduced by the crematorium manager in 1991 to be used at the request of families where ashes were to be returned."

The tray was used up to the mid 2000s when it was sent to Kirkcaldy Crematorium, from where it was never returned. A new tray was purchased in December 2012 but was withdrawn from use in April 2013 following health and safety concerns and re-introduced in May 2014 following the development of a Risk Assessment.

One Cremator Operator told the Investigation,

"We always used to have a tray at Dunfermline and it was taken away from us. When I started full time there was a baby tray (1991). We did not have infant mode back then. There was no air modes or anything like that - you put the flame on, put the baby in and left it - that was it. There was always some remains because the temperatures and the air force wasn't as hard as it is now."

The date when the original baby tray was removed is subject to some disagreement. The information in response to the questionnaire issued by the Investigation states that it was removed in 2005. The Cremator Operators indicate that it was in 2008. A Cremator Operator advised that they continued to use the tray for a period after they had been advised by management to stop.

A Cremator Operator said that when he started in 2003,

"I think we had a tray and we had it up until I think it was 2008/9 and then our tray was taken to Kirkcaldy for some reason. They were needing a tray so they took our one and we kept asking for the tray back because although we don't do a lot of babies it was something we needed here."

ii Cremation Process

Non-viable foetuses were described as being cremated individually. These babies were brought to the crematorium by Funeral Directors.

When Dunfermline Crematorium opened in 1973 ashes were not returned to next of kin for non-viable foetuses, stillborn babies or very young babies. It is notable however that one of the cases referred to the Investigation is dated 1973 and the register records the ashes as having been dispersed. A Cremator Operator spoke of the original twin flux cremators and said,

"At the very start it was, unless the baby was a year old say, full term, you didn't give ashes back, that was the rules. In the early days we wouldn't use a tray unless the baby was full term. NVFs were just cremated on the hearth. In those days it was a honeycombed hearth and you just put the baby in, cremated it and when you came back in the morning there was nothing there, because if it there was anything there it'd fall through to the secondary chamber."

Cremator Operators believed that until the machines were replaced in 1998 ashes were not expected and therefore staff did not look for them. The Cremator Operator confirmed,

"In those days with NVFs, you would not check for any ash or any remains because you did not expect there to be any. That all changed when the new machines came in around 1997/98 because of flat hearths."

When the machines were replaced ashes were not retrieved unless a tray was used. It became clear to the Investigation that although a tray was available it was only used where there was a specific instruction from the Funeral Directors to retrieve ashes. A Cremator Operator said,

"Even with the new machines (1998) though, you did not get remains because you didn't have infant mode. If you put on say standard mode it'd hit in at say 45% air and the air can go right up and it is quite a powerful draught that comes through."

However, information from the cremator manufacturer anticipated manual override of the system by experienced Operators. According to a report provided by Facultatieve Technologies Ltd to the Investigation,

"Time savings can be made by careful and thoughtful manual intervention by an experienced Operator, using knowledge and experience to judge the best performance characteristics. Time can be saved by finishing off the cremation in manual… Other circumstances may occur where the Operator may wish to intervene and perform the cremation with the controls in manual mode… the Operator is able to directly control the combustion air and burner levels, only the draught control and secondary care will usually remain in automatic mode… The Operator is able to switch between automatic and manual control at any stage in the cremation; thus total control over the full range of different cremation characteristics can be achieved."

Such manual intervention was found to be very successful over many years at Seafield and Warriston crematoria, whose Superintendent Jane Darby described the technique to the Mortonhall Investigation.

Dr Clive Chamberlain, a Chartered Engineer, member of the Council of the Combustion Engineering Association and expert witness to the Mortonhall Investigation ^[47] explained in his evidence why manual intervention in the cremation process is beneficial saying,

"the usual conditions for cremation of adults is not suitable for infant cremations, and it is a matter of establishing whether there can be suitable conditions created… the essential characteristic of infant cremation must be a gentle process."

A Cremator Operator also said,

" NVFs were done last thing at night. When we check the hearth first thing in the morning there might be just a bit of ash lying as if you've burnt paper or something like that - nothing skeletal. You would see something. If there was anything in it we'd rake it out as a normal human being as normal into the ash cool. If there was anything, put it in the cremulator ^[48] and just disperse it because in that day we'd disperse it the next day, the following day after cremation. We'd never return it to the Undertaker. You were just not expected to return anything then. We might use the tray for stillbirths if requested."

It is difficult to understand how a parent would know to request the use of the tray if this information was not given to them by Funeral Directors or the hospital staff. A Cremator Operator explained that,

"If the family were adamant they wanted ashes back the Undertakers they'd come and say, 'look will you try and get ashes back for this nice family'. We would try but could not guarantee because at that time, we didn't have infant mode. If the Undertaker didn't come and say, 'we're needing ashes' then there was no ashes. If the Undertaker said nothing at all and just said 'it's a cremation, there's been no request for ashes' the baby would go onto the hearth. If there was something there it would be raked out depending on what it is. There's very, very little and by the time you rake it out it disperses itself anyway as you rake it out. If there's anything that goes into the ash can (where ashes cool) it'll go through maybe the cremulator and then just dispersed, there's hardly anything. If we did find something it would get dispersed. We wouldn't go back to the Undertaker in those days and say 'we've got something'."

The Investigation was given the impression that Funeral Directors made more effort for some families than others. This Cremator Operator explained that the same approach was adopted for babies,

"If they want ashes back we got the ashes back...This is if ashes were requested but 9 times out of 10 the Undertakers didn't want you to return anything. They didn't want us to return ashes because it's a service they provide for free that they don't want to do."

The Investigation put this assertion to the Director of Crosbie Matthew, Sheila Matthew, who said,

"I suppose it does give Funeral Directors a bit more work but we've not changed the pricing as a result of it. How we price for all the baby work is really to cover our costs and yes maybe it's another couple of phone calls but we're up and down to the crematorium anyway so it's not really that much more added. We're going there. It's maybe more significant for an Undertaker who isn't going up as often. So no it really hasn't made any difference in terms of the costing. It's more just a case of making sure that you've got it right and that all the paperwork's in place and making sure that it's all tracked through."

The Cremator Operator said the attitude of the Funeral Directors was,

"Bringing baby through, no ashes, family not interested and that was it. They would put on the forms no ashes no remains."

The Cremator Operator described a culture where trying to obtain ashes for infants, stillborns and non-viable foetuses was the exception. While this in some way may have been underwritten by a belief that there were no ashes, the illogicality of it was borne out by the fact that when required and the tray was used ashes could be obtained,

"I've always got ashes from an infant using the tray. It might be coffin ash but it is something."

However, the Cremator Operators thought they were instructed by Funeral Directors not to obtain ashes,

"We got no remains because that's what we've been told there will be no remains. If you were told there would be no remains but there actually was something you would not return it. 'No remains' was an instruction"

When this was put to Sheila Matthew of Crosbie Matthew she responded,

"The background is that we were informed by Fife Council crematoria that there would be no remains. All our procedures were based on this assumption. If the Form A said 'No Remains' - I think this would mean that the family had understood that there would be no remains based on the information given to us and explained to them...If the form was completed incorrectly, then I'm sure that the crematorium office would have followed this up for clarification. We do not issue instructions to the crematorium as to how to perform their job. We deal with cremated remains all the time, by passing them onto the family or carrying out their wishes, it is an integral part of our job. If there were remains, then...are there records as to what happened to these alleged remains? Surely the crematorium would have to act according to their own regulations should this have happened. More recently, since the crematorium have changed their procedure and told us that they can obtain cremated remains, we ask every family at least twice for their instructions, just in case they have changed their minds, especially if their original written instruction was to disperse at the crematorium. We double check that this is still the case before it is carried out."

William Greig, Bereavement Services Officer, told the Investigation,

"We did not speak to those parents about whether there was or wasn't going to be ashes because they seemed to be under the impression from the Funeral Director that there wouldn't be any remains particularly foetuses at the time and I think the Funeral Directors were actually saying to the family there wouldn't be any remains. We just raked out whatever was in there and put that out in the gardens."

The decision about what would happen to remains was at that time taken at the crematorium without any consultation with the families. The Cremator Operator said,

"The form's got 'no remains' so if there was any remains you went 'oh alright they don't want them' and dispersed them because sometimes you thought it'd be better for the family not to have remains . They weren't given the choice. There isn't any way of working out what cases there were remains but we've actually put in 'no remains' because that was the practice."

The Cremator Operator indicated that he was not happy with that approach,

"I would have been much happier saying, 'there's ashes, what do the family want?' But you have to remember then the Undertakers have to drive through here, pick the ashes up, take them back to the family that they've told there'll be no ashes. When we got remains but the Undertaker did not want them, we dispersed them but in the records we put 'No remains'. This means there were remains that were dispersed but the record would tend to suggest there weren't any remains and I feel bad but that was the practice."

When the tray had been removed from Dunfermline crematorium ashes were not recovered. It is clear that the tray was removed from Dunfermline and taken to Kirkcaldy and never returned.

"They took the original tray off us 2008, 2009 maybe. We were without a tray for four or five years. They took the tray to Kirkcaldy, I asked for it back but they said they'd lost it. So without a tray you're just cremating NVFs, stillborns and infants on the hearth. As for remains if it's not in the tray, when the airs come on it scatters everything round about."

The tray in Dunfermline was seen as a tool that allowed retrieval of ashes in some cases but was not used unless ashes were specifically requested. After the removal of the tray the Cremator Operator said,

"We were quite upset here when they took our tray away. We had a perfectly good system before they took our tray away that allowed you to get remains maybe not always but often."

Without the tray the prospect of getting ashes was reduced at Dunfermline unless they adopted manual intervention to carefully control the temperatures and air flow as was done in a number of other crematoria. Another Cremator Operator said,

"Cremating in that way (no tray) we got remains on very few occasions. I think there was maybe a couple of occasions where I can remember and one lady she had actually insisted that she got a proper size baby casket and we got some ashes. With a casket you have a better chance but with a cardboard box and no tray, no."

The likelihood of obtaining ashes was further reduced by the cremulation process used. ^[49] A Cremator Operator acknowledged,

"I always raked whether I saw something or not in the hope I might get something. I went through the process but putting baby ashes into the cremulator as we once did meant there wasn't any remains at the end that you could visibly see...In the time before infant mode and without a tray whatever I recovered went into the cremulator."

The inability to retrieve ashes when not using a baby tray affected non-viable foetuses to a greater extent than stillborn babies or infants. A Cremator Operator told the Investigation,

"While I might not get remains from an NVF then I pretty much always got something from a stillborn. With infants who have breathed, without a tray I would say I got ashes most of the time."

Facultatieve state that,

"Facultatieve Technology guidance manual has been giving advice on how to cremate infants since the 1990s if not before and recommends the use of a tray and not using the main burner, well before the notion of infant mode"

iii Baby Trays ^[50]

The original tray which was used when Cremator Operators considered they were instructed to retrieve ashes by Funeral Directors was sent to Kirkcaldy on a date between 2005 and 2009. From then until 2012 there was no tray. William Greig who was Bereavement Services Officer for Kirkcaldy and Dunfermline said of the tray,

"I remember it being left at Kirkcaldy. That was the last we seen of it. We actually tried to get it back to Dunfermline and to be fair all of the staff were advocating the use of the trays in 2006."

The Bereavement Services Officer, William Greig, purchased a tray in December 2012 which was put into immediate use. However a meeting took place on 13 February 2013 which was attended by Kirkcaldy Cremator Operators, the Bereavement Services Officer, a Health and Safety Officer, a Quality Control officer and others. It was decided at the meeting that the baby tray was very unsafe, despite the guidance and advice on its use in the Facultatieve operating manual and it was agreed that it was not to be used at Dunfermline and Kirkcaldy until further notice.

However, the Bereavement Services Officer confirmed to the Investigation "No-one ever got hurt by a tray."

There is an entry on the minutes of the meeting on 13 February 2013 attributed to the Bereavement Services Officer, William Greig, which states,

"Advised that if recent media issue had not arisen we would have continued advising that there were no remains for anything, however now this would need to be tightened up."

He is also attributed as saying,

"Concerned that where we had been stating no remains that we would be open to criticism if we now started having remains."

There was discussion about obtaining a bespoke tray and everyone agreed that the way forward would be to purchase a baby cremator. The costs of this were to be investigated. No further notes or minutes have been supplied in relation to this.

Risk registers provided to the Investigation do not refer to the baby tray until May 2014 when the risk of injury to Cremator Operators from use of the baby tray is noted. However it is worth noting that personal protection equipment had always been available at the crematorium. Thomas Graham, Support and Development Officer, told the Investigation,

"They had PPE before they were using baby trays - you've still got to wear PPE when you open the chamber door for the heat that comes out."

iv Definition of Remains

None of the Cremator Operators had a defined age under which they understood ashes were not available.

William Greig, former Bereavement Services Officer, explained that what was seen as ash and not remains was dispersed without the knowledge of the family,

"I think in the cremation register that it says dispersed and then (No family) in the most occasions. It was dispersed without family - probably without the family being aware that it was taking place - it was recovered and it was dispersed in the gardens. I think they had been told that there would be no recovery of remains. I think they had been told that and just because of the guy's nature who in these positions, if there was anything there whether it was cardboard or bits of remains of teddy bears or whatever, they thought it right to be dispersed in the garden."

This was also what was explained to the NHS staff who attended study days at the crematorium after the issues at Mortonhall Crematorium came to light.

In all of the media coverage the Council's position was that where a baby had died the crematorium staff would do their best to meet the wishes of parents. The likelihood of obtaining ashes described by the Cremator Operators is at variance with this media line. A media statement on 10 January 2013 stated,

"However in line with national guidance, we advise parents that on most occasions with a cremation of this nature (infant cremation) there won't be any remains because a skeleton isn't formed until late in a baby's development. It's obviously a really distressing time for parents but we give them this information because we want them to know what to expect."

In an article entitled 'We take the best possible care of your baby' printed in the press on 29 May 2014 Liz Murphy, Bereavement Services Manager is quoted as saying,

"We will explain the various options which are open to them in such circumstances from leaving it to ourselves to scatter any ashes in our special Garden of Remembrance at Kirkcaldy Crematorium to having a small private ceremony here or a full service if that is what they wish."

This is in contrast to the information given to the Investigation that arrangements were made through the hospital or Funeral Directors.

This article came out after the publication, and in apparent ignorance of, the Mortonhall Investigation Report which confirmed the physiology of baby bones and the ability to obtain remains from foetuses as early as 17 weeks' gestation. The Council insisted in the article that in the majority of cases, no cremated remains are obtained from an early stage foetus as they claimed remains are essentially soft tissue.

Liz Murphy, Bereavement Services Manager, told the Investigation,

"The advice that we always got was that there wouldn't always be ashes in every case because of the nature of the development of a baby. I have a letter from Duncan McCallum from the Federation ( FBCA) from 2007 I think it was."

In fact, the letter is dated 17 December 2008 and states,

"In cases where bereaved parents desire the cremation of an infant or of foetal remains, they should be warned that there are occasions when no tangible remains are left after the cremation process has been completed. This is due to the cartilaginous nature of the bone structure. If the warning is not given the parents may have been denied the choice of an earth burial and thereby subjected to understandable distress."

However, under the heading 'Cremation of Infants and Foetal Remains', it also states,

"Cremation trays should be used when cremating stillborn or infants in order to establish if any 'tangible' remains exist after cremation."

Duncan McCallum declined to make any comment on the contents of this letter.

The FBCA carry out periodic audit visits to their member crematoria. A report of such a visit dated 1 August 2007 makes no mention of infant cremations or trays. The covering letter to that report confirms that,

"The Federation provides for all its Members a comprehensive Technical Advisory Service which is based on experience and knowledge accumulated over many years on all matters relating to the cremation service."

Liz Murphy confirmed that the subject of ashes never came up at FBCA or ICCM ^[51] meetings prior to the issues arising about Mortonhall.

Liz Murphy said of the issue of ashes,

"It was a grey area and that was the general thinking throughout from those guiding voices. It was also the medical profession to be fair. Even the discussions we had at meetings everybody was of the belief that a full term baby didn't have properly developed bones and that was an issue, perhaps a reason why sometimes there were remains and sometimes there weren't. Another issue, which I know is something that has come out through reports, was people's sufficient understanding of what cremated remains were. I suppose ours was that we were looking for skeletal remains rather than everything that was left after cremation."

She goes on to say,

"We would look for them - if there was something there we would definitely give something back."

This position is clearly contradicted by the Cremator Operators at both Dunfermline and Kirkcaldy crematoria.

Thomas Graham, Support and Development Officer, told the Investigation that Cremator Operators are quite concerned that what is left after cremation is coffin ash. Despite the publication of the Mortonhall Investigation Report and the Infant Cremation Commission Report ^[52] , staff members had clearly not been briefed on the findings of the Forensic Anthropologist and witness to this and the Mortonhall Investigation, Dr Julie Roberts, to enable them to understand fully the physiology of baby cremation.

11.6 Administration and Record Keeping

i Bereavement Services

Official administration and record keeping for Dunfermline Crematorium is handled by the clerical officers based at an office situated at the gates of the crematorium. Dunfermline staff tried where possible to refer to non-viable foetuses by a name rather than just a number.

There is a small team of Bereavement Services Clerks in charge of the processes. They are now line managed by the Business Support section of Fife Council but rely on the Bereavement Services Manager, Liz Murphy, for immediate guidance.

Funeral bookings are made by Funeral Directors and booked into the diary system on the BACAS system (the computer record keeping system) which was introduced in 2001. The office gives confirmation of the date and time of the funeral service and the name of the deceased to the Funeral Director.

When all of the paperwork is checked the information in relation to the cremation, to include what is to happen to the ashes, is added on to the BACAS system and the paperwork is printed off for the Cremator Operators including sticky labels for the ashes container. The crematorium staff now has access to BACAS. After the cremation the Bereavement Services Clerk would only get involved if the ashes were being collected by family. If the ashes are being collected by Funeral Directors, they go directly from the Crematorium. The clerk confirmed that if there were ashes from a non-viable foetus she would be informed. However, when she started working at the crematorium in 2000 she understood, incorrectly, that there were no ashes for NVFs because different cremators were in use,

"When I started it was understood that there'd be no ashes from an NVF because it was different machines they were using in those days. So far as I'm aware that had also been the understanding of Funeral Directors. I don't know what understanding local hospitals might have had."

When this clerk began working there was a baby tray in use at Dunfermline. The clerk confirmed that,

"When a cremation is complete the only paperwork that would come back to me from the technicians would be if ashes were taken away.

If there were ashes from an NVF I would get told. There's a bit in BACAS that you could complete to show that there had been recovery of ashes and we would need to say what happened to those ashes, whether they were returned or whether they were dispersed.

I sometimes got told and sometimes the boys would update it along there when they had access to BACAS. Before they got access (to BACAS) the ashes bit of BACAS would stay blank until they came back and told me. I relied on them coming back and telling me. If they didn't it might stay blank."

Liz Murphy Bereavement Services Manager, said,

"In all likelihood any other cases would have been left blank by staff as we were not good at feeding back the information unless they had been collected."

The instruction for the ashes has already been put into the BACAS system before the cremation and the Clerk confirmed that,

"There could be a set of circumstances where I would record in advance what the disposal of ashes was to be if I entered say, dispersed, but that was changed and nobody told me or there were in fact no ashes to disperse and nobody told me. If the technicians don't tell me about ashes or it got missed somehow the BACAS record would not be accurate."

The Register of Cremations which is the official statutory record of the cremation is created automatically from BACAS. The practice of inserting the disposal outcome of the remains of the baby on the Register before the actual cremation had taken place has rendered the records wholly unreliable and meaningless as a statutory record of the actual outcome of the cremation.

Since 2001 there has also been a separate register kept for the cremation of non-viable foetuses which is also generated by the BACAS system.

ii Records kept at the crematorium

There was not always an option for 'no ashes' or 'no remains' in the BACAS recording system. A clerical officer was asked what she would do if there were no ashes before that option became available and she replied,

"If there was not a box in BACAS that said 'no ashes' I would not be able to update BACAS properly. There might or might not have been a box - I can't remember. It might have been that the ashes box was left blank"

This issue was never raised with the supplier of BACAS. This was despite the fact that another issue was raised in an internal report prepared about the Mortonhall Investigation Report by Liz Murphy Bereavement Services Manager in 2014. The report stated,

"Issue with BACAS which has automatically populated 'no Remains' into sections that were left blank for remains when system was upgraded. Only solution to redress is to go back through records and manually input correct record."

Liz Murphy, Bereavement Services Manager told the Investigation,

"There also appear to be issues with BACAS self-populating blank entries into the older system when they moved over to the newer system."

It is surprising that these issues were never raised with the supplier of BACAS by Fife Council. The Investigation contacted this supplier. Martin Caxton, General Manager of Clear Skies Software which provides the BACAS system to Fife Council told the Investigation,

"The disposal terminology in the original BACAS system was fixed (i.e. the users could not alter the wording. In the current version of BACAS the users can define their own disposal wording. In the conversion between the old and current versions of BACAS the default wording was changed to 'Strewn by Staff' which for most users was interchangeable with 'Disperse'. A small program, however, can be run to return the wording to its original text... although the system has a number of programming checks...the final check is provided by the users as they use the system and discrepancies are identified and rectified if possible."

Nonetheless these records had been left blank which allowed this automatic insertion of information to happen. It was raised by this Investigation as an issue with the supplier rather than by Fife Council. It would appear that staff at Fife Council had not checked for any anomalies after the BACAS system was upgraded.

An Internal Audit report dated 28 March 2014 has been provided. Neither it nor the BSI assessments made reference to any difficulty with the computer recording system. It did however find that entries on the record for dispersals were not countersigned.

11.7 Communication

i Communication between the NHS and the crematorium

Liz Murphy told the Investigation,

"I think there might have been a mixed message with midwives at the hospitals (because that has been an issue over the years) with the completion of the application forms for foetuses. We use a different form for them and I think it is only recently I've become aware that there's maybe been mixed messages coming from the Funeral Directors as well. I think some Funeral Directors have in their head that there definitely weren't going to be ashes for any foetuses. It's not always the same member of staff that would be filling the applications and dealing with the families"

Cath Cummings, Head Midwife (retired in 2016) told the Investigation that in Fife women were offered cremation for non-viable foetuses after sixteen weeks' gestation much earlier than in other places. She states that they were always told there would be no ashes for non-viable foetuses,

"We were always informed there would be no ashes from cremation here in Kirkcaldy. If we were asked that is what we would have told parents."

This is despite the existence of a Bereavement Services Group in place since the 1980s with representatives from Crosbie Matthews Funeral Directors and Liz Murphy from Fife Council.

An NHS booklet was developed by this Group which advised that there was no guarantee of any cremated remains and it was very unlikely any would be recovered. This booklet was in circulation in 2010 and 2011. A 2008 version stated this more starkly,

"You must bear in mind that cremated remains are not available afterwards."

An updated version of the booklet, dated April 2013 states,

"Unfortunately due to the age of your baby it is very unlikely that there will be any ashes /cremated remains available following a cremation. On the very rare occasions where there are ashes/cremated remains, you will be notified by the Funeral Director or by staff from the Crematorium. Following such notification you can decide what you would like done with the ashes/cremated remains."

This was the position of the Scottish Government at the time and was confirmed by the Chief Medical Officer in 2012. This information has still not been updated at the time of writing despite the fact that Fife Council crematoria have been returning ashes from every cremation since at least June 2015 (the date from which they were required to report any instance of non-recovery of ashes)

The information given to NHS staff changed as the Mortonhall issues emerged. The Head Midwife told the Investigation,

"After we were told that it was possible some families might get ashes we did some study days at the crematorium (this was after Mortonhall came to light). It was explained that it depended on temperatures and how ashes were recovered whether there would be any or not. I understand that anything that was swept out after the cremation that was not considered at that time to be ashes was scattered in the baby garden."

In relation to the timing of completion of the Application for Cremation (Form A) Cath Cummings said,

"We find that most families want to know what will happen to their baby and want to discuss it soon after delivery. However if they are not ready they do not have to rush it."

Dr Tydeman, Consultant Obstetrician, NHS Fife said in relation to a particular case,

"I would have told [Kirkcaldy parent] that there would be no ashes following cremation of the baby. This is something we were always told was the case. We believed that any baby right up to term and in the early neo-natal period vaporized during cremation, although I found this very hard to accept. We were told there was inadequate mineral content in the bones to withstand the process. This was a widely held belief. This was the culture in which I was trained."

Dr Tydeman continued,

"Several years before, we had challenged whether you could get ashes. During 2006 two specialist midwives and I became aware of inconsistencies on whether ashes were available or not. The two midwives visited the crematorium to satisfy themselves about what we were being told by the Undertakers and to challenge the information with which we were being provided. They had a discussion with the Crematorium staff who confirmed that there were no ashes because of the ferocity of the process."

The foetal midwives who visited Kirkcaldy and Dunfermline crematoria in April 2006 told the Investigation ,

"We were shown the facilities in full and at both locations we raised the question of whether ashes were available, both sites informed us that due to the efficiency of the cremators there was no possibility of ashes for foetuses."

A Cremator Operator who had regularly obtained ashes using the tray advised the Investigation that he was not present for that visit. The information given to parents by NHS Fife is still that ashes cannot be guaranteed despite a one hundred per cent success rate in retaining ashes at Dunfermline since the re-introduction of the baby tray. The Foetal Midwives told the Investigation,

"When the concerns were released regarding Mortonhall in the media we checked again with Crosbie Matthew and were told that rarely ashes were available and if the parents wanted to be informed we were to give them that option, this was not a guarantee only occasionally an option. This has remained our current practice."

The current checklists used by midwives with bereaved families state

"There is now a possibility that ashes will be available from cremation, The Funeral Director/ Crematorium staff will contact you. You can then decide what you would like done with the ashes."

Crosbie Matthew Funeral Directors confirmed to the Investigation that they do contact families after retrieving the ashes, unless the family has chosen not to be involved at all in the cremation arrangements for their baby. Sheila Matthew said

"In order to allow for any change of mind on their wishes, we find it is better practice to double check that we are doing exactly what they want to happen. We think that sometimes at the time of loss, the next of kin are not really taking in all the information and may need a bit more time to be certain of the right decision for them. We then arrange to carry out their instructions."

At a time of deep distress and often shock parents interviewed for the Investigation stated that they felt that they had little time to make decisions about the final act of care for their baby before leaving the hospital.

A local Funeral Director confirmed that the Form A was normally done at the hospital but went on to say,

"We don't rush anything too fast just in case they'd had a change of heart about what they want to do. They might decide they don't want cremation, they want burial. So there's quite a bit of time and also if the baby is away for post-mortem then you've automatically got time - a week or two weeks."

ii Funeral Directors

Crosbie Matthew are the main Funeral Director dealing with Dunfermline Crematorium and their representative told the Investigation that until publication of the Mortonhall Investigation Report they did not expect to get ashes from non-viable foetuses or very young babies. They had two people working with them who had previously been Cremator Operators so they did not query this. Sheila Matthew, a Director of Crosbie Matthew told the Investigation,

"Prior to the publication of the Mortonhall report, I think my understanding of ashes would have come through Liz Murphy who I've obviously worked closely with for a number of years. The understanding was that ashes would not be the coffin per se but the infant, which is obviously impossible to differentiate between the two. We were always told that there aren't any recoverable ashes because of the temperatures of the ovens and the size of the baby, especially if they were very tiny. If they were slightly older you might have had some ashes."

Most Cremator Operators told the Investigation that they had no contact with families.

One Cremator Operator told the Investigation,

"If the Undertaker hasn't asked for ashes we phone and we tell them 'we have ashes' and they (the Undertaker) might well suggest that we do not."

The Cremator Operator said when interviewed in April 2015 he recently telephoned the Funeral Director to advise that there were three sets of ashes and that the Funeral Directors telephoned back and instructed him to disperse them. He confirmed however that they would not be dispersed until there was a written authority. This Cremator Operator told the Investigation,

"We will not say in future there were no ashes when in fact there were and we're going to keep them. We will say to the Undertaker tell us in writing what you want done with them"

A Funeral Director told the Investigation,

"I think we were really clear that the crematorium procedure was that there were no ashes. So we had to make sure that they knew that and if they weren't happy with that well would they prefer a burial?"

There was no evidence of families being directed to Perth crematorium which the Investigation has been advised was providing ashes or indeed any knowledge that it was doing so. When asked about this Sheila Matthew, Director of Crosbie Matthew, said,

"We would give them the option of Dunfermline or Kirkcaldy to choose. I wouldn't have known if another one gave ashes so I wouldn't have offered that."

A Funeral Director who had been a Cremator Operator told the Investigation,

"In 2005, I became a Funeral Director. I would have said that from NVF that the likelihood of there being any cremated remains would be none. If the baby is older I would have said there's a bit more chance that there might be something and I would have also told families that we would say to the crematorium technicians that if there was anything there for them to let us know regardless of what we've put down on any forms. We fill in the forms. Technically it should be the parents that do it but it's filled in - you've got to appreciate that they're very upset. So we try and do as much as we can for them but they are done and they are read over and they're given to the family for them to check and then the family sign them."

He went on to say,

"I am asked when Mortonhall came out did I change what I told the families. No Mortonhall had nothing to do with me. There's no way that anything that I ever did in my whole time resembles Mortonhall. I would tell them that there might be a chance that there might be nothing left after cremation. That is what we've always been told and not only from my experience from being a cremation technician but since I've left and we've been told that by the cremation authorities that that's what we've to tell people.

If a family told us that they're very keen to get ashes, we would only say to them we would check with the crematorium if there were any ashes at the end and let them know. The crematorium would have let us know if there were any but we could phone them and check. There have been one or two that were a little bit older."

Sheila Matthews Director Crosbie Matthew said that a follow-up letter confirming all arrangements was sent out to next of kin. Copies of the current template letters were shown to the Investigation. A Cremator Operator told the Investigation,

"Some of the letters (to families) from the Funeral Directors are saying 'on the rare occasions that there is remains the Funeral Director would come and collect them.

It is rare not to get ashes now but in the last few weeks (April 2015 interview) a member of a family showed me a letter from an Undertaker, it would have been Crosbies saying that it is rare to get ashes from a baby. But they must have known that we get ashes most of the time. We're phoning them often enough to tell them we have ashes for them to collect."

The letter shown to the Investigation by Crosbie Matthew about non-viable foetuses states,

"We take advice from Fife Bereavement Services, Fife Council, to find out whether there are any cremated remains available following a cremation. On the rare occasions where there are remains, parents will be notified and asked what they wish to do with them."

A Funeral Director employed by Co-op Funeralcare in Fife since 1998 told the Investigation,

"From the age of about a year and a half and under, from what I'm led to believe going back over these years, there was never the possibility to give ashes back to a family. The crematorium won't be able to get anything back because there's no trace of human remains."

He went on to say,

"All I can remember being told in training is for a child you can't get ashes back. I can't really remember who told me. It would be the crematorium because they're the only people that would say something like that. I don't think we got training on that aspect but it was mentioned about the bones I can recall from some books I read, but it didn't state anything about ashes..."

It is clear that Funeral Directors working in Fife did not expect to be able to return ashes from non-viable foetuses and young babies to families. It is much less clear why, that being the case, they often completed Applications for Cremation with an instruction that the ashes should be dispersed. Nor did there appear to be any curiosity about whether ashes could be retrieved from a different crematorium or willingness to explore such an option for families who were distraught at the idea of having nothing left of their baby.

iii Communication between Partner organisations

An interdisciplinary group made up of midwives, Sands representatives, hospital managers, lay people and Funeral Directors interested in the whole process had been meeting on and off for 19 years.

Grant Ward, Head of Services spoke of a good working relationship with Crosbie Matthew, Sands and NHS Fife but said,

"... I am not trying to be overly defensive about that. It's partly back to the overall process - our role versus the role of the Funeral Director and I think that might be something to look at in your report. I wouldn't be surprised if some of those communication issues and process issues were something that emerged from your investigation and how those could perhaps be improved and tightened."

iv Bereavement Services Group

In addition, the Bereavement Services Group meets from time to time to look at various issues. Sub groups take on responsibility for different projects. This group was responsible for arranging a special room in the hospital, called the 'Butterfly Room' where babies can be kept rather than in the mortuary before leaving the hospital and Snowdrop gardens at the Crematorium.

A report presented to this Bereavement Services Group meeting on 3 Dec 2008 set out the services provided by the Funeral Directors, Crosbie Matthew. In relation to each category; stillborn/neonatal, under 24 weeks' gestation it stated, 'There are no cremated remains available'

However, the Bereavement Services Group had Process flowcharts drawn up (in 2013). The flowcharts for non-viable foetuses refer to the cremated remains being collected or scattered in the Garden of Remembrance. The flowcharts for stillborn babies or neonates refer to the cremated remains being collected or scattered in the Garden of Remembrance if there are any cremated remains.

11.8 Impact of Mortonhall Investigation Report and the Infant Cremation Commission

A further Briefing Note to Senior Management and the Council was issued by the Bereavement Services Manager, Liz Murphy, dated 15 May 2014. It refers to regular dialogue between Bereavement Services (Kirkcaldy and Dunfermline Crematoria), Fife NHS and Funeral Directors and, states that,

"The wording of information provided to parents now advises that is very unlikely that there will be any ashes following cremation."

It goes on to say that,

"The cremation process continues to be closely monitored and the use of a special cremation tray for foetal and infant remains has recently been re-introduced to try and help improve the chances of ashes being retrieved."

The Investigation was advised that when the baby tray was fully re-introduced in May 2014 the system changed so that the cremator was set to infant mode, which had been introduced in the 2013 upgrade. The box or coffin of the non-viable foetus was placed on to the baby tray which was then pushed just inside the charge door. The details of the cremation are entered into the computer. A visual check through a specially designed spy hole is carried out and when there is no longer the flicker of a flame the Operator puts on personal protection equipment and removes the tray through the same door through which it was charged (placed into the cremator) on to a trolley. When the tray has cooled the remains are brushed into the cremulator tray and crushed by hand using a pestle and mortar. The ashes are put into baby urns if they are to be collected and into individual high density plastic bags if they are to be dispersed.

This new system has ensured that remains are retrieved on every occasion.

A Cremator Operator said,

"Ever since we've started using the tray there's always some kind of remains there."

Another said,

"Prior to using the baby tray it was pretty rare to get remains on NVFs. But if they ask me now I could pretty much guarantee there will be something there."

A Safe Working Practices guide dated 2014 has been introduced for the Cremation of Foetuses and Babies at Kirkcaldy and Dunfermline crematoria.

Since the reintroduction of the tray at Dunfermline Crematorium staff have successfully recovered ashes in all cases from around 13 weeks' gestation onwards. One Cremator Operator said,

"We use the tray on every baby and every baby we cremate we get ashes from."

The cremulation process has also changed to enhance the possibility of having ashes to return although the Cremator Operators described feeling some discomfort with crushing bones by hand,

"We use the mortar and pestle. I don't like doing that because it's not that easy, you try to blank it out. Sometimes you can actually see and identify bones."

i Staff Reaction

Cremator Operators were upset by the fact that they were not getting ashes and could have been. Liz Murphy told the Investigation,

"Staff have found it really hard, the fact they weren't looking for ashes as per the new agreed definition i.e. they were only looking for skeletal remains of which in some cases there were none and the fact that they're now getting ashes as per the now agreed definition, where before they thought they couldn't get them. They find that quite upsetting."

This does not reflect the position at Dunfermline as clearly the Cremator Operators there were aware that ashes could be retrieved with the use of a tray. Working practices and the failure to modify those were the cause of the failure rather than any understanding of the definition of ashes.

A long-serving Cremator Operator who felt that it was often easier for everyone if there were no ashes said,

"We maximised the opportunity using the tray but it all depended on what the Undertaker wanted or told you he wanted and it wasn't until we lost the tray and got it back again and all the Mortonhall stuff came out that we got an instruction from management that the Undertakers were not to be told any more lies but it's what they wanted to hear."

The Chief Executive, Steve Grimmond said,

"I think my reflection would be that there is recognition of the sensitivity, that staff feel that there is an anxiety that they believed genuinely that they were acting and following the practice that was informed by professional advice that was around. They now know with the benefit of hindsight that there is different advice and so there is a sensitivity around that and probably a kind of morale issue that flows from that into feeling exposed by that."

Grant Ward, Head of Services acknowledged that,

"Given all the media coverage, I think there's probably a morale issue and a sense from Liz and Willie (before he left) and the guys - and I think witch hunt is putting it too strongly - of a sort of perceived grievance from those operating within the crematorium."

11.9 Summary of Findings for Individual Cases

One family of a baby who died in 1973 told the Investigation that the Funeral Directors (Co-op) did not mention ashes to them. A certified copy of the Cremation Register states 'disperse (no family)'. The original handwritten Register of Cremations says 'dispersed', as does every other entry for a baby that year at Dunfermline. The words 'no family' have caused much extra distress to a family who were unaware that ashes had been obtained for their baby. The Investigation understands that this option 'disperse (no family)' was available on the BACAS system and chosen when transferring entries from the original Register to the computerised version. The family has been provided with a copy of the original handwritten Register of Cremations by the Investigation.

The mother of a four month old baby who died in 1988 told the Investigation that she was advised by the Funeral Directors (Co-op) that there would not be any ashes. This was before a baby tray was used in Dunfermline. The mother told the Investigation that she telephoned the crematorium several times to ask whether there had been ashes of her son, but her calls were not returned. She found out through participation in a BBC documentary that the Register of Cremations records that her son's ashes had been dispersed. This mother was further upset to learn from this Investigation that it was possible to receive a copy of the Register of Cremations for her son as she recalled being told by Fife Council that there was nothing they could provide. In fact the records were the same as those in the aforementioned case from 1973 and the Certified Copy of the Register records 'disperse (no family)'. This mother told the Investigation " it should say family weren't given the chance". Again, the original Register stated that the ashes had been dispersed as did the entries for every other baby cremated at Dunfermline in 1988.

A family of twins born in 1989 did not receive ashes. One of the twins was a non-viable foetus and the other died at one day old. A certified copy of the Register of Cremations was available for the twin who had lived for one day. It stated that the ashes had been strewn by staff. However this may mean that the disposal column had in fact been left blank when the entry was added to the BACAS computer system as 'strewn by staff' was not a term used at Dunfermline but was a term used when the new computer recording system automatically populated a blank column. The original manual Register records that the ashes were dispersed. The Bereavement Services Manager told the Investigation that she understood the twins had been cremated together but that there was no record of the non-viable twin as at that time there was no requirement to register details for non-viable babies.

Another family in 1980 did not receive ashes. The Register of Cremations records that they were 'dispersed'.

All of these families told the Investigation that they had used the Co-op Funeral Directors. Unfortunately, due to the passage of time, none of the individual Funeral Directors involved in these cases was available for interview. However a representative of Co-operative Funeralcare working in Fife when asked about the Co-operative's policy on ashes from infant cremations said,

"I'm just trying to work out if the Co-operative had a policy on what we told families. I don't know. I know for a fact that the crematorium policy is you can't get children's ashes back. So I've obviously developed these thoughts in my own way. I don't think the Co‑operative has actually put anything in place anywhere."

It was not only in Fife that families were informed by Funeral Directors that there would be no ashes following the cremation of their baby. In Fife, as in other places, the Registers of Cremation contain uniform entries of 'dispersed' in the time period when they were recorded manually. This prevents the Investigation from ascertaining with any certainty the exact location of the ashes though there is no evidence to suggest they are anywhere other than in the Garden of Remembrance.

11.10 Conclusions

1. Like Mortonhall this was a section of the City Council working in isolation without any strategic direction, development or quality control of the service, so far as it related to babies, infants and non-viable foetuses. There was little knowledge by Senior Management of the service provided to the families of these babies. There was insufficient interest taken or leadership shown by management. As with Mortonhall, much of what was learned by Cremator Operators at Dunfermline was received wisdom from more experienced peers. The belief that there would be no recovered ashes from infants, stillborn babies and infants was contradicted by what was known to be recovered in many other crematoria including Perth, only 28 miles away, as well as in Dunfermline itself when a tray had been used in earlier years. It is also clearly contradicted by the evidence of the Forensic Anthropologist, Dr Julie Roberts, who states that bones in cremated foetuses from as young as 17 weeks' gestation can and do survive the cremation process.

2. Reliance on a definition of skeletal remains means that families were not given the opportunity to have ashes back. Dr Julie Roberts stated in her report,

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

3. The removal of the baby tray despite the discontent of the Cremator Operators and the delay of over a year in allowing its use after it was re-introduced highlight a lack of insight or appreciation of the importance of this issue.

4. Training was largely carried out in-house and there was no appetite to look beyond and seek best practice from other crematoria, professional organisations or manufacturers of equipment. The inter agency Bereavement Services Group did not address the issues of baby cremation until after the Mortonhall Investigation. It is incumbent on all those professional agencies involved in the cremation of these babies to ensure that they communicate effectively with each other and have appropriate joint training and joint understanding of their obligations to the parents of these babies. This inertia allowed unacceptable practices to develop across all of the relevant agencies in Dunfermline.

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

6. As with other crematoria there was an absence of any local written instruction or guidance. This meant that the actual practices employed in the crematoria were not documented and available for inspection by normal quality assurance procedures. Had such written guidance been shared between the two crematoria for which Fife Council was responsible, the effectiveness of using a tray may have been recognised and maintained in Dunfermline and implemented in Kirkcaldy.

7. Methods of safely using a baby tray could and should have been implemented in a more timely manner given that trays were already in use in many crematoria throughout Scotland and indeed had been used in Dunfermline in the past. Personal protection equipment was already available and no injuries had occurred, making the delay in dealing with health and safety issues difficult to comprehend.

8. It is important that those suffering the unexpected loss of an infant or baby must be given adequate time and information to make a decision about the cremation of their child.

9. NHS maternity staff (Forth Park and then Victoria) and Funeral Directors understood there to be no ashes from non-viable foetuses and young babies and advised families to this effect. Funeral Directors completed the Form A instruction to scatter in these cases although they advised families there would be no ashes following the cremation of their baby. As a result of this understanding many parents were deprived of the opportunity to seek the return of their baby's ashes. Crematorium staff at Dunfermline have admitted that on occasion following cremations that there was 'something' left and that these were scattered without recourse to or the knowledge of the families concerned.

At the time of writing, bereaved parents are still advised by the NHS Fife leaflet that it is very unlikely that there will be any ashes following infant cremation. This is despite the Mortonhall Investigation Report, the Infant Cremation Commission Report, all of the publicity surrounding this issue and indeed the fact that some of those responsible for its publication have been interviewed by this Investigation. It is astonishing that the booklet which is the only written document and the leaflet bereaved parents take home with them has not been revised. The Investigation recommends it is updated with immediate effect.

10. Funeral Directors interviewed for the Investigation still referred to the " rare occasion we might get ashes" in 2015 despite the conclusion of the Mortonhall Investigation Report and the Infant Cremation Commission. This is difficult to understand as Cremator Operators have advised that they always obtain ashes since the re-introduction of the baby tray and the Funeral Directors are regularly taking instructions for these ashes from families after they have recovered the remains from the crematorium. The Investigation recommends all staff are updated on the current position and all letters and leaflets are amended to reflect the new position.

11. Urgent steps should be taken to ensure that communication between the NHS, Funeral Directors and the crematorium is as effective as it can be. Despite the existence of a Bereavement Services Group, these agencies have failed to communicate and understand the issues affecting non-viable foetuses, stillborn babies and infants and the needs of their parents.

12. By leaving the disposal column blank on the older computer system Fife Council created a situation where the computer system was able to populate inaccurate information into the Register when the new BACAS system was introduced. Although this error was identified, no steps have been taken to correct the inaccuracy of the Register for that period. This casual and careless approach to a statutory obligation is of considerable concern.