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

12 Falkirk Crematorium

12.1 Introduction

A total of four cremations of infants or babies conducted at Falkirk Crematorium were referred to the Investigation. The earliest of those cremations took place in 1993 and the most recent in 2005.

Falkirk Council manages Falkirk Crematorium which is situated in Camelon Cemetery, Dorrator Road, Camelon.

Opened in December 1962, Falkirk Crematorium has a Chapel of Remembrance and a Garden of Remembrance. Inscriptions within the Book of Remembrance are displayed in the chapel.

In 2013 Falkirk Crematorium carried out 2,003 adult cremations. In the same year there were four child cremations, five cremations of stillborn babies and fifteen individual cremations of non-viable foetuses. There were seventeen shared cremations of non-viable foetuses.

12.2 Management

The crematorium at Camelon is managed by the Bereavement Services Department at Falkirk Council.

Bereavement Services is a division of Falkirk Council's Corporate and Neighbourhood Services. At the time of the Investigation in 2014 the Director of Corporate and Neighbourhood Services, Stuart Ritchie, reported directly to the Council's Chief Executive. Between Stuart Ritchie and the Bereavement Services Manager there were three layers of management namely the Head of Resources and Procurement, David McGhee, the Estates Manager, David Crighton and the Projects Development Coordinator, Wraight Shepherd. Eleanor Thomson was the Bereavement Services Manager and reported to the Projects Development Coordinator.

Falkirk Crematorium has a Manager, William Candlish, who has been in post for approximately five years. Before his promotion he was a Cremator Operator. He reports to Eleanor Thomson who has been the Bereavement Services Manager since April 2006. She was previously a clerical assistant in the department.

Two administrative staff and three Cremator Operators complete the current organisation.

The Investigation was provided with charts setting out the structure of the management team from 1996.

David Ure, the Crematorium Superintendent from the late 1980s until 2006 told the Investigation there was little direct Council involvement in the crematorium during his time. He was of the impression they " avoided the place". As a result, he said, " Council officials exerted precious little influence in my work".

The current Crematorium Manager, William Candlish, said he had some dealings with Eleanor Thomson's line manager, Wraight Shepherd, but not with other senior management.

Eleanor Thomson, who has been in post Since April 2006 and was previously a clerical assistant in the department, agreed that,

"We very much tend to operate on our own autonomy."

She described the senior management's attitude being,

"it's not broken so we don't need to fix it."

She acknowledged, however, that over the last three years a restructure involving the transfer of Bereavement Services from Community Services to Corporate and Neighbourhood Services had resulted in senior management adopting a more " proactive" approach. This was influenced, in her view, by the developments coming from the Scottish Government in the light of the Mortonhall Investigation. This had resulted in there being a new dedicated Cemeteries Development Group and a Crematorium Development Group within the Council.

A Cremator Operator who retired in 2008 said of the crematorium,

"to outsiders (even the council) it was taboo, they didn't want to know. Crematoria are like islands… they work away the best they can and outsiders understand that somebody's got to do it but they're glad it's not them. We very rarely got visits from the senior managers."

In the course of the Investigation it became apparent that there were vacant posts within the senior management structure with no Head of Service for Corporate and Neighbourhood Services and no Estates Manager. Furthermore, there was uncertainty about whether these positions would be filled given the financial cutbacks. The Bereavement Services Manager, Eleanor Thomson, described the impact of recurrent change,

"I find myself quite often having to start from scratch with senior management and having to explain just who I am and what I do."

Explaining where Council policy comes from and how it reaches operational staff Eleanor Thomson said it,

"would come through the Head of Service, Stuart Ritchie, and then it would trickle through the management hierarchy and then come to me. A lot of it comes to me as well first through the FBCA … and then I would pass the information on to senior management."

12.3 Policy, Guidance and Training

Witnesses interviewed for the Investigation were able to speak to working practices at Falkirk going back as far as 1982. They agreed it has always been usual for there to be remains following infant cremations at Falkirk Crematorium. Although this could not be guaranteed, the Council policy is for Cremator Operators to do their utmost to recover remains whenever possible.

David Ure, the Superintendent until 2006 described how although,

"there were occasionally circumstances when we were not able to get remains from the cremation of infants… we would move heaven and earth to try and procure remains.

I tried to explain to families as best as I could, so they could understand, that there might not necessarily be anything to collect, that we are dealing with a very small body here."

The current Bereavement Services Manager, Eleanor Thomson, explained that it is Council policy to treat everything left after the cremation as cremated remains,

"and that's what goes back to families that want them back."

She explained that this policy does not distinguish between bones and coffin ash. The reason given for this was that in the case of an infant or a non-viable foetus it would be virtually impossible to separate ashes from cremated remains.

In relation to the success rate for achieving remains the Investigation heard,

"there is very rarely nothing to give back to families. We would always try and get something back."

The Investigation interviewed the Crematorium Manager, William Candlish, who started as a Cremator Operator in 1995 and was promoted about five years ago. He said his,

"role is to oversee the day-to-day running of the crematorium, make sure the cremations are going right, clients are happy with the service and everything runs as smoothly as possible for the people that are there."

He described how a perfect member of staff should behave. They,

"should be in the background and shouldn't really be seen. Everything should run so smoothly that it's like a nice slow flowing river."

The earliest case from Falkirk Crematorium to be referred to the Investigation dates from 1993. At that time the crematorium had a Superintendent, David Ure, who had been appointed in about 1989 and only left in 2006, two years after his official retirement. He told the Investigation about his role, describing how,

"Initially my job involved the smooth through put of the daily workload."

In particular he was responsible for,

"front of house and managing the process around the chapel; the public coming for mourning; the Undertakers; the actual cremation process; and the office which administered all of this."

David Ure recalled his induction which involved carrying out two cremations one after the other. He had to,

"clear out a cremator of one set of remains before I installed another body. Consequently I got the exact amount of ash from that body which I had cremated, as opposed to having a mixture of the previous cremations."

The process of thoroughly cleaning out the cremator between cremations was one he considered especially important in relation to infant cremations to ensure only the ashes of the individual baby were recovered and available for the family.

However, a Cremator Operator with experience of cremating babies at Falkirk until 2008, before a tray was introduced in 2014, referred to another practice that he deployed. He said,

"I would put the babies in when the adult wasn't quite finished… but they're completely separate, and in the morning I'd take the ashes out separately. I didn't mix them."

This practice was put to another Cremator Operator. Although he insisted that the cremator is,

"always completely cleaned out before the baby goes in"

it would appear that he too sometimes adopted this method. He explained that,

"if it's been a big body and it's taken longer then I'll rake it to the front and just leave some of the ashes there for a while, but it's away from the baby's coffin, the baby's coffin is at the other side, not anywhere near the ashes."

He explained that the following morning he would collect the baby's ashes first through the charging door.

While David Ure was clear that only one set of remains is allowed in the cremator at any one time, this is open to doubt in the light of the evidence to the contrary (above) from the two Cremator Operators.

Notwithstanding any attempt to keep the ashes separate, this practice would be contrary to the FBCA Code of Practice Rule 5, issued in May 2005, which requires that,

"Each coffin given to the care of the Cremation Authority shall be cremated separately."

David Ure, the retired Superintendent, does not remember there being any written guidance for Cremator Operators. Instead the process was passed on by word of mouth,

"We got told the relevant importance of identification of cremated remains and the consequences if we did not follow procedure, and if we didn't follow procedure the disciplinary was awesome to say the least."

A Cremator Operator with fifteen years' experience at Falkirk Crematorium confirmed the absence of local guidance. He told the Investigation,

"I don't have any specific guidance from the council on how to do cremations. It's all in the Code of Practice from the Federation."

In his time as Superintendent David Ure never felt the need to change any of the actual cremation processes which he considered to be well thought out. His personal involvement in directing the cremation process was identifying the body when it came into the crematorium by checking the name on the cremation card against the name plate on the coffin. Otherwise he said,

"I felt able to trust the Cremator Operators, who were charged with the cremation exercise, to do it properly."

David Ure told the Investigation,

"We had a very strict procedure for cremating children, it was the last thing at night. The reason for this was when you opened the door there was so much turbulence and the temperature in there was so overwhelming that when you put the coffin in - whoosh - away it would go and you could see the dust and stoor and everything else getting swept up, so much so that when you closed the cremator door you had to leave it till the following morning, because if you'd to open the door prior to that the dust and ashes would be scattered all over the inside of the cremator. Occasionally you would get the odd bit of hard bone, particularly a knee joint or an elbow or something. It was dense bone material. The majority just crumbled under the temperature of about 800°. The ashes that were left in those circumstances were removed. We had to make sure that all the bone material was removed and again take care of it as best we could."

David Ure could not recall there being any cremations of non-viable foetuses in his time although all four cases referred to the Investigation involved non-viable foetuses and took place while he was in post. However, there would not have been anything on the plate of the coffin to alert him to the fact that it contained a non-viable foetus.

It would appear that in recent times the number of cremations of non-viable foetuses at Falkirk has increased. As well as individual and shared non-viable foetus cremations there are also 'Sensitive Disposals' which occur when the family do not wish to be involved but have requested an individual rather than a shared cremation. This would be arranged by the hospital with the Funeral Director, usually under a contract with Co-operative Funeralcare.

A Cremator Operator describing his experience of shared non-viable foetus cremations, explained that they aim to have nothing left at the end of the cremation. To achieve this the container is placed in the middle of the cremator and the ignition burner is employed. Any ashes that do remain at the end of shared cremation are scattered in the Garden of Remembrance.

i Training

Describing the training she received, the Bereavement Services Manager and former administrative officer, Eleanor Thomson, said,

"I felt it was quite lacking for me, it was merely a case of one day I was in the admin office and the next day I was in the manager's office. Fortunately the amount of experience that I had held me in good stead for that. I just had a general chat with the previous post holder and he did explain what the FBCA and ICCM are."

She described her current role as,

"to oversee the daily workings of the crematorium and thirteen cemeteries, all the admin processes and everything to do with Bereavement Services. I deal with members of the public, Funeral Directors, attending meetings, management team meetings or FBCA and ICCM meetings, because the Council has membership of both of those."

The Investigation asked the Crematorium Manager, William Candlish about the training given to Cremator Operators. In his opinion there is more training now than there was in the past. This was confirmed by a Cremator Operator whose training in the 1980s consisted of one week's training at Linn Crematorium. After that there was no contact with other Cremator Operators in the twenty-five years that he worked at Falkirk. Nor had he ever seen any written guidance or instructions from managers.

Today, according to William Candlish, a new technician trains for three or four months, undertaking an average of 200 cremations, before being tested by the Federation, which involves going through a cremation from beginning to end. There is also training on machine maintenance delivered by the manufacturer and every Cremator Operator has an individual training record.

At the time of the Investigation there was no specific training on baby cremation. Following publication of the Reports of the Mortonhall Investigation and Infant Cremation Commission, specific two day training events were organised through the FBCA with the emphasis on infant cremation. Falkirk Crematorium also provides refresher training for the Cremator Operators and their Manager, which they undertake at five yearly intervals.

12.4 Cremation Process and Equipment

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

Most of the cremations that take place at Falkirk Crematorium are of adults and many of the features of an adult cremation are replicated during the course of a baby cremation ^[53] .

i Cremators

The Investigation was not provided with any evidence about the type of cremator that was in operation in 1993, the year of the earliest of the Falkirk cases. The then Superintendent, David Ure, could only say they were " ancient pieces of equipment".

At the time of the Investigation Falkirk Crematorium was equipped with three FT 300/2 Facultatieve Technologies gas-fired cremators, two of which were installed in 1995 and one in 1999 according to the manufacturers.

A reporting upgrade for the equipment was implemented in April 2013 which included infant mode. According to the manufacturer Facultatieve:

"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."

William Candlish, the current Crematorium Manager described how, before the upgrade, baby cremations were carried out by manually adjusting the controls. This resulted in conditions similar to infant mode but infant mode means the cremation is slightly slower. The big difference with infant mode, he explained, is that the computer does the majority of the work.

Despite the manufacturer's manual referring to the cremation of infants using a tray, none was introduced until 2014 (see below). Before then a baby or non-viable foetus was cremated at the end of the day on the step hearth. The temperature was lowered to just below 750 °and the airs limited to control the heat in the chamber. After 30 to 45 minutes, once the cremation was finished, the cremator was switched off and the remains allowed to cool down naturally overnight. In the morning they were raked using a hand-brush through the charging door.

The cremators have stepped hearths and the Cremator Operators found that cremating a baby's coffin on the hearth with the temperature set to a low heat enabled them to obtain ashes which could be returned to families. Since 1993 and until the introduction of the tray, the practice was to carry out any baby cremation after the last adult of the day had been cremated, usually in the late afternoon.

The cremators were primarily designed for adult cremations with the coffin charged (inserted) at one end through a large door. After the cremation a rake is inserted through the much smaller door at the opposite end of the machine, where there is a spy-hole through which the Operator can observe the progress of the cremation. The ashes are then raked into the ash cooling area.

Prior to introduction of infant mode in 2013 the manufacturer's manual anticipated manual overriding 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."

Dr Clive Chamberlain, a Chartered Engineer, member of the Council of the Combustion Engineering Association and expert witness to the Mortonhall Investigation ^[54] previously explained 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."

ii Baby Trays ^[55]

A baby's small coffin, or box containing a non-viable foetus, may be placed on a steel tray inside the cremator to better contain any ashes and prevent them being lost by being spread throughout the cremator by the force of the air jets.

Following on from the Mortonhall Investigation, Lord Bonomy's Infant Cremation Commission Report ^[56] recommended that,

"The Cremation Authorities which have rejected the use of trays for baby cremations on health and safety grounds should urgently consider, in light of the experience of others, the introduction of a local protocol to allow trays to be used in a way that will expose no one to undue risk."

The Crematorium Manager, William Candlish explained that until about August 2014 a baby tray was not used at Falkirk Crematorium. He thought the reason for their introduction was " probably to do with Health and Safety" and the recommendations about using trays to recover remains. Until then ashes were being produced without the use of a tray, a possibility that was not recognised in some other crematoria. Falkirk Crematorium now has two sizes of tray, one for a full term sized baby and the other for a smaller baby.

The tray is used in conjunction with a bespoke trolley and is charged using a long hook to push the tray into the cremator. The cremation takes place at the end of the day and once the cremation is complete, it is left to cool overnight in exactly the same area as it was before, on the step hearth. In the morning it cools further on the trolley.

Speaking of the new equipment William Candlish said he had undertaken research with other crematoria " to learn from their mistakes" and discussed the issue with Eleanor Thomson. Although overall he felt the trays were an improvement he acknowledged that they are not without problems, explaining,

"I honestly don't think the buckling problem will ever go away but the ones we got were reinforced… with extra welding and tubular steel. Although it can still bend and buckle it's not to the same extent as the one that's not been reinforced."

Significantly, in the Manager's opinion the amount of cremated remains,

"hasn't changed with the introduction of the tray"

although the process is " probably easier" because the technician no longer has to lean into the cremator to brush it out. He considered that,

"Health and safety-wise it's a good idea."

The need for extreme care, in order to minimise the risk to Cremator Operators of being burned, was accepted by Facultatieve in their operation and maintenance manual dating from 1996. This explained,

"Before withdrawal of the tray the cremator should be allowed to cool sufficiently to prevent the possibility of injury to the Operator, and it may be best to leave the cremated remains in the cremator until the following morning."

iii Dispersal of Ashes

As explained above it has long been the policy at Falkirk Crematorium to treat everything left after the cremation process as ashes, to be disposed of according to the wishes of the family. There are three options at Falkirk Crematorium: uplift, retain for further instruction, and inter in the Garden of Remembrance.

David Ure, the former Superintendent described the procedure,

"We would put the ashes in a container and put it to the side. If it was to be picked up… it would be presented to the family in that form. So the family always got ashes back if they wanted them back… as far as I was concerned and as far as the Operators were concerned."

Eleanor Thomson, the Bereavement Services Manager told the Investigation that regardless of the ashes instruction,

"For all cremations we do there is a period of about four to six weeks after the cremation that the remains are retained, just to give breathing space for families."

In some cases the instruction 'retain' is used, in which case Eleanor Thomson told the Investigation,

"We would always contact the Funeral Director to come and collect the ashes if the instruction was retain."

The Investigation was told that where ashes are interred in the crematorium grounds a record is kept of the location. The Crematorium Manager, William Candlish, told the Investigation,

"We would be able to say which baby is in which particular grave. It would have a GR Number. GR stands for green. It is our newest section, in use for a good twenty years."

The Investigation learned that reluctance to scatter ashes in the absence of a very definite instruction has led to problems with unclaimed ashes being retained indefinitely at Falkirk Crematorium. As David Ure explained,

"The only thing which I drew cognisance with was the fact that the ashes could sit there for years and when I arrived at the crematorium initially there were sets of ashes, not just children's ashes, but sets of ashes had been up there for eighteen months thereabouts, because the people never came back. Whether they had forgotten about or whether they were still trying to make up their minds, I don't know."

He explained that determined efforts to contact families and obtain their instructions were often unsuccessful.

"I wasn't able to come up with a solution other than pursuing it is as vigorously as I could in individual cases."

Eventually, in about 2002 they introduced a children's section of the cemetery to address this issue. David Ure told the Investigation,

"and that's where a lot of cremated remains are interred where there was no instruction contrary to what we were doing."

He had, he said, asked the Council,

"What happens if these families come along maybe two, three years later on and ask for the ashes back? There would be a question of going and recovering them but by that time you invariably find that the container they are in had deteriorated and the ashes were absorbed."

12.5 Administration and Record Keeping

David Ure, the Superintendent until 2006 told the Investigation that although in theory he was responsible for the office functions, in practice he had relied upon the office staff. The only time he would become involved was if there was some difficulty, as would occasionally happen, for example where there was a disagreement between different members of the bereaved family about the arrangements. Otherwise, the office staff,

"were extremely proficient in their job and things tended to run smoothly without my intervention."

However,

"if there had been a major problem the buck would have stopped with me."

The booking system at Falkirk Crematorium has been computerised since September 1994 when Gower Consultants' Epilog database was installed. This system includes the facility whereby the final location of ashes after cremation can be recorded. In addition there is a record of every cremation kept at the crematorium. The Crematorium Manager, William Candlish, told the Investigation,

"if somebody wants to come into us at the crematorium and say my dad was cremated twenty-five years ago and it was January we can look it up [in the crematorium and in the office] and know exactly where the remains are if they've been interred in the Garden of Remembrance."

Eleanor Thomson, the Bereavement Services Manager and a former Administrative Officer, is responsible for the administration. Speaking of her role at Falkirk she explained that during her many years at the crematorium she had always been involved in the administration.

Funeral bookings are made by Funeral Directors or the hospital, directly with the administrative team based at the office. The crematorium mainly deals with Co-operative Funeralcare, though they can take bookings from any Funeral Director. Falkirk deals with Forth Valley Royal Hospital, though any hospital may access the crematorium providing it completes the Council's paperwork and adheres to its procedures.

Eleanor Thomson told the Investigation that the office staff check any anomalies prior to the Medical Referee coming in to authorise cremations. Paperwork that is not fully completed is sent back to the Funeral Directors to correct. She explained to the Investigation,

"You can find sometimes the application form comes in and it hasn't been ticked what's to happen to the remains. You have to get in touch with the Funeral Director and find out so they may come back and say retain them at the moment. So we'll tick the retain box and that instruction then goes via the diary sheet to the crematorium so they know the remains are to be retained. Then after that cremation has taken place those remains are to be retained and are kept in the particular niche for that Funeral Director.

If there is a change in instructions we ask for an email, we ask for confirmation, if anything is to happen the office staff would say you'll need to send an email in or a fax."

Speaking about ensuring the Register accurately recorded any change of instruction Eleanor Thomson said,

"Before the computer we would have manually changed the record. If they [the ashes] were uplifted and maybe after a period of a week or two weeks you would go to that particular cremation and write down uplifted on the register and the date. Then you would also have all the original cremation cards so if anything was changed we would go back and write in what the disposal was. In many instances we would get them uplifted and then they are brought back so again we would have to go back into the database or back to the card and change it."

As described, these processes seem to be satisfactory.

The Investigation was told by Eleanor Thomson that at Falkirk the cremation card is a self-adhesive label which is stuck onto another sheet of paper and goes to the Cremator Operators after being checked by Eleanor Thomson as Bereavement Services Manager and signed by her or by William Candlish, the Crematorium Manager. The Cremator Operator carrying out the cremation adds their signature to the paper. Afterwards it goes back to the office with the information about what happened to the remains added. There is also an 'authority to uplift' slip for use if ashes are to be taken away. This is attached to any receptacle containing the remains and includes a name, date of cremation and the Funeral Director's details. There's also a section for the signature of the person uplifting.

Thinking back to the time when non-viable foetus cremations were introduced at Falkirk, Eleanor Thomson told the Investigation there had been no formal documentation. It was when hospitals no longer wished to dispose of non-viable foetuses as clinical waste. Today the Crematorium keeps a separate register despite there being no statutory requirement and the non-viable foetus cremations are given a separate cremation number. Forms come via the Funeral Director not from the hospital directly. Until November 2013 they were cremated individually but after that date collective or shared disposals were introduced involving the cremation of non-viable foetuses with other non-viable foetuses from Forth Valley Hospital. When dealing with shared cremations the crematorium is not provided with individual names. A maximum of ten non-viable foetuses are cremated in a single container.

i Findings on Record Keeping

In the four Falkirk cases referred to the Investigation the Form A (Application for Cremation) which includes the Instructions for Ashes proved the most significant of the cremation paperwork. As was the case elsewhere, some parents could not remember signing any forms. They included a family whose baby was delivered in 1997 at twenty-one weeks' gestation and cremated at Falkirk Crematorium.

Commenting on a completed NHS form she had been shown the mother told the Investigation,

"The signatures are mine and [my husband's], so we signed this form on the day after the delivery. I can't remember signing it, it's a haze.

I can't remember any discussions leading up to the signing of this form. It says we understand there will be no identifiable remains resulting from the cremation. I can't remember anyone talking about the remains."

The parents were also shown the Application for Cremation Form A. Despite having signed a form suggesting there would be no 'identifiable remains' the form assumes there will be ashes, stating they are to be interred in the crematorium ground.

"That was not our wish. I wanted my son's ashes because … we wanted to take his ashes … and scatter them in the sea.

I got told from the Funeral Director if there was any ashes you can get them. I always remember them saying it could be a wee drop in a matchbox but as I said it was my son's ashes, I want them. I think it was the day of the funeral we were told that, we were sitting in the car at the Camelon, at the bridge, we were talking to the Undertaker. Prior to that nobody said anything about ashes. I specifically said to the Co-operative man on the day of the cremation, 'look I want the ashes'."

On Form A, in the section for the instructions for ashes, the word 'retain' was crossed out with a tick entered next to 'inter in crem grounds'. Form A appears to have been signed by a Funeral Director. The final disposal was recorded in the Register of Cremation as 'inter GOR' (Garden of Remembrance). The location of the ashes is not recorded in the Register. The family has, however, been informed of the location following a request to the crematorium for information. They said,

"We know from the letter that went to the MSP, from the [Council] Chief Executive, where it's interred in the Garden of Remembrance. The letter explains where exactly."

They expressed concern to the Investigation that this area is not dedicated to babies or children and that their son's ashes rest with unknown adults.

The experience of discovering years later that there were ashes is not unique to this mother. In another Falkirk case the family lost a baby in 2005 at about twenty weeks' gestation. In a letter sent to the First Minister in June 2013 the mother remembered that having opted to have their son cremated they were told the day before by hospital staff " that there would not be any ashes". Yet, they were to learn, several years later, that there had been ashes, and they were interred at the crematorium.

In their case the Instructions for Ashes on Form A has a tick next to the option 'inter in crem grounds'. The Register of Cremation entry is 'inter GOR' [Garden of Remembrance]. This is not the outcome this family would have chosen.

These two families visited the crematorium together and were shown the sites where they had been informed that their babies' ashes were buried. Initially surprised that the plot numbers did not appear to be chronological, further enquiries resulted in the discovery that the plots are collective, rather than individual, plots. Given the previous misinformation the parents find it very difficult to accept the reliability of any information. They have been left deeply suspicious of information about their babies' final resting place.

In another case dating back to 2003 the mother delivered her baby at home at just short of twenty weeks' gestation. She told the Investigation that at the second hospital to which she was taken following the delivery she was asked if she wanted burial or cremation for her baby. She was then told by a nurse,

"due to my baby being so small I would be left with hardly any ashes. My brain was saying a different thing, but who am I to disagree with a professional who knows about cremation better than I do? Every time the cremation was spoken about I did mention, if there are any ashes left, I would like to keep them please. I remember signing two bits of paper. Not really reading, because I was being hurried along."

The following day having been " offered the chance to buy an urn" her expectation was that,

".. my baby was big enough to leave ashes. I had to sign more paperwork and was hurried along again, [the] nurse had already scored out bits and answered bits."

Following the cremation the mother heard nothing further about ashes.

Despite her plea for any ashes to be returned to her the Instructions for Ashes section on Form A has ' yes' noted against option (b) 'Interred in crematorium ground'.

The form is signed by the mother. The Form A ashes instruction appears to have been completed by the Funeral Director when adding the date and time of the funeral service.

There is an NHS form granting the hospital authority to arrange the funeral. Two boxes have been ticked against statements " I/we have been informed that there will be/ will not be any remains (ashes) after the cremation of my/ our baby" and " I/we understand and accept the standard burial or cremation and other arrangements as explained to me/us by a Senior Midwife". The part of the form which states ' If ashes yes or no' has been scored through. The form has been signed by the mother and by a Midwife.

There is an 'Application for Cremation of Foetal Remains' form signed by the mother. It also states that,

"it will not be possible to recover any remains following the cremation and that if this application has been made on behalf of the parent(s) that this has been made known to them."

In 2014 the mother read a newspaper article about a parent in a similar situation to herself. She made contact with that parent and with others. Another mother who worked for the charity Sands at that time offered to carry out a search to find out if there had been ashes in her case.

The outcome of the search was that there had been ashes and these had been collected by the Funeral Director following which, according to the Funeral Director, attempts were made to contact the mother to arrange collection of the ashes. When they proved unsuccessful the ashes were removed to another funeral home for storage. Only because of her perseverance the mother received the ashes of her daughter eleven years after the cremation took place.

The Investigation has a copy of the receipt that shows the ashes were collected from the crematorium the day after the cremation. A handwritten note states 'Change of instructions from inter to uplift' suggesting that on the day of the funeral the instruction on the Form A was changed and it was requested that the ashes be returned to the Funeral Director. There was no documentary evidence to explain how this happened.

According to David Ure, the former Superintendent at Falkirk Crematorium, not every Form A included a completed Instructions for Ashes section. In his view the question of how to dispose of ashes was not easy for families. He told the Investigation,

"When it came to the cremated remains the expectations of the family is where confusion arose… I was dependent on the family giving an instruction on what was to happen to the remains after the cremation. Now this is where the technical difficulty comes in. Families are beset with grief… they couldn't relate what they wanted to do with the remains. Do they want them kept at the crematorium? Do they want them disposed of at the crematorium? There are almost limitless possibilities."

He estimated that about two thirds of Applications for Cremation for infants had no instruction on them. He believed in some cases families could not make up their mind, or there was a conflict of opinion within the family. He did not refer to the alternative explanation, that the families had been told there would be no ashes by the hospital or the Funeral Director.

David Ure spoke of the Funeral Directors' role in this situation.

"Ostensibly the Undertaker is filling in the paperwork for all of this. However, when the family couldn't make up their mind the Undertakers would leave the space in the form blank.

Now the instructions on what's to happen to the remains - are they to be retained, are they to be interred - is normally on the card. There is a space on the card for that and it will usually be completed under normal circumstances. But in cases when it is children, for some unknown reason it's a subject that seems to be taboo, a human failing. So when the part of the card which set out the instructions on the disposal of ashes was not completed I assumed that there had been no instruction given. I therefore retained the ashes until such times as we were in contact with the family or contacted by the Undertaker on what had to happen."

This was a different practice from that adopted by his colleague Eleanor Thomson, who was promoted after his retirement and who would actively contact the Funeral Director to obtain the family's instructions.

The earliest of the Falkirk cases was referred to the Investigation by parents who lost a baby at around twenty-four weeks' gestation in 1993. This baby is believed to be the first non-viable foetus to be cremated at Falkirk. The parents could not recall filling in any forms in relation to the cremation, and no relevant application or accompanying forms have been identified or passed to the Investigation. In the absence of any statutory requirement to retain records relating to non-viable foetuses this is not surprising and there is no criticism implied.

The father remembered being told by both hospital staff and the Funeral Director that there would be no ashes. He said,

"I can't properly remember if the Undertaker told us it was because of the size of the coffin and because [ the baby] was so small. He may have. I know I was told there would be no ashes but I am unsure as to whether I was given a reason for that… We accepted what we were told at that time. When the people you are dealing with have that information, you trust them. I think he told me there would be no ashes when he rang to arrange the date and time for the funeral. It wouldn't have been the first time I spoke to him to tell him what had happened. Obviously he had been in contact with the crematorium to arrange the funeral so it is possible someone there told him there would be no ashes. I don't know."

The family arranged for an entry to be put in the crematorium's Book of Remembrance and visited each year for twenty years.

"When the Mortonhall story broke something twigged and we wondered if it was the same for us, whether there could have been remains and we weren't told. We contacted Sands in Glasgow and within four days they told us that [our baby's] remains were in a plot behind the crematorium in a wooden casket, and they gave us the plot number. It was hard to believe we had been going to the crematorium for over twenty years and nobody had told us."

The Investigation has seen the entry in the Register of Cremation. It says ' Interred section GR4 396'.

The father told the Investigation,

"Until this interview I had never seen the certificate of cremation, the certificate that the ashes had been interred or the diary page from the Undertaker's notebook."

The family reported that they have no idea where the instruction to inter the ashes at the crematorium came from. It was not their wish.

The Investigation examined a sample of entries in Falkirk Crematorium's Register of Cremations. The entries in the ashes disposal column consisted of 'inter' or 'uplifted'. These entries were supported by a date or a plot number. This supports the crematorium staff's contention that it was normal for ashes to be obtained.

12.6 Communication

The Investigation asked whether there was any information sharing between Falkirk Crematorium and the staff at other crematoria.

David Ure, the former Superintendent said he had been a Member of the FBCA and went to meetings. More recently Eleanor Thomson, the Bereavement Services Manager, attends meetings on behalf of the Council, which has membership of both the FBCA and ICCM.

It was, she said, usual to discuss matters with other Crematorium Managers,

"particularly if anything cropped up to do with SEPA. We would exchange information about that and someone would say, 'what kind of report did you get back?' For a while there was a bit of conversation about the temperature in secondary chambers and everything like that…because most of us have the same operating procedures from Facultatieve Technologies there was always an exchange of information here."

It was also clear from the evidence provided by the Crematorium Manager that since the publication of the Mortonhall Investigation Report in 2014 he had consulted with colleagues from outside Falkirk when exploring the options in relation to trays for infant cremation.

Asked about the information that hospitals give to parents concerning the availability of ashes a retired Cremator Operator said,

"One time [about twenty years ago] I had a nurse here from the Royal Infirmary. She was telling them in the maternity ward that there wouldn't be any ashes for infants. How we found out about what she was doing I just can't remember… we took her round and showed her the process. She was gobsmacked. With a stillborn I usually got bones left after the process and she had been talking about stillborns saying there would be no ashes.

I don't know or understand how that 'understanding' of having no ashes came about. I thought personally when I was reading about this, if that's the case they must be doing the cremations with air, processing it like a normal adult."

A midwife who had qualified in 1988 and had some involvement with the parents in the Falkirk case from 1993 told the Investigation about her experience of dealing with bereaved families. She said she had received no training on the subject of ashes and that she,

"didn't really talk much about ashes to be honest. I think maybe if they were fuller term you might have thought there's a better possibility of getting ashes if the Undertakers were able to do that."

Eleanor Thomson said,

"With the NHS there always seemed to be a difficulty in regards to communication and to what paperwork should be filled in and what could and couldn't be done. There seems to be 'a black hole', the information didn't seem to be getting through. Communication seemed to be very poor. There was a lack of communication between Falkirk Royal Infirmary and Stirling Royal Infirmary. Paperwork from the two was different. We drew up a form for the medical practitioner or state registered midwife to sign."

William Candlish described there being " quite a few meetings with hospitals". In particular these meetings concerned the shared cremation contract with the NHS that started about eighteen months previously.

David Ure said that interaction with Funeral Directors was always good in his time. He was,

"not aware of Undertakers thinking that we didn't get ashes or remains from an infant cremation."

This view was confirmed by a Cremator Operator who had worked at Falkirk for twenty-five years before retiring in 2008. According to him the local Funeral Directors understood the process for getting ashes and knew that there would be ashes following the cremation of stillborn babies and infants. He said they had talked about it.

Eleanor Thomson, however, suggested some Funeral Directors,

"were unaware of their obligations. On many occasions paperwork had Funeral Directors as applicants and I would say we can't accept that. Even as a clerical assistant I would tell Funeral Directors to take the application back and get it filled in by next of kin."

The Crematorium Manager, William Candlish said there were occasional meetings with the Funeral Directors, but they were not always well attended. If any Funeral Director had told their clients that " you never get ashes from babies", this information would not have come from the crematorium.

On the interaction she had with families Eleanor Thomson recalled when she worked in the office as an administrator,

"Some families would come in maybe after the cremation had taken place about the Book of Remembrance or they'll maybe come in to find out what area within the garden the ashes are interred in."

Asked whether there were conversations about ashes she said,

"I don't recall any parent ever asking me about ashes for their child. I would have had to direct them to the staff at the crematorium because I wasn't in a position from a professional point of view to be able to answer that."

Asked whether families had discussed ashes with him the Crematorium Manager said his only direct dealings with families was at the point of cremation and none had asked questions about getting remains back. He explained,

"until somebody asks we normally wouldn't tell them where in the garden we put the ashes. It doesn't really matter whether it's an adult or a baby, they've actually got to… phone us… and we'll tell them."

A Cremator Operator told the Investigation about an incident when a young woman visited the crematorium to deliver music for the funeral of a baby that had died in utero. She was going into hospital to be induced. She told the Cremator Operator that she had been told by a midwife there would be no ashes. All she wanted was enough to put in a locket. The Cremator Operator was able to assure her that there would be enough ashes to put in a locket. He said,

"You would have thought I'd given that lassie £1,000 because she was so happy to know she was going to get something back. Midwives, Undertakers have no right to say there will be no ashes because they don't do the process. I don't have any idea where they could have got that information."

The Bereavement Service Manager told the Investigation about enquiries she had received in relation to shared cremations.

"I have had one or two phone calls from bereaved parents asking whether cremation took place and what happened to the remains and we can't identify it because it was collective disposal. Unfortunately then I am left with the unpleasant task of reiterating that to them, that it was a collective disposal and there's no nice way or soft way to say that."

12.7 impact of Mortonhall Investigation and the Infant Cremation Commission

Following the Mortonhall Investigation Report and the Infant Cremation Commission recommendations Falkirk Crematorium introduced baby trays and a bespoke trolley. While the absence of a tray did not prevent their routinely returning ashes to families, the Crematorium Manager, William Candlish, was of the opinion that the tray had improved health and safety considerations for his technicians.

A further impact of the Infant Cremation Commission concerned the commitment to introduce a new standard Form A that has been introduced for all crematoria across Scotland. The Crematorium Manager, William Candlish, told the Investigation that at Falkirk in anticipation of this they have introduced an accompanying Additional Particulars Form specific to Falkirk, giving Funeral Directors more information and a chance to answer additional questions concerning, for example, the size of the coffin.

The Authority for the Disposal of Cremated Remains is on one side of this A4 sheet and is clearly set out in a suitably large font. The options are(a) Taken away by representative (b) Interred in Crematorium Garden of Remembrance and (c) Retained to await instruction. If (b) is chosen the remains are retained for one month " to allow for a suitable time to reflect on this decision". In the case of (c) if there are no further instructions, the Funeral Director will be instructed to uplift the remains.

12.8 Conclusions

1. The Investigation was impressed by Falkirk Crematorium's history of returning ashes of babies to their parents. Despite having membership of the FBCA they did not adopt the Federation's guidance on ashes. Nor had they needed to rely on a tray to ensure ashes were retained. Instead they had a modified procedure involving cremating on the stepped hearth at a reduced temperature in order to produce more gentle conditions appropriate to infant cremation.

2. Despite not having previously used a tray, Falkirk Crematorium observed the Mortonhall and Bonomy recommendations and implemented a tray and accompanying equipment. In doing so they took advice from other crematoria and thoroughly researched what was available. As a result they have been satisfied with the investment in new equipment this involved and have demonstrated a willingness to respond to changing times.

3. The crematorium was also proactive about producing a form with additional information for Funeral Directors to ensure the Instructions for Ashes are clearly and boldly set out.

4. The Investigation learned that the Cremator Operators and their Manager undertook refresher training. This is not routine across all crematoria.

5. The four cases referred to the Investigation all related to non-viable foetuses and are evidence of the confusing and inaccurate messages from NHS staff and Funeral Directors which parents have received. Too often such messages were contradictory so that ashes instructions (that did not reflect parents' wishes) would be included on one form although the parents had signed a statement on another form purportedly acknowledging there would be no ashes. One case also highlighted a failure by the Funeral Director to return ashes to a mother, although the same firm collected them from the crematorium within one day of the cremation.

6. In three cases referred to the Investigation the crematorium was given instructions which were contrary to the parents' wishes. These instructions were provided by NHS staff or the Funeral Directors under the mistaken understanding there would be no ashes. The ashes were interred at the crematorium when the families would have wished to have them returned. Furthermore, the families had to wait years to find out the truth. This has caused considerable avoidable heartache to those concerned. The provision of incorrect information to parents highlights the need for improved communication and joint training across agencies to ensure that there is no room for misunderstandings that can have such a profound effect on the needs of parents.