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

13 Glasgow Maryhill Crematorium

13.1 Introduction

A total of four cremations of infants or babies conducted at Glasgow Maryhill Crematorium were referred to the Investigation, two of which related to twins. The earliest of those cremations took place in 1994 and the most recent in 2010.

Glasgow Maryhill Crematorium is situated in the grounds of Glasgow's Western Necropolis on Tresta Road. It was Scotland's first crematorium, built in gothic revival style and opened in 1895 by the Scottish Burial Reform and Cremation Society. According to the crematorium's website,

"The Society was established as an educational body, designed to promote cremation as a more sanitary form of disposal for a fast growing population in Glasgow."

Over the years there have been various refurbishments and there are now two chapels. The Book of Remembrance is displayed in the arcade area at the rear of the Old Chapel.

A Wall of Remembrance surrounds the crematorium's garden and plaques in the wall can be leased for a renewable ten year period. There is a separate Garden of Reflection where ashes may be scattered.

Glasgow Maryhill Crematorium carried out 1,393 adult cremations in 2013. In the same year there were six child cremations, six cremations of stillborn babies and nine individual cremations of non-viable foetuses.

Shared cremations of non-viable foetuses are not carried out at Glasgow Maryhill Crematorium. The crematorium has no contracts with any hospital for disposal of non-viable foetuses.

13.2 Management

Glasgow Maryhill Crematorium is managed by the Scottish Cremation Society Ltd, a regulated charity. The Investigation was provided with information concerning the management structure going back to 1994.

The management of the crematorium is overseen by a Board of Directors which meets quarterly. None of its members has a background in the cremation industry. Instead they have assorted backgrounds including architecture, banking, the law and engineering and are expected to contribute their professional skills and expertise to the organisation. There are currently seven members of the Board, two of whom have been in office since 1994. John Chapman is the current Chairman and has been in post since 2014.

Gordon Armour is Executive Secretary, a post he has held since 2008. Both he and his predecessor have played an active role in the Federation of Burial and Cremation Authorities ( FBCA). However, his knowledge of baby cremation was limited, as he told the Investigation,

"I think we only became aware of the possibility of having infant mode software when we were discussing with Facultatieve a replacement for what we already had… one of the people heavily involved in the Federation had said to me about the approach to dealing with baby cremations and he had said to me it wasn't the same as for adults because of the small size of the baby."

Between 1994 and October 2012 the Manager of the crematorium was John Smith. Lucille Furie, the current Manager, was appointed in January 2013. She had previously been Bereavement Services Manager at Glasgow City Council.

The evidence from Cremator Operators suggested that the Board had little involvement in the day to day running of the crematorium. One Operator told the Investigation,

"we very rarely saw them here. We were just left to get on with it."

According to some Cremator Operators the Board's remoteness made it difficult to get their ideas for improvement heard. Their perception was that they did not have the ear of those in authority.

Some Cremator Operators also expressed frustration that despite her role as Secretary of the FBCA in Scotland and Chair of the Institute of Cemetery and Crematorium Management, Scotland & Northern Ireland Branch. It was they who had informed their most recent manager, Lucille Furie, about ashes being available from non-viable foetuses. The Operators told the Investigation that when she moved to Maryhill from Glasgow City Council, Lucille Furie brought with her the belief that cremations of non-viable foetuses did not result in bony remains. It was only their practical demonstrations that convinced her otherwise.

13.3 Policy, Guidance and Training

It seems to have been accepted by Cremator Operators at Glasgow Maryhill Crematorium that infant bones survive cremation. Their own experience informed them that even with small non-viable foetuses there can be identifiable bones. One Operator told the Investigation,

"Every one of them is very, very difficult. We tend to take a bit more care. We always have here, I must admit, taken more care … We've always used a tray here. I've heard that some crematoria don't and I don't understand why they would say that and I've heard that it's a year or two years [the cut off for ashes] ... I can't understand that. Personally I've had a small non-viable foetus (as they regard it) and there's still bone there. You're talking the size of fish bones but I know a bone when I see one. I've been doing it that long and for somebody to say that they can't get anything back…. and even if we don't see anything, everything that's in that tray, it doesn't matter if it's still a bit of a box that's in that tray, goes back to the family."

Referring to his experience of babies who have lived he said,

"[The ashes from] a one year old won't fit into a baby urn. This is why I can't understand folk saying there is nothing. It really is unbelievable."

The Executive Secretary, Gordon Armour, describing the Board's policy on returning ashes said,

"The position in Maryhill is that whatever was there you would always either give it back or dispose of it in accordance with the wishes of the family. There wasn't a view that nothing comes from this process."

The administrator responsible for paperwork at Glasgow Maryhill Crematorium told the Investigation,

"I have never been notified of a case where there were no ashes from an NVF or told there was nothing left at the end of the cremation. That's not happened. They always maintained that if anybody wants ashes back, they can have whatever there is."

The Investigation was interested in whether there were written policies and guidelines on the cremation process. A Cremator Operator said,

"We've got our manuals downstairs and we did have manuals when we started as well but there were more guidelines then than there are now. It's more advanced now as somebody's had a look at it and thought right we need to make this all one thing.

[The previous Manager] had the procedures but they weren't displayed. Well now I think Lucille [Furie] has them. There's a few new procedures being written since Lucille came as well. We worked on a few things and got it down on paper in black and white rather than hearsay. So if I want to check something I would go to Lucille instantly."

i Operational Practice

The Investigation interviewed five Cremator Operators and learned that three had only joined Glasgow Maryhill Crematorium from other crematoria in the previous two years. The other two had been there for approximately twenty-six and fourteen years respectively.

The Cremator Operators had undertaken the FBCA training in order to become qualified. The Cremator Operator with twenty-six years' experience told the Investigation about the training he received.

"I had to go over to the Linn Crematorium which was the training crematorium at the time and I went there for I think six weeks training...Then I just came back here and … that's when I got my certificate… Since then we've had the training for the new cremators going in but that was the training on how to operate them and the safety procedures but there's not really been any further training on actual cremating."

Further training, including refresher training, is not a standard requirement at Glasgow Maryhill and nor are there any arrangements for personal appraisals.

One Operator revealed that,

"when I first went to Glasgow Maryhill the only additional training I got was just on the machines because they were different machines."

In relation to cremating babies the Investigation heard that,

"There is nothing written down here that you have to follow, no guidance imposed on you by the owners as to how you should cremate a baby. It would just go back to a sort of code of practice that's accepted."

Elaborating on this the same Cremator Operator told the Investigation,

"At Maryhill there is a code of practice. It says all cremations must be carried out with the utmost respect. It does cover babies in a way, it just doesn't specify."

As at some other crematoria, the Cremator Operators work on a rota that involves spending time doing 'front of house' work in the chapels as well as cremating. A Cremator Operator described how,

"When you are front of house you are basically organising and overseeing and making sure that the actual chapel is running like it should do."

The Investigation heard that it is the practice at Glasgow Maryhill Crematorium to conduct foetal or infant cremations as part of the day's routine proceedings, and as soon after the funeral service as practical, not at any specific time of day. It has always been the Society's policy to endeavour to return the ashes to parents if they have requested them. The quantity of ash would vary depending on the age and size of the infant and the size of the coffin. Sometimes only a very small amount of ash would be recoverable.

A Cremator Operator who joined Glasgow Maryhill in 2011 said,

"we don't 100% say there's remains there, but you get back what remains are in the tray."

The crematorium's position on the return of ashes was understood by David Eagle, the Regional Operations Manager for Glasgow Co-operative Funeral Care and previously Funeral Home Hub Manager for Bellshill. He told the Investigation,

"When I started my career (c 2000) there was varying policies across each of the individual crematoria. … at Glasgow Crematorium, which is run by the Scottish Cremation Society up at Maryhill, it was a case of ask and we shall see. There was no guarantee but it was a matter of ask if there's ashes to be available then we will let you know. So that would be the information that we would convey on to families, particularly baby and infant families. Whether there were any ashes to be returned, we would not know until the cremation has actually taken place."

The Cremator Operators were asked by the Investigation whether any shared cremations had been carried out at Glasgow Maryhill Crematorium. Although it is lawful to cremate non-viable foetuses with other non-viable foetuses through shared cremation, this did not take place at Glasgow Maryhill and there was no contract with the NHS for cremation of non-viable foetuses. Nor, the Investigation was told, had a non-viable foetus or baby ever been cremated with an unrelated adult.

The Cremator Operator with twenty-six years' experience told the Investigation,

"There would never be an occasion where we would cremate more than one person's ashes together. I haven't experienced cremating a mother and child together, but if it was asked for, and if the family really wanted it, then you could say well certainly if you want to stay together. So you could have done it then but I was never asked for it."

13.4 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 baby trays, and the policies applied.

Most of the cremations that take place at Glasgow Maryhill Crematorium are of adults and many of the features of an adult cremation are replicated during the course of a baby cremation ^[57] .

i Cremators

At the time of the Investigation Glasgow Maryhill Crematorium was equipped with two Facultatieve gas-fired cremators. They were the FTII and the FTIII, installed in 2013 and 2014 respectively. Both are double-ended with Light, Standard, Heavy, Special, First and Infant modes. The current machines replaced two Tabo cremators installed pre-1990 which were upgraded in 2009.

The cremators are primarily designed for adult cremations with the coffin charged (inserted) at one end through a large door. After the cremation the Operator places a rake through a much smaller door at the opposite end of the machine, where there is a spyhole through which the Operator can observe the progress of the cremation. The ashes are raked into an ashes cooling pan underneath this rear door.

An automatic charger is used to transfer the coffin from the trolley and position it in the cremator. A Cremator Operator, described how he would cremate a baby where the coffin was too large to go in the tray (see below for information about the use of trays).

"You put the baby on its own on the automatic charger and the automatic charger puts the baby into the middle just as it would with an adult coffin. The setting would be infant setting. As with every cremation you look to see when the cremation is complete. Then you have to carefully pull them through the normal means through the back of the cremator, rake the ashes to that end of the cremator into the cooling tray and then they are in there for an hour. Then they cool and you can manually cremulate them. Same for every cremation, there is a card that follows the coffin."

Facultatieve described to the Investigation the effect of using infant mode. They explained,

"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."

Facultatieve anticipated there would be a manual override of the system by experienced Operators. Their advice was,

"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 ^[58] 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 ^[59]

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.

The Investigation learned that at Glasgow Maryhill Crematorium a tray has been continually in use since the 1980s. The Cremator Operator with twenty-six years' experience told the Investigation,

"We've always used a tray, since I started here twenty odd years ago and [a colleague] tells me that when he started 40 years ago they had baby trays here, which might have been a bit unusual because I know that not every crematorium had them then."

The same Cremator Operator described the benefit of using a tray. He said,

"If you use a baby tray no matter what size the coffin is, it can be the smallest NVF or a wee small box, there's always something in the tray and when I say always something it's like maybe a wee bit of ash from the coffin because they're in the tray and the air doesn't get in the same so it's not all blown over the cremator if you like. It gets contained in that tray so you always get something and if you look at it very closely sometimes there's tiny, tiny wee bones but what we gave them back was whatever was in the tray."

At the time of the Investigation there were two baby trays in use at Maryhill, one suitable for non-viable foetuses and the other for full term infants. The Cremator Operators confirmed that a baby tray is always used.

Executive Secretary, Gordon Armour, confirmed the crematorium's ability to retrieve ashes and the uninterrupted use of baby trays at Glasgow Maryhill Crematorium. He said,

"We've always, to my knowledge, had something recovered… Even with the old Facultatieve plant and without the modifications we were getting ashes and we never withdrew the tray at any stage because of health and safety so I've been told."

While in some crematoria the poor quality of the baby trays has been an issue leading to their withdrawal, this was not the case at Glasgow Maryhill Crematorium. A Cremator Operator explained,

"I know when the first lot that we had wore out with the heat and things that one of the Directors got a friend of his to make new ones right away so that they were there all the time. There wasn't any gap I don't think because we always had them. I don't know why we had them. We had two, both exactly the same."

A Cremator Operator with experience of cremating at Daldowie and Linn told the Investigation that the trays in use at Maryhill were more effective that those he had used in the Glasgow City Council crematoria. He recalled,

"Then when I came here to Maryhill I got a tray that worked and didn't buckle and an automatic charging machine."

The Cremator Operator with twenty-six years' experience cremating at Maryhill, gave the Investigation a detailed account of the process when cremating using a tray,

"The baby tray is just a rectangular metal tray with a deep side on it. It may be about four inches high all round and that's it. You bring the tray back out the same door you put it in. We use a metal hook and there's handles on the baby tray that you can catch it and just pull it out. It's actually quite flat. It gets lifted down and put down to cool.

What we're using at the moment over it is actually a door from the old crushing machine. That's a stainless steel door and it's fireproof so that goes on the hot tray… if you don't put something on it as it's cooling, what's in the tray sparks and goes everywhere and you would finish up with dust everywhere. Part of the coffin and maybe part of the baby would be on the floor if you didn't cover it and that's bound to happen.

When it cools what we do is empty it into either one of the cans that the adult ashes go into or if it's very, very little then we use a pestle mortar and we cremulate that. We brush all the tray down. We brush everything down into a corner. It's a bit awkward to be honest with you but there's not much other way of doing it. So you brush it down into the corner. The tray is lifted up and whatever's in that is brushed out. If I hold the tray up someone else will brush out what's in the corner into it and they would just crush it up by hand and then it's put into the wee bag and the baby urn and that's the process. The wee urn is put into a wee box and the label goes on the box…

With the tray being so hot you would tend to leave the babies till the end of the day; put them in the tray and you would cremate the baby last thing at night so that you could take the tray out in the morning which, although it would still be hot, was cooler but it was difficult to touch…You can imagine trying to pull it out if it was red hot. You could easily have an accident, but that was the way it was done. When you used to do it by yourself the only precaution was leaving it till the last thing at night and then there would be two of you to deal with it in the morning. Now it's done in its order mostly."

iii Dispersal of Ashes

Only two options for instructions for ashes are used at Glasgow Maryhill Crematorium. They are 'scatter' and 'take away'. The instruction 'N/A' or 'no ashes' is not available on their computer system.

The Executive Secretary, Gordon Armour, described the policy at Maryhill about the retention of ashes prior to their disposal. He said,

"The legislation deals with the norm and it says within twenty-eight days but historically we tended to hold on to the ashes longer than the twenty-eight days. We would tend to hang on to them for quite a while and make a few phone calls with the Funeral Director."

According to a witness with twenty-six years' experience of being a Cremator Operator at Glasgow Maryhill Crematorium,

"Scattering of ashes we do a month after, because when I started at first it used to be the next morning that you scattered the ashes but I didn't think that was right because people are in grief and they might make one decision and then regret it. So we actually talked our bosses in Bothwell Street into keeping them for a month so it gave the people a wee chance to change their mind. But they weren't always scattered exactly at the end of the month. We would phone the Funeral Director and say, 'look these ashes are coming up for scattering'. Sometimes they would be there for three months but you would give them every opportunity to change their mind."

Comparing this practice with the system at Daldowie and Linn another Cremator Operator said,

"There are times when ashes lie there and nobody comes to get them. We give them four weeks' notice at Maryhill which is four weeks longer than you would get at the Daldowie and Linn. There it was always the next day but here we give them four weeks' grace and sometimes you do have to phone up an Undertaker and say 'why have you not picked them up?' One or two can end up like, 'oh we thought the family were going to do it' or 'let me phone the family and I will phone you back'. If they don't phone back we chase them a wee bit. At the end of the four weeks I think the presumption is that if you are not picking them up we will be scattering."

The Investigation learned that in reality ashes are sometimes retained at Glasgow Maryhill for far longer than four weeks. A Cremator Operator explained,

"Normally it's the Undertaker who collects the ashes. The Undertaker's contacted and it's up to them to take it away and then contact the family. Normally we leave it for another fortnight. It's the whole pressure thing as well. You don't know how the families are feeling either. Whether they're wanting them back right away and can they handle that so we just let the Undertaker know. They'll get in touch with the family. It's their responsibility. We've not got the details for that anyway and if they do not come back to us we're supposed to scatter the ashes like adults every four weeks so they're kept and then they're scattered the following month on that date. But with baby ashes because we've contacted the Undertaker and because we've not had any answer back we're not then bound to do anything with ashes. We have to wait until somebody comes back and gives us some sort of clarity of where they're going and what's happening."

The Investigation learned from Gordon Armour as well as some members of staff that reluctance to scatter ashes in the absence of a very definite instruction has led to problems with unclaimed ashes being retained indefinitely at Glasgow Maryhill Crematorium. An example of such a situation was where a family,

"had moved house and the Undertaker is still trying to get in touch with them."

However, there were other situations (referred to below) where, according to the Cremator Operators, Funeral Directors had initially told families there would be no ashes. When told by the crematorium staff after the cremation that ashes were in fact available, the Funeral Directors had apparently been reluctant to go back to families with this information. This led to an increase in the ashes retained at the crematorium and decisions having to be taken from time to time on how to dispose of ashes that were not collected.

At Glasgow Maryhill Crematorium land space is limited and a key experienced Cremator Operator described how over the years the area for scattering of ashes had moved. He told the Investigation,

"They used to be scattered in the Garden of Remembrance. There's a map somewhere … It just became full. So we decided to turf the rose beds over and use the area at the back of the crematorium. I think that was about fifteen years ago. They call that the Garden of Reflection.

If someone wanted to know where ashes had been scattered you couldn't point with any particularity. It would just be in that area. It might be 1,100 yards x 60 yards or so but I'm not really sure. When I came here at first … you had twelve beds over there and each bed was for a month of the year. So as we took them out at the end of a month we would go in and we could look at the date and say well that's May, June or whatever and they would be buried in that bed… they're just scattered on the grass now but that's the way it was done. So you could at that time say where they were."

A Cremator Operator told the Investigation,

"I don't think I've ever came across a situation where a baby's ashes have been down for 'scatter without anybody attending'. With an adult's cremation we get instruction a lot of the time to scatter ashes…. But with a baby I certainly don't think that's ever the case."

During this Investigation an anonymous letter was received alleging that there were boxes of unclaimed ashes, including two containers of babies' ashes, at Glasgow Maryhill. The Investigation passed this information to the Executive Secretary, Gordon Armour, who instigated an audit which revealed that there were five sets of baby ashes, including the two previously identified, as well as the ashes of twenty-five adults. Although none of the ashes related to cases referred to the Investigation they were relevant to the Investigation's wider terms of reference that include " a more general investigation into practices and operations at any specific crematorium where case-specific investigations give rise to more general concerns". Gordon Armour has made it a priority, where possible, to inform families about the existence of the ashes and to ascertain and carry out what they wish to happen next. As at March 2016 he had made final arrangements with three out of the five families with regard to their babies' remains. Going forward, ashes will be reconciled every month and the person scattering the ashes will sign to say this has been done.

13.5 Administration and Record Keeping

Record keeping for Glasgow Maryhill Crematorium is carried out by a dedicated member of staff at Scott Moncrieff, Chartered Accountants. This role involves receiving and processing the forms required for a cremation to take place at Glasgow Maryhill Crematorium and to complete Form G, the Register of Cremations. The current post-holder has held the position since 2008 and is based at an office in Bothwell Street.

Maintaining a Register is a statutory obligation, though not in relation to non-viable foetuses, involving the recording of the cremation number, date of cremation, date and place of birth, age and gender of the baby, name of the Applicant for Cremation and disposal method/ final resting place. Previously typed manually, the Register of Cremations has been computerised since the introduction of the BACAS administration and booking system from ClearSkies Software in 2004.

The member of staff responsible for the administration explained to the Investigation that the options for ashes' disposal are contained in drop down boxes on BACAS. They consist of 'scatter' (with or without family attending) and 'take away' (by the Funeral Director or other).

The administrator explained to the Investigation that the same options apply to a non-viable foetus.

"The Form A for an NVF has a disposal instruction on it. If they want to take away they can have what they want. If there's anything there they can have it. The request is ashes to be taken away."

In relation to the option 'no remains' available in some other crematoria, she explained,

"There has never been an option on the drop down menu on BACAS to say 'no ashes' or 'no remains'."

The system records whether ashes have been dispersed in the Garden of Reflection or taken away for private disposal. In the event that families return ashes to the crematorium for disposal, this will be recorded.

There is no legal requirement to keep any record of cremation of non-viable foetuses. However, a non-statutory Register is kept at Glasgow Maryhill Crematorium.

i Findings on Record Keeping

Of the four cases referred to the Investigation, two date from 2002. These are twins, one of whom was stillborn and the other lived for two days. The Investigation was told that cremation records held on microfiche, which should have been retained for fifteen years, were accidentally destroyed leaving only the Form G, Register of Cremations, entry available to the Investigation. The recorded ashes disposal entry is 'T/A' meaning 'take away'. Unlike other Register entries there is no recorded date of uplift in the Register, and the family did not get the ashes.

An email from the Administrator to the parents explained,

"I can advise you from the hand written statutory records that the ashes, if any, were to be taken away. There is no record of a date being recorded for the ashes being collected and per our statutory forms 'Ashes not collected within one month will be dispersed in the Crematorium grounds'. On that basis I am led to the conclusion that the ashes would have been scattered in the Garden of Reflection. I realise that this may not provide the details you were particularly seeking and I can only apologise for this situation."

Both the twins' parents could remember a discussion about ashes at the hospital. They had received support from someone they understood to be the Head of Department or Chief Midwife. Speaking of her, they said,

"She was very nice and she was very supportive throughout the process. She was very direct in stating there will be no ashes. 'You don't get ashes from babies'. She said their bones are too soft."

The mother, who had particularly wanted the babies cremated at Glasgow Maryhill so they would be with a close family member, described her feelings.

"…when the twins passed away we went up to that graveyard every month for a long time after they died. If we thought that my kids' ashes were sitting there and to be told that I've not bothered to pick them up or whatever the situation it is. People see how upset you are. You can imagine the day of a funeral with your children. You've got all these dreams ahead of you and it all comes crashing down just like a building.

For me now to go through this and to explain it makes all that grief raw again when you should be moving on. Having been told there were none I had no expectation of there being ashes and I would have never thought to go and ask because I'm listening to what the hospital's told me."

The Funeral Director had confirmed to the mother that there would be no ashes. The mother recalled,

"I distinctly remember asking during that call as well and getting told that there won't be any ashes and I remember just feeling silly to ask it again but I think I just thought I could have got the ashes."

The father of the twins added,

"You're trying to deal with a situation. So if somebody tells you something you just get taken along and you just accept it. You don't actually question it or think about it. They do this every day. We had never been through this.

So it seems disappointing from my point of view that we've been misled or misinformed, though from the midwife's perspective I don't think it's been a deliberate attempt to misinform.

Ultimately we would like to know where they were scattered and if it was in the gardens. At least we can go and understand that. And also to make sure that they weren't just discarded. They weren't just thrown in the bin."

The mother said,

"I just can't believe really that we're still talking about this. It's so upsetting. We don't want this to get somebody into trouble. We just want an answer to what happened."

The Funeral Directors have also told the Investigation they do not have the ashes nor any paperwork relating to these babies despite the hospital confirming that their records show the twins were collected by Co-operative Funeralcare.

In a 2010 case involving a baby girl delivered at around twenty-four weeks' gestation and referred to as a non-viable foetus in the relevant paperwork, the mother remembered discussing the forms at Glasgow's Southern General Hospital. She particularly recalled that the midwife,

"went through this in quite a lot of detail and it said that we must be aware that because the baby would be so small the chances were that there wouldn't be any ashes. But the crematorium would contact us if there were ashes so that we could dispose of those how we chose to."

According to The Co-operative Funeralcare in a letter dated 2013 to the parents' MSP, the cremation was arranged under a contract between Funeralcare and NHS Greater Glasgow and Clyde and the paperwork was filled in by a representative of the NHS.

The instruction on the Form A was 'N/A' (interpreted as no ashes or not applicable) and appears to have been written by the Midwife. A letter that the parents passed to the Investigation from the NHS Chief Executive to the parents' MSP in 2013 informed them that, due to the passage of time, it was not possible to explain the choice of instruction. The letter confirmed that,

"the instructions contained within the policy that was available for staff use at the time were as follows, 'Any ashes, which will have been placed in a casket, can be collected the following day. There may be very little or no remains from cremation of a baby. Parents should be advised of this'. This part of the policy remains the same today."

Despite the Form A (Application for Cremation) suggesting there would be no ashes, the ashes disposal column on the Register had the entry 'scatter'. The Investigation asked the Administrator where that instruction had come from. She said,

"When 'N/A' is written on a Form A, I understand that means parents have been told there will be no ashes following the cremation of their baby. In those circumstances I would enter 'scatter' as the instruction in case there were in fact any ashes as something would need to be done with them."

As Cremator Operators do not see the Form A, it is assumed they followed this instruction from the Administrator, meaning that any ashes from the baby's cremation would have been scattered without the parents' knowledge because of the Administrator's action.

When Gordon Armour, Executive Secretary, was informed about this specific case he said he was very surprised. His view was that,

"If ashes were recovered in circumstances where the Undertakers had an understanding that there may be no ashes, or there may be a difficulty regarding ashes, and they were to say they're not likely to get ashes or there will be no ashes and score this through on Form A then I would go back to them. It's my understanding (and some of the Board members have been on the Board for quite a long period of time) that the baby trays were something that we've had for a very long time and we've always, to my knowledge, had something recovered. Therefore we wouldn't have the expectation that there wouldn't be ash."

A Cremator Operator who has cremated at Maryhill for many years told the Investigation that in his experience not all Funeral Directors were happy to pass on the message that there were ashes once they had informed a family to the contrary. He described the response of some as,

"Oh we've told the family there will be nothing so just leave it at that. They didn't want to go back to the family. And there were times as well that we had ashes there even although they were down for a scatter but we still phoned them and said 'look there are ashes here'. They might say 'we don't want to upset them'."

This scenario was, he said, not unusual,

"If they [Funeral Directors] had put the ashes down for a scatter, they never wanted to get a family and say, 'look we've spoken to the crematorium and there will be ashes there'. They always felt that it would upset somebody by saying that and they didn't want to upset people. But I would have thought it would have been better just to go and tell people that there will be something there."

The Investigation asked what would happen to those ashes. The Cremator Operator replied,

"Well we would probably scatter them. If they don't want to come and take them then we would scatter them."

13.6 Communication

A Cremator Operator told the Investigation he had no experience of meeting and sharing good practice with Operators from other crematoria. Another Operator agreed.

"I've been nowhere else and don't have contact with other crematoria."

One of their colleagues told the Investigation he had made visits, but outside work hours,

"because it's something I like to do in my own time and see other colleagues in the other parts of the world."

Asked whether they had any contact with bereaved families one of the Cremator Operators said,

"I'm open to talk to families if they want. If they want to ask me as many questions as they like they are very welcome."

A willingness to speak to families was confirmed by one of his colleagues who told the Investigation,

"Some people would come up and visit the crematorium. I would always go out on a Sunday and speak to folk and just show them round and talk to them. I like to get folk downstairs and show them the procedure and some of them are a wee bit nervous about it but when most of them do it they feel better if they have taken ashes away and you show them what the procedure is… once they see how it's done they do feel better about it."

On whether Funeral Directors wanted to know more about the cremation process a Cremator Operator explained,

"I talk to Undertakers regularly in connection with general things, how's life, how's work? They probably talk about ashes and particular cremations sometimes but not that I can remember. But they don't make it a point to talk about it all the time, they are curious at times, some of them will come down and say, 'So what goes on?' and we are quite happy to give them a tour."

One of his colleagues firmly believed that not all Funeral Directors and hospital staff were well informed about cremation, leading to the less knowledgeable providing families with inaccurate information. Identifying a need for greater sharing of information between hospitals, Funeral Directors and the crematorium he was asked what was needed,

"I think informing people better at the very first point with the Funeral Director or even at the hospital. The hospital should be sending people out here who deal with families when they've had a baby or any death really."

The same member of the crematorium staff spoke about the myth that there are no ashes from babies. He said,

"The Funeral Directors - a lot of them seem to have this idea and I think that came through the District Council - that there would be no ashes under a certain age because very often we would phone and say 'look, there will be ashes from this. We always get something'. I'm not saying it will be bone but there will always be something in that tray."

On whether it was the responsibility of crematoria to educate others, the same Cremator Operator told the Investigation,

"As far as the baby ashes are concerned I think we've always done the right thing in trying to advise the Funeral Directors but they didn't always listen to us."

He was incredulous about some Funeral Directors' level of understanding.

"We've been told that Funeral Directors were being told that there would be no ashes for a year and under. I mean a year, that's a full-grown baby. The ashes from a year old baby wouldn't fit into a baby urn. You would have to give them a normal adult urn of maybe say a third full and there would be more than enough for that but too much for a baby urn."

His colleague agreed that some Funeral Directors lacked awareness of the availability of ashes for babies. He told the Investigation,

"I think the Undertakers need a bit of guidance on it. You would think they wouldn't, but I think they need a bit more guidance."

The same Cremator Operator was of the opinion that poor communication between some Funeral Directors and their staff resulted in families receiving inaccurate information. He said,

"the Funeral Director will sit with the family and take all the information and will mark down whatever he has to mark down but it's then up to the office girl to deal with all the paperwork and the aftermath of all that and to me there's no communication between both parties.

I wouldn't categorise it as everyone - certainly not every Undertaker but there have been times where girls from the office will call up and they will say, 'Oh I thought there wouldn't be anything'. This would happen time and time again…"

This he suggested might be due to,

"just a few individuals who may be not paying attention."

Ultimately he did not, however, believe that the Funeral Directors alone were responsible for creating the misleading messages. Some crematoria did indeed apply distinct cut off dates for ashes depending on foetal age. Furthermore, he believed the FBCA guidance about ashes consisting of skeletal remains had contributed to the confusion.

The Executive Secretary Gordon Armour was certain that any message to the effect that there would be no ashes would not have come from the crematorium. Discussing a Maryhill case with which the Investigation was dealing he said,

"If in one of the cases from 1994 the baby's father was told there would be no ash by the Funeral Director that definitely wouldn't have been from us. I could say that with confidence because of my discussions with the Directors who have been there for a lengthy period of time and indeed my immediate predecessor and his predecessor. Certainly it was his recommendation that we've always had something so we would not have been saying that there wouldn't be any ashes. We would have said there's no guarantee of what you're getting is human ash. It may be residue."

13.7 impact of Mortonhall Investigation and the Infant Cremation Commission

Since Glasgow Maryhill Crematorium has routinely used trays for infant cremations and returned ashes to families over many years, they had no need to make operational changes in these areas following the publication of the Mortonhall Investigation Report and the recommendations made by the Infant Cremation Commission.

It did however take the media attention surrounding Mortonhall to alert some Funeral Directors to the fact that Maryhill was able routinely to furnish families with their babies' ashes. This was explained by a Cremator Operator who told the Investigation,

"I think it's only since the Inquiry started that they started to think maybe that we are being told the truth by the crematorium and maybe there are ashes. I think that's only when it changed."

13.8 Conclusions

1. The Investigation noted Glasgow Maryhill Crematorium's history of returning ashes of babies to their parents, although this did not always happen as the outcomes of the four cases referred to this Investigation demonstrate. Although members of the FBCA they did not use the Federation's definition of ashes as 'skeletal remains'. Discussing this topic, Executive Secretary Gordon Armour offered an explanation for Glasgow Maryhill Crematorium adopting a different approach from that of some other crematoria. He told the Investigation,

"As to why culturally the profession really didn't focus on the scattering of ashes over many, many years I think that there's a fundamental difference in the way we're organised as a charity because the Board are very concerned that we shouldn't just comply with the legislation but we should also be thinking about what we're doing. This issue has if anything strengthened that view on the Board. I feel that with the Local Authorities the structure is so different that we have the advantage of being a small organisation."

2. The evidence that Cremator Operators at Glasgow Maryhill Crematorium have for many years been able to retrieve ashes demonstrates what can be achieved by experienced Operators even when using less sophisticated machinery. Commenting on these achievements by his predecessors one Cremator Operator told the Investigation,

"We have baby urns in the columbarium there. We have a big tower there. It's got 3,000 sets of ashes in it and we've got wee baby and stone urns and there's ashes in them from a hundred years ago. So they must have had baby trays or something similar to the trays we have even back then because as I say there are ashes in there that are a hundred years old and they're baby ashes. So they were able to collect them all that time ago without any modern equipment or anything."

3. While the number of cases relating to Maryhill referred to the Investigation is small, the distress caused in individual cases should not be underestimated. In one case it has not been possible to investigate fully due to the accidental destruction of the relevant records. No reason as to how this happened has been provided and the undated disposal 'taken away' recorded in the Register of Cremations does not afford closure to the parents as they did not receive any ashes.

4. In another case the Form A Instructions for Ashes entry is 'N/A' and the entry in the NVF Register is 'scattered'. Despite the Crematorium's success at returning remains to families, this was not universally understood by NHS staff and Funeral Directors. It is perhaps not wholly surprising that, faced with different outcomes at other crematoria, they may have made inaccurate assumptions about what could be done and where. With the benefit of hindsight the situation might have been rectified by a call from the crematorium to the hospital or Funeral Director to advise that there would, more likely than not, be ashes and to ask what should happen to them. There is no evidence that such a call took place or if it did what the response was. The crematorium's Executive Secretary was surprised that the crematorium's administrator entered 'scatter' as the final disposal without reference to the parents.

5. The absence of a very definite instruction has led to problems with unclaimed ashes being retained for many years at Glasgow Maryhill Crematorium. The new Burial and Cremation (Scotland) Act 2016 will address this issue for the future.