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

14 Kirkcaldy Crematorium

14.1 Introduction

A total of five cremations of infants, babies or non-viable foetuses conducted at Kirkcaldy Crematorium were referred to the Investigation. Four of these cases were from 2010 and one from 2011. None of these families had ashes returned to them following the cremation of their baby.

Kirkcaldy Crematorium was opened in 1959. It is one of two crematoria managed by Fife Council. The other is Dunfermline Crematorium. A large red sandstone chapel is set in woodland grounds. In addition to the Gardens of Remembrance there are beds of commemorative roses and azaleas together with a commemorative wall and commemorative kerbs. Books of remembrance for babies are displayed within the crematorium offices.

Generally, cremated remains can be either collected by next of kin or Funeral Directors on their behalf or they are scattered in the Garden of Remembrance. Ashes are scattered one month after the cremation takes place. The ashes are scattered in a different area of the garden depending on the time of year in which the cremation took place. There are four sections. There is a Snowdrop Garden at Kirkcaldy Crematorium specifically for babies. The crematorium has a relatively small number of infant and stillborn cremations (eleven in 2013) but a higher number of non-viable foetus cremations (sixty eight in 2013), some of which are 'shared' cremations where families have agreed that the cremation can be shared with other non-viable foetuses.

Two other Crematoria are situated in the area; Dunfermline Crematorium which is also managed by Fife Council and Perth Crematorium. Perth Crematorium is situated approximately 38 miles from Kirkcaldy.

Kirkcaldy Crematorium is equipped with two Evans Universal and one Facultatieve Technologies FT11 double-ended, gas-fired cremators. The Evans Universal cremators were installed in 1998 and the Facultatieve Technologies FT11 was installed in 2012. Prior to the installation of the Evans Universal cremators, Kirkcaldy Crematorium used twin flux cremators.

14.2 Management

i Structure

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

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

ii Approach

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

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

The Head of Service, Grant Ward, said,

"My contact with the crematoria has largely been through Liz (Murphy) (Bereavement Services Manager), so I wouldn't profess to have an intimate detailed technical knowledge of the crematoria or their operation...It's obviously become an area of much greater focus for us but I wouldn't want to profess that it was a sort of hands-on day to day involvement. I've got a range of responsibilities and I very much rely on Liz and I have every confidence in Liz."

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

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

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

A Cremator Operator said,

"no-one has come down from the Council for example to say is there a way you can get remains form a baby or have a look around and ask themselves whether there might have been a better way to do it. We had health and safety guys come down to assess our method and managers and hierarchy come down now and again"

Another said,

"Liz and Willie were there but I have not been at the crematorium when senior people from the Council have come to visit."

14.3 Response to Mortonhall Investigation and Infant Cremation Commission

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

"Any ashes present after a cremation will always be offered back to a family via the Funeral Director...If cremation is chosen instead of burial, bereaved families are advised that more often than not there will be no ashes/cremated remains left for return. This reflects the national guidance via the Federation of Burial and Cremation Authorities ( FBCA ^[60] )"

The Briefing Note goes on to say,

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

Despite this discussion there was no realisation that other crematoria were returning remains with the use of a baby tray ^[61] . The former Bereavement Services Officer, William Greig, who now works at Perth Crematorium, approximately 28 miles, away informed the Investigation,

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

Indeed a tray was in use at Dunfermline Crematorium between 1991 and the mid 2000's. Despite common management of Kirkcaldy and Dunfermline Crematoria there was no tray used at Kirkcaldy in the same period. It is clear however that the tray was taken from Dunfermline and brought to Kirkcaldy. It was not returned to Dunfermline and there is no record of what happened to it.

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

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

At the time of the briefing the baby tray (purchased in December 2012) had been taken out of circulation and was not re-introduced until May 2014.

14.4 Policy, Training and Guidance

i Written Policy

Although a former Operator, who left Kirkcaldy Crematorium 10 years ago, referred to " strict guidelines on what you could and couldn't do" he also went on to say,

"They had literature. They had books. They had brochures and things like that of how the machine should be operated but I'm not aware of any local operation procedures written just for the crematorium."

A former Cremator Operator stated,

"I am asked if I ever saw any literature about whether there were remains or not. The only thing we ever had was training manuals that was issued to us from the manufacturers and these manuals told us basically what we're to do and what we weren't to do and baby cremations were included in that meaning that you couldn't leave anything in overnight and things like that."

A current Cremator Operator told the Investigation,

"Although I've been trained and I've got guidance manuals from the manufacturer the Council have also got operational policy guidance on what I should be doing."

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

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

He also referred to older written procedures,

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

The Flowcharts issued in March 2010 shown to the Investigation do not set out any specific steps for non-viable foetus, stillborn or baby cremations. A draft flowchart for Baby Cremations dated December 2014 which shows the use of a baby tray was provided to the Investigation. John Swan, Corporate Development Lead Officer, confirmed that the baby tray was purchased in December 2012, but withdrawn from use in February 2013 following health and safety concerns. It was reintroduced in May 2014, and the flowchart was drawn up for the process of using the baby tray in December 2014.

Liz Murphy, Bereavement Services Manager referred to a folder of FBCA training notes ^[62] . However, she confirmed,

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

A Cremator Operator from Kirkcaldy's sister crematorium in Dunfermline provided the Investigation with an extract from a Facultatieve manual which stated,

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

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

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

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

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

A Cremator Operator told the Investigation of the current position,

"Although I've been trained and I've got guidance manuals from the manufacturer the Council have also got operational policy guidance on what I should be doing. The policy guidance basically covers the whole process from coming in the front door; checking the identification of the coffin as it comes through; charging it; cremating it properly; raking it out; cremulation of it; taking metals and that out of the remains. The Council guidance will be somewhere down there in the cremating area."

ii Training

The training of staff at Kirkcaldy Crematorium throughout the period has mainly been in-house training on general cremation practice. When it came to the cremation of foetuses and babies staff learned from their more experienced peers or supervisor. However special training for the cremation of babies was not included. The same trainer trained one of the Cremator Operators for Dunfermline but despite this the practice of using a baby tray was not adopted in Kirkcaldy Crematorium.

An external examiner from the FBCA attended after the Cremator Operator had carried out fifty cremations for the practical examination. No part of the examination referred to the cremation of babies.

14.5 Cremation Equipment

i Equipment

The two Evans Universal 300 cremators and the Facultatieve Technologies FT11 cremator used in Kirkcaldy Crematorium were upgraded in 2010 with mercury abatement software and then with software designed to improve monitoring and reporting of emissions in 2013. The upgrade also provided a new programme called infant mode. Describing infant mode, Facultatieve 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."

ii Baby Trays ^[63]

Bizarrely, despite having a common manager there was no consistency in relation to the use of a baby tray between the two crematoria within Fife Council.

Apart from a brief period when a baby tray was borrowed from Dunfermline Crematorium there was no baby tray used at Kirkcaldy Crematorium until the Bereavement Services Officer purchased a baby tray in December 2012 which was put into immediate use. An Internal Audit Report dated 5 ^th February 2013 noted,

"Serious health and safety risks associated with cremating babies."

A meeting took place on 13 February 2013 which was attended by Cremator Operators, the Bereavement Services Officer, a Health and Safety Officer, a Quality Control officer and others. The meeting decided that the baby tray was very unsafe, despite the guidance and advice on it use in the Facultatieve operating manaual and it was agreed that it was not to be used until further notice.

However, the Bereavement Services Officer, William Greig, told the Investigation, "No-one ever got hurt by a tray."

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

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

He is also attributed as saying,

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

There was discussion about obtaining a bespoke tray and everyone agreed that the way forward would be to purchase a baby cremator. The costs of this were to be investigated. No further notes or minutes have been supplied in relation to this. Despite this discussion a baby tray was reintroduced in May 2014.

A further Internal Audit Report dated 25 June 2014 documents the protection measures in place to reduce the risks associated with the cremation of babies to include the use of a screen to shield the tray from the work area. The items to be addressed in relation to the use of the baby tray were outlined as: a need to test the suitability of the material of the screen; the fact that some personal protection equipment had not been issued and the unsuitability of the tray for holding the baby coffin. No follow up actions on these issues have been provided to the Investigation. However it is worth noting that personal protection equipment had always been available at the crematorium. Thomas Graham, Support and Development Officer, told the Investigation,

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

14.6 Cremation Process

i Non-viable Foetuses

Non-viable foetuses were described as being cremated individually or in shared cremations with other non-viable foetuses. Those cremated in shared cremations came from Crosbie and Matthew Funeral Directors who had an arrangement with Forth Park Maternity Hospital until it closed and since then with Victoria Hospital Maternity Department. These cremations were termed 'multiples' which meant that there were a number of foetuses in a cardboard box. These were sent to Kirkcaldy Crematorium once a month. The term, 'individual non-viable foetuses' meant that there was just one non-viable foetus in the box. Occasionally a non-viable foetus came in a coffin.

The cremation process was the same for individual and shared non-viable foetuses. The box was placed just inside the cremator directly on to the solid hearth and then pushed further into the machine so that the box or coffin was under the main burner (contrary to the manufacturer's instructions) which was at the top end of the machine. The door was closed and the details of the non-viable foetus or non-viable foetuses were entered into the machine. Infant mode was not available until 2013 (and not used until 2014) and the standard mode would have been selected. The 'airs' which are the method of ventilating the machine would then be changed to direct them to where the Cremator Operator wanted them to focus.

One Cremator Operator told the Investigation,

"When you cremated NVFs under the previous procedure before the tray, I don't think there were ever remains. If you saw some remains you would always try to rake it out. I can't actually remember trying to rake out after them. You were told you wouldn't get them back from an NVF but then that wouldn't make any difference because you'd always check."

Another said,

"We were not able to recover anything before trays. As soon as I open that door to put the rake in, everything is just moving, just turbulence. This is what we get, fly ash, so no nothing was recovered. You would look but if it's a non-viable foetus I could pretty much guarantee the way we were cremating before there was just nothing there to rake. Obviously if you have got the door open and you take a visual check and there is nothing there then you wouldn't rake anything."

Another said,

"I was taught to put it (the baby) in right under the flame and just hit it (the baby) with the flame. The effect of that was that there was nothing left at all.

I'd visually look and if there was nothing I'd just leave it but if there was something I'd try and take it out, but normally it's like talcum powder. Anyway by the time it gets down to the funnel for sitting in to cool there was never anything. I can't recall a time when I did manage to recover any remains of NVFs under the old (pre-baby tray) system."

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

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

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

Dr Clive Chamberlain, a Chartered Engineer, member of the Council of the Combustion Engineering Association and expert witness to the Mortonhall Investigation ^[64] explained in his evidence why manual intervention in the cremation process is beneficial saying,

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

William Greig, former Bereavement Services Officer, confirmed that afterwards they raked the cremator out and dispersed what was there,

"Not all the time there was something there. Sometimes there was. Sometimes there wasn't. If there was something there we dispersed the ashes in the baby gardens and we used to tell the parents."

William Greig also said,

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

A former Cremator Operator who had worked with the old twin-flux cremators with a honeycombed wall (which meant you heated one side from the previous cremation) advised that with those machines the box or coffin was left overnight with the machines off. He confirmed that when using the 'old' machines Cremator Operators were able to brush up the cremated remains the next morning. He said with regard to the new cremators,

"The question was raised then, 'so what do we do?' and it was that well you can't do anything. There's no way you can get cremated remains. We the Operators raised the question."

ii Stillborn babies and Infants

This process was described as similar to the process for non-viable foetuses. A Cremator Operator told the Investigation,

"I didn't really get remains under the old (pre-tray) system…Because I'd put infants, stillborns and NVFs right in the path of the main burner. That's where it's hottest."

The manufacturer, Facultatieve told this Investigation that,

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

Another Cremator Operator told the Investigation ,

"With a stillborn, the process was much the same prior to the trays and you couldn't guarantee there would be remains left. I'm pretty sure I cremated a stillborn under the old process; I think I got remains but it was a long time ago. As soon as you open the machine the suction goes down in the machine. If ashes were recovered what would happen to them would depend if they were wanting them back. If they were then they would get them back. I'm not sure exactly what the instruction was in those days if we were to get remains when we didn't expect to.

With infants who have actually breathed, prior to the use of the trays, again it was just the same process.... I'm not sure if we were able to recover ashes."

Another Cremator Operator summed up the prospect of getting remains,

"If there was evidence of something there they would have got them back and the chances would be increased the bigger the baby and the bigger the coffin."

iii Definition of Remains

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

"I've never heard it said that you would never get ashes from a baby under a specific age. I mean we were basically told years ago that you weren't likely to get remains back from under a full term cremation. I think that was just passed down from whoever was teaching."

Staff members used the terms 'ashes' and 'remains' interchangeably and all shared the view that it would be comforting for families to get something back. A Cremator Operator said of Non-viable foetus cremations,

" NVFs would normally come up in a cardboard box so there is fewer remains at the end of that, it's what we call fly ash, it's paper really as opposed to a coffin where it is actually wooden. From my experience since the tray was introduced I would pretty much imagine parents are grateful even to get fly ash."

In contrast to another Operator's evidence, William Greig, former Bereavement Services Officer, explained that what was seen as 'fly ash' and not remains was dispersed without the knowledge of the family,

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

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

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

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

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

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

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

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

In the same article William Greig, former Bereavement Services Officer, is attributed as saying that the whole system for babies and infants was different,

"The whole process is gentler and wherever possible, we will try to get some ashes for the family."

While that may have been the case after the tray was introduced (in the same month as the article was published) it contradicts the evidence given to the Investigation by Cremator Operators at Kirkcaldy that, prior to that, non-viable foetuses, stillborn babies and infants were placed directly under the main burner.

Liz Murphy, Bereavement Services Manager, told the Investigation,

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

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

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

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

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

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

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

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

Liz Murphy confirmed that the subject of infant ashes never came up at FBCA or ICCM ^[65] meetings prior to Mortonhall.

Liz Murphy described the issue of ashes as,

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

She went on to say,

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

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

Thomas Graham Support and Development Officer told the Investigation that Cremator Operators are quite concerned that what is left after cremation is coffin ash. Despite the publication of the Mortonhall Investigation Report and the Infant Cremation Commission Report ^[66] , staff members had clearly not been briefed on the findings of the Forensic Anthropologist and expert witness to this and the Mortonhall Investigation, Dr Julie Roberts, to enable them to understand fully the physiology of baby cremation.

14.7 Administration and Record Keeping

i Bereavement Services

Official administration and record keeping for Kirkcaldy Crematorium is handled by the clerical officers based at an office situated at the gates of the crematorium.

There are two clerical officers in charge of the processes. They are now line managed by the Business Support section of Fife Council but rely on the Bereavement Services Manager, Liz Murphy, for immediate guidance.

Funeral bookings are made by Funeral Directors and booked into the diary system on the BACAS system ^[67] (the computer record keeping system) which was introduced in 2001. The office faxes confirmation of the date time and name of the deceased to the Funeral Director.

When all of the paperwork is checked, the information relating to the cremation, to include what is to happen to the ashes, is added on to the BACAS system and the paperwork is printed off for the Cremator Operators including sticky labels for the ashes container. One of the Cremator Operators collects the papers for the next day.

The crematorium staff now have access to BACAS, which was introduced in 2001,

"After the cremation takes place I'd get the paperwork back to let me know if the ashes are a 'take-away'. This lets me know if the family or the Funeral Directors will collect them so I'd get take away slips back signed to say who has actually taken the ashes away."

This information is also added to the BACAS system. However if ashes are dispersed this is not confirmed,

"I don't get confirmation from the guys that it's (dispersal) been done, I only get it when the ashes have been taken away and by whom."

Liz Murphy Bereavement Services Manager said,

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

The instruction for the ashes has already been put into the BACAS system before the cremation but if something changes then an amendment slip is generated and the instruction is changed showing who advised of the change.

Non-viable foetuses are given a separate number. The paperwork for shared cremations comes from Crosbie Matthew, the Funeral Directors. They have an arrangement with the hospital (historically Forth Park but now Victoria) and the foetuses are identified by a reference number only. The paperwork is signed by the hospital mortuary attendant for shared cremations of non-viable foetuses.

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

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

ii Records kept at the crematorium

There has not always been an option for 'no ashes' or 'no remains' in the BACAS ^[68] computerised recording system. A clerical officer was asked what she would do if she was told there were no ashes and she replied,

"It's usually 'disperse' because on the application form I get from the hospital or should I say Crosbies [Funeral Directors] they will say what is to happen to the ashes. They will circle what is to happen with the ashes. If ashes have to be dispersed in the gardens I will just put dispersed in the A section which is the baby section. That was the case before the trays."

When asked if a situation might occur where the family are told there are no ashes but the record shows dispersal. She replied,

"Aye. BACAS has been changed to give me the option now, but historically that would be a problem. I have always been told there is no ashes before the tray, but that wasn't an option available to me on BACAS."

Another clerical officer confirmed that the non-viable foetus paperwork from the hospital has changed and now gives options for ashes whereas before it did not and it was assumed that the instruction was to scatter in the Garden of Remembrance,

"Before that if it was a non-viable foetus, unless we were told differently it was assumed that the ashes were going to be dispersed in the gardens. Now the parents have got a say."

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

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

Liz Murphy, Bereavement Services Manager told the Investigation,

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

The Investigation contacted Martin Caxton, the General Manager of Clear Skies Software which supplies the BACAS programme to Fife Council. He told the Investigation,

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

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

The BSI assessments made no reference to any difficulty with the computer recording system.

14.8 Communication

i NHS Evidence

Liz Murphy, Bereavement Services Manager told the Investigation,

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

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

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

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

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

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

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

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

This was also the position of the Scottish Government at the time and was confirmed by the Chief Medical Officer in 2012.

This information has still not been updated at the time of writing even though Fife Council crematoria have been returning ashes from every cremation since at least June 2015 (the date from which they were required to report any instance of non-recovery of ashes).

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

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

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

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

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

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

Dr Tydeman continued,

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

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

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

The information given to parents by NHS Fife is still that ashes cannot be guaranteed despite a one hundred per cent success rate in retaining ashes at Kirkcaldy since the introduction of the baby tray. The Foetal Midwives told the Investigation ,

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

The current checklists used by midwives with bereaved families state,

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

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

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

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

Sheila Matthew, Director of Crosbie Matthew confirmed that the Form A was normally done at the hospital but went on to say,

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

ii Funeral Directors

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

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

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

"Because of the delicacy of matters I have in the past with one or two that has just been down as 'dispersed' picked up the phone myself, phoned Crosbie and Matthew and they then spoke to the families themselves to make sure that they are getting the correct information from the hospitals or wherever."

He added,

"...if the family have come to the service and it's on the ticket to say you know scatter in the gardens I would normally say to the family and so would my colleagues, 'if there is remains would you like them back?'"

The former Bereavement Services Operator, William Greig said of Funeral Directors,

"They were saying that there were not going to be any remains on foetuses. Well 99 times out of 100 if it was an actual baby then we got remains"

A Funeral Director told the Investigation,

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

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

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

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

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

He went on to say,

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

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

A Cremator Operator confirmed to the Investigation,

"Sometimes if the family is really desperate to get them (ashes) the Funeral Director might come to me and ask 'Will we get ashes from that cremation'…but again all I can say is if there's ashes you would get them. If there weren't any then you couldn't."

The Investigation was shown the sample letters sent out by Crosbie Matthew. The letter sent in relation to non-viable foetuses states,

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

This does not reflect the current position at Kirkcaldy and Dunfermline Crematoria where ashes are obtained from 13 weeks' gestation.

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

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

He went on to say,

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

It is clear that Funeral Directors working in Fife understood there to be no possibility of returning ashes from non-viable foetuses and young babies to families. It is much less clear why, that being the case, they often completed Applications for Cremation with an instruction that the ashes should be dispersed. Nor did there appear to be any curiosity about whether ashes could be retrieved from a different crematorium or willingness to explore such an option to families who were distraught at the idea of having nothing left of their baby.

iii Communication between Partner Organisations

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

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

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

iv Bereavement Services Group

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

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

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

14.9 Impact of Mortonhall Investigation Report and the Infant Cremation Commission

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

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

It goes on to say that,

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

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

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

A Cremator Operator said,

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

Another said,

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

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

Since the full introduction of the tray at Kirkcaldy the Crematorium has successfully recovered ashes in all cases from around 13 weeks' gestation onwards.

i Staff Reaction

Cremator Operators described to the Investigation how upset they felt because they previously were not obtaining ashes and could have been. Liz Murphy told the Investigation,

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

Working practices and the failure to modify those were the cause of the failure rather than any understanding of the definition of ashes. Cremator Operators expressed disappointment that other crematoria had been obtaining ashes for years and they did not know about it. A Cremator Operator told the Investigation,

"When we started using trays and realised you got something back to give to the parents we were all, I mean, I am, generally gobsmacked. From the tiniest NVF at 12 weeks because we are using this baby tray, I mean what it looks like to me is like if it's the ribcage it looks like a nail clipping and were just told that that wasn't possible. We didn't know that places like Seafield Crematorium in Edinburgh have been able to use the tray for years and years and years."

Another Cremator Operator said,

"I did start to think about it when I was using a tray and I think the other boys will say that as well…it hits home to me now that I'm able to recover something using a tray where I couldn't before. It has affected me"

Another said,

"When we first started using the trays and realised that it's possible to recover ashes we felt pretty bad. I think we all did when we seen what was being recovered and it was confined to that tray."

The Chief Executive, Steve Grimmond said,

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

Grant Ward, Head of Services acknowledged that,

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

14.10 Summary of findings for individual cases

The parents of a full term baby who died on the day he was born in 2010 told the Investigation that despite the fact that their son weighed 7lb the Funeral Director (Co-op) told them that there would be no ashes. When they probed this further they said it was explained to them that this was because babies' bones were not fully developed. The family were not made aware that other crematoria did return ashes. The Application for Cremation (Form A) was signed by the baby's father and countersigned by the Funeral Director. The section in relation to the disposal of ashes was completed with the abbreviation 'N/A' taken to mean not applicable. This family placed additional objects in the coffin in an effort to increase the likelihood of ashes. When the parents in this case read the article in the local press on 29 May 2014 in which Fife Council said,

"The potential for securing ashes increases as the length of gestation increases, although the retrieval of cremated remains cannot be guaranteed. If there are ashes these will be offered to the family or the Funeral Director or, if requested, can be scattered in the specially designated baby areas within the Gardens of Remembrance..."

they contacted the journalist to question the statement since their experience was that they heard nothing further from the crematorium or the Funeral Director. The Certified Copy of an Entry of a Cremation records the disposal for this baby as 'No Remains'. However when the Investigation checked the original Register of Cremations, there was no disposal recorded in it. The Bereavement Services Manager explained to the Investigation that the entry on the Certified Copy had only been made when the record was requested by this Investigation and had been taken from the Cremator Operator's records. The Register of Cremations is a statutory document and the Certified Copy should be an accurate copy of the original. There is a failure in Fife Council's statutory obligation to maintain a Register with a recorded disposal outcome for ashes if that column is left blank. The addition of information six years later at best undermines the value of the Certified Copy register and is a cause of real concern.

The Funeral Director in this case told the Investigation that he would go out of his way to get something back for families but that,

"From the age of about a year and a half and under, from what I'm led to believe going back over these years there was never the possibility to give ashes back to a family. The crematorium won't be able to get anything back because there's no trace of human remains. There's very little from a very young age from an infant already and the bone is really just cartilage, it's not actually bone. It's not developed at that stage. What I would say is we were always told by the crematorium you can't get ashes but in the few occurrences for the few funerals I've done for children they would try and get something out in order to get it back to families."

Parents of another baby who died on the day he was born, this time in 2011 were first told by the Consultant in the hospital that there would be no ashes following the cremation of their son. This information was then confirmed by the Funeral Director that the consultant recommended they used (Crosbie Matthew). Once again the Form A is signed by the parent and countersigned by the Funeral Director. In the section for the instruction for disposal of ashes the word 'NONE' has been written. The Certified Copy of an Entry of a Cremation records that there were no remains. In this case, the original Register checked by the Investigation also recorded 'No Remains'.

Another family of a baby born at 23 weeks' gestation in 2010 and who lived for a day told the Investigation that the Funeral Director (Crosbie Matthew) said that there would not be any ashes,

"He said there would be no ashes. He said that if there were any remains they would not be (our daughter's) remains. He said that her bones could not survive the cremation process and that any matter left over would be strictly from other things, other than her……. We would have wanted whatever was left, even as he described it. She was cremated in clothing and with a teddy bear and some letters, plus the coffin. But he went on to say the fire would be too hot and there would be nothing."

Despite this, the Application for Cremation (Form A) has been completed with the option 'disperse' circled. This is followed by a note which states 'Family have been told there will be no cremated remains.' The Certified Copy of an Entry of Cremation records that the ashes were 'Strewn by staff'. The original Register records the ashes were 'Dispersed'. However this may mean that the disposal column had in fact originally been left blank as the term 'strewn by staff' was not a term used at Kirkcaldy. It was a term used when the upgrade to the BACAS computer recording system automatically populated this column where it had been left blank.

In the case of a baby delivered at 21 weeks' gestation in 2010 the option 'disperse' is circled and the words 'Baby Section' have been written in to the section on the Application for Cremation (Form A) which deals with the instruction for the disposal of ashes. The Certified Copy of an Entry of Cremation records 'No Remains.' The original Register in this case recorded the instruction for ashes in the disposal column and said 'disperse -any ashes to be dispersed in baby garden'. It would appear that in this case the original entry which was the instruction was later updated following the cremation to record that in fact no remains had been recovered.

The parents of a baby delivered at 23 weeks' gestation and who lived for forty minutes told the Investigation that they chose the Funeral Director Crosbie Matthew because they knew them from a previous funeral. The family told the Investigation that they had a full sized child coffin as there was no smaller one available at the time. They recalled the Funeral Director did not offer a choice of crematorium. The parents told the Investigation,

"They did not mention anything to us about not getting ashes back. If there was no ashes we would never have went ahead getting the cremation done. We would definitely have got the burial - why have nothing when you can still have something? We were going to bury her ashes so that we had a place to go. Whether it be her ashes or the whole coffin we would have buried it to have somewhere to go."

The Application for Cremation (Form A) is signed by the baby's father but the section for the instruction for the disposal of ashes is blank. The baby's mother recalled being shocked to find out after the funeral that there would be no ashes. She told the Investigation,

"After her funeral, I phoned up Crosbie Matthew and I says can you tell us when we're getting our daughter's ashes back and they were stuttering on the phone and they said 'there's no ashes'. I went 'what do you mean there is no ashes?' I was shocked. They said 'oh no your daughter doesn't have ashes'. They said that it would be because the baby gets burned at the higher temperature there's nothing left."

They tried to probe further and were met with silence. They told the Investigation,

"We felt robbed. We still feel robbed."

14.11 Conclusions

1. Like Mortonhall this was a section of the City Council working in isolation without any strategic direction, development or quality control of the service, so far as it related to babies, infants and non-viable foetuses. There was little knowledge by Senior Management of the service provided to the families of these babies. There was insufficient interest taken or leadership shown by management. As with Mortonhall, much of what was learned by Cremator Operators at Kirkcaldy was received wisdom from more experienced peers. The belief that there would be no recovered ashes from infants, stillborn babies and infants was contradicted by what was known to be recovered in many other crematoria including Perth only 38 miles away, as well as in Dunfermline Crematorium a short distance away and under common management when a tray had been used in earlier years. It is also clearly contradicted by the evidence of the Forensic Anthropologist, Dr Julie Roberts, who states that bones in cremated foetuses from as young as 17 weeks' gestation can and do survive the cremation process.

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

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

3. The delay of over a year in allowing the use of the baby tray after it was introduced at Kirkcaldy highlighted a lack of insight or appreciation of the importance of this issue.

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

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

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

7. Methods of safely using a baby tray could and should have been implemented in a more timely manner given that trays were already in use in many crematoria throughout Scotland.

8. Notwithstanding the lack of local written guidance and the failure to use a tray the method of cremation of non-viable foetuses, stillborn babies and infants at Kirkcaldy could and should have been modified as recommended in the manufacturer's guidance. This guidance had been available at Kirkcaldy for many years. Instead, the practice at Kirkcaldy Crematorium was to place the coffins or boxes directly under the main burner which ignored the manufacturer's advice, thus virtually eliminating any prospect of obtaining ashes.

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

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

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

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

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

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