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

16 Woodside Crematorium, Paisley

16.1 Introduction

The Investigation was asked to look at five cases in relation to Woodside Crematorium, Paisley between 1990 and 2007. The families did not receive ashes for their baby.

Woodside Crematorium, Paisley opened in 1938. It is an independent crematorium run by Paisley Crematorium Company Ltd. The Crematorium is a listed building situated on a hilltop setting in over 20 acres of Paisley Woodside cemetery. In the Gardens of Remembrance there are 11 lawn areas. The lawn area in which ashes are scattered or interred is noted in the Register of Cremations. There is a Book of Remembrance together with memorial plaques on the walls overlooking the roses and lawns.

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. They are scattered four to six weeks after the cremation takes place. The crematorium has a relatively small number of infant, stillborn and non-viable foetus cremations (four infant and two stillborn in 2013 and six non-viable foetuses in 2013). In 2013 there were 1,442 adult cremations.

16.2 Management

i Structure

The management structure for Woodside Crematorium, Paisley is a Board of Directors to which the Crematorium Manager and Registrar reports. It employs one Cremator Operator and three other staff members who are trained to cremate and provide cover when required.

The Crematorium Manager and Registrar, Frank McFadyen, is permanently based at the crematorium. There is a Permanent Secretary to the Board of Directors and then Board members and a Chair.

ii Approach

The Chairman of the Board of Directors at the time of the Investigation, John Paton, told the Investigation,

"I, as Chairman, probably would speak to someone in the crematorium not always every day but at least every second day. We have a monthly inspection of the crematorium and the grounds. Each Director (on the Board) is charged with that and we take it in rotation. I spend at least one afternoon a month at the crematorium. I speak to the General Manager/Superintendent almost every day. I feel I am on top of the situation at the crematorium so far as operations are concerned."

Frank McFadyen, Crematorium Manager and Registrar, attends FBCA and ICCM ^[69] meetings and reports back to the Board. The Chairman of the Board of Directors attends these occasionally. The Chairman of the Board of Directors told the Investigation,

"The most recent one I went to was the one where the Mortonhall and Aberdeen issue rose its head. "

16.3 Response to Mortonhall Investigation Report and the Infant Cremation Commission

The management at Woodside Crematorium, Paisley explained that they had been obtaining ashes for infants since it opened in 1938. They were not, therefore, concerned that the issues raised in the Mortonhall Investigation Report had any application to them. The Chairman said,

"Over the years the crematorium has not really detected any appetite to address the issue of infant or child cremations because we felt, apart from probably the use of baby trays, we were doing everything that was considered appropriate in the cremation of infants plus the fact that volume was so low."

Nonetheless, a baby tray was purchased in January 2014 before the publication of the Mortonhall Investigation Report and has been used for the cremation of non-viable foetuses, stillborn babies and infants since then.

As required by statute, records were kept at the crematorium for fifteen years. Accordingly, not all records were available for the dates of the cases submitted to the Investigation.

16.4 Policy, Guidance and Training

i Written Policy

As with many crematoria the main source of information for written procedure is the manufacturer's operating manual. The Crematorium Manager and Registrar, Frank McFadyen told the Investigation,

"We don't have any further in-house procedure manual, we just work from the manufacturer's recommendations."

The Investigation was shown a more recent instruction to staff known as the Infant Cremation Commission and Cremating Procedures for Infant Cremations of Babies, Foetuses and Stillbirths. There is another form signed by the employees dated January 2015 attached to which is the cremation practice guidance whereby staff have acknowledged that they fully understood the procedures and the importance of them.

The National Committee on Infant Cremation Code of Practice, dated January 2015, is also available to the staff. None of these policies were in place at the relevant time of the cremations which are the subject of this Investigation.

The Chairman explained in relation to the cremation of adults,

"We don't have a manual of instruction. There are rules and they know the rules and it goes back to the Funeral Directors. They are the point of contact between the bereaved family, we are only providing a service to the Funeral Director."

ii Training

Training on the single-ended machines took place in 1995 and was carried out by Facultatieve. The Cremator Operator was trained by his predecessor. He trains the other staff all of whom are appropriately qualified. The Crematorium Manager and Registrar Frank McFadyen did have contact with other crematoria from time to time.

16.5 Operational Practice/Cremation process

i Equipment

At the time of the Investigation, Woodside Crematorium, Paisley was equipped with one Evans Universal 300/2 single-ended, solid hearth gas-fired cremator which was installed in 1995. It was further equipped with a FT11 single-ended, solid hearth gas-fired cremator which was installed in 2003. Both cremators were upgraded with software in 2013 which provided infant mode ^[70] and new monitoring and reporting mechanisms on emissions.

Staff at Paisley Woodside Crematorium told the Investigation that ashes have normally been recovered at Woodside from foetal or infant cremations since 1938.

ii Baby Trays ^[71]

A baby tray was purchased in January 2014. The Cremator Operator told the Investigation that he had heard about baby trays from an engineer ^[72] previously and had made enquiries about getting one but one was not purchased at that time. He said,

"I'm more happy with the baby tray. I'd asked for a baby tray in the past because one of the engineers had mentioned it to me."

iii Cremation Process

Before the introduction of the tray in January 2014 the coffins of non-viable foetuses, stillborn babies and infants were placed just inside the cremator door of the single-ended cremator. The ashes were raked out the following morning. In a single-ended cremator the ashes are raked out from the same door through which the coffin is charged (inserted). Infant mode has been used since 2013. Prior to 2013 the basic profile was used but was often modified through manual intervention. Such manual override was found to be very successful over many years at Seafield and Warriston crematoria where it was described during 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 ^[73] 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."

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."

In accordance with the recommendations of the manufacturers, Facultatieve, the Cremator Operator at Woodside Crematorium, Paisley, who began work in October 2002, took great care to modify the procedure to enhance the possibility of recovery of remains. The Cremator Operator told the Investigation,

"But it was basic and after a short term we realised that a basic profile didn't fit every cremation, every cremation was different. Sometimes you want to control the air and heat yourself. The computer became more advanced and it had more profiles on it."

This Cremator Operator explained,

"I was told if it's a pre-viable foetus there wouldn't be any ashes. I wasn't really told about stillborn. I think within two or three weeks here I'd worked out that I was getting them anyway. I found out that I was getting ashes off pre-viable foetuses right away.

In all the books I've got it says that the parents have to be told before the cremation of a pre-viable foetus that there won't be any remains."

When he realised he was obtaining remains he showed these to local Funeral Directors and the Crematorium Manager and Registrar. He told the Investigation,

"I also got Undertakers in because I didn't want them to think that nobody got any ashes back from a baby and then all of a sudden I'm getting ashes back. I wanted them to see that definitely there was something there and I was pointing them out to the Undertakers. I wouldn't normally do that to people but I thought if it was the Undertakers that I show and say look that's an arm, a leg and all the rest of it and that was a pre-viable foetus."

He explained that he cremated non-viable foetuses, stillborn babies and infants last thing in the day so that the cremator was at a sufficiently high temperature and the ashes could be raked out the following morning. He almost always obtained ashes. On the rare occasions when he did not he would telephone the office and advise them that there were no remains. He said,

"I was passionate about baby ashes because I knew I could get them back and it was important to families if they had asked for them."

However, if parents had not asked for the return of ashes, the ashes were scattered in the Garden of Remembrance. Non-viable foetus Registers did not record the disposal. No records were available for the 1990 case referred to the Investigation as it pre-dated the fifteen year period for which records have to be retained. Records were sampled in the Registers of Cremation for two cases, one from 2002 and the other from 2006. This examination confirmed that remains were obtained and either delivered or dispersed. The Crematorium Manager and Registrar, Frank McFadyen told the Investigation,

"I think prior to 2002 it was very rare that parents asked for them to be returned. It's only now in the past few years nearly every child's ashes has been asked to be returned. That said, pre 2002 ashes were quite often returned. In fact we have records going back showing ashes were returned even as far back as 1938. It just depends on the family's desire to have them back and if they don't we just disperse them."

A family's desire to have ashes returned may however be influenced by what they are told by Funeral Directors in relation to the possibility of ashes being obtained. John Boyle, manager of J & W Goudie, Funeral Directors told the Investigation,

"On the reverse of the Form A it asks the day and the time of the cremation but we will also ask what is their intention or what they want to happen to the ashes following cremation and we give them the option that they will be returned to them; that they can be scattered; that they can be returned back to the funeral home within reason until they make a decision about what they want to do with them…What we will say is, 'if there are any ashes we will give them back to you'."

He went on to say of Woodside Crematorium, Paisley,

"I know for a fact that Woodside will do their utmost best to return anything that's there but I can't tell you and I couldn't honestly say to you how many occasions that we have done or we haven't been able to. I think it would probably stick in my mind if there were many cases when we didn't get anything back, because we would be disappointed for them…If it was a recurring problem my staff would have brought it to my attention."

A pestle and mortar is used for cremulation ^[74] for very small babies or non-viable foetuses.

iv Definition of Remains

The Cremator Operator made a very clear distinction between ashes and remains explaining that his view was that he should be returning remains of the baby rather than remains of the cremation procedure which would include the ash of the coffin. This affected the quantity of remains returned. He accepted that the Scottish Government was proposing in the new Burial and Cremation (Scotland) Bill that everything should be returned.

"Up until about six or seven months ago I just delivered the remains of the baby, I didn't give (back) what was the remains of the cremation procedure. I picked out bones which was easy. It amounts to about a teaspoon or two teaspoonfuls and that's it but I felt as if families are getting back what they are wanting. It was remains of the baby they're getting back as opposed to ash, bits of coffin and (to me) a lot of rubbish was going with it."

In contrast the Chairman said,

"I think the fact that you give everything that's on that tray back in a box to the bereaved parents is a great comfort to them, they're not really bothered too much what the ashes consist of, what they have come from, they are the ashes of the child."

There was no defined age under which it was understood ashes were not available.

16.6 Administration and Record Keeping

Official administration and record keeping is all carried out on site at Woodside Crematorium, Paisley. The Crematorium Manager and Registrar maintains the records with some support from an administrator .

Funeral bookings are made by Funeral Directors and booked into the diary system. Cards are completed containing the details of the cremation including what is to happen with the ashes. The Cremator Operator told the Investigation that,

"The cards for the babies always said 'deliver if any'. In the morning the office would phone me up and ask if there were ashes from the baby cremated the night before, because they make up the certificates for the families. If the card said 'Dispersed' I would hold on to them. Once or twice I got a good set of ashes and I phoned down to the office and said that I got ashes here and they phoned the Undertaker and the Undertaker got in touch with the family to see if they wanted to change the instruction from 'dispersed.' I think they came back and dispersed themselves "

Following the cremation the information from the cards is entered into the Microsoft Office Professional Access system (the computer record keeping system). The information is updated with the date of collection of ashes when the ashes have been collected. The Crematorium Manager and Registrar explained,

"So the original one would have an entry which was the intention as expressed on the form. But we would go back into and update that with the date.

On the retention of ashes there's an option on the back of the application form for ashes to be retained. And it states quite clearly that they should get back to us within a period of a month and thereafter if we don't hear anything then we would disperse the ashes in the garden."

Although the Cremator Operator told the Investigation that,

"In virtually every case I always get something back as I said apart from the very early period when I've lost them a couple of times."

However he confirmed that before January 2014, if there was no skeletal remains there he would still put down 'dispersed'. He said,

"If there's nothing left I put down 'dispersed'. 'No ashes' should be put on it. But I've already phoned and told the office there's no ashes. "

The cases for which there were records all stated 'dispersed'.

He admitted that there have been a few times when he lost ashes when he began cremating either due to air coming on before the ashes had been removed or the suction of the door closing blew them away. However, there was only a small number of occasions when he did not get ashes. He was able to learn from those occasions and avoid those factors. He said,

"There's been a few times that I did lose infant remains because when the machine cools down the air has come on and it blew it (the remains) away completely. I can learn from that and I don't do that anymore…Another problem you can have is with the suction of the door when the machine is closing down - it can go up to about 80% in which case it's sucking everything away and I found that's why I lost remains one time. All these things happened to me just once or twice but you find out and make sure it doesn't happen again."

The Investigation sampled Registers from 1985, 1990, 2002, 2005 and 2006. Unlike the findings at other Crematoria, the Registers never record 'no remains' and in several cases from each of the years, the Register records a date to indicate that remains were collected.

16.7 Communication

i Contact with Funeral Directors

Funeral Directors submit the Form A and an additional form which asks additional questions including questions in relation to the instructions for the ashes. All paperwork was kept for a fifteen year period.

Funeral Directors sign a form of discharge when they collect ashes. If ashes are not collected a letter is sent to the Funeral Director and if the ashes are still not collected within two to three weeks they are dispersed. This is recorded in the Register of Cremations.

The Chairman stated that the Funeral Directors were the client of the crematorium and explained,

"We never have a situation where our client is the hospital, the NHS Trust. Our client would be the Undertaker. I'm also Chairman of the Funeral Directors so I know about that side. The instruction would always come from the Funeral Director although the parents have got the most interest, the biggest stake if you like, on what's happening. An awful lot of the current criticism is directed at crematoria but there is no regulation of the funeral industry. You can start up tomorrow as a Funeral Director if you like, nothing to stop you. The interaction we have as a company with our local Undertakers is pretty good. I think it's got to be very clear that very, very seldom have we got any contact with the parents."

The Cremator Operator told the Investigation,

"I was scared that they're (parents) getting told there probably won't be any (ashes) and when they're grieving they don't take everything the way it should be"

ii Contact with Families

Staff at Woodside Crematorium, Paisley advised that they did not have much direct contact with families except when they would collect ashes after the cremation or where they attend the scattering of the ashes. If a family member is collecting the ashes they must have the authority of the applicant to do so.

16.8 impact of Mortonhall Investigation and the Infant Cremation Commission

A baby tray is now used in every case at Woodside. As Woodside Crematorium, Paisley was already recovering ashes for infants in most cases there was no internal audit of processes carried out.

The processes for the cremation of non-viable foetuses, stillborn babies and infants have now been documented.

The cremators are single-ended and the baby tray is removed from the door through which it was charged. The tray was still extremely hot but could be left to cool overnight.

The Cremator Operator said,

"The safety issue obviously is how we get the tray out when it's red hot. I just lift it out and I put it down and leave it to cool down and then I can handle it…With the tray what I do is put the tray on the edge and I just push it in with the rake as well and that pushes it far in. I've got a handle for lifting the tray out in the morning and I will take it out and use the rake and I pull the tray right to the edge and then lift it up."

The Chairman told the Investigation,

"If there were health and safety issues relating to the use of the tray the Board would look at it, but you have got to take steps to ensure that there is no health and safety issue in that the tray's inserted at the aperture… and left overnight, therefore it's easily handled when it is extracted from the actual cremator."

16.9 Summary of Findings for Individual Cases

The earliest case referred to the Investigation from Woodside Crematorium, Paisley was of a one day old baby who died in 1990. As the cremation took place more than 15 years before the Investigation, access to records was limited to the Register of Cremations and a copy of a diary page.

This family was told by the Crematorium staff that the ashes had been scattered among the rose beds as there was no instruction to return the ashes. The baby's father told the Investigation he had been told by the Funeral Director that there would not be ashes. The Register of Cremations records 'Dispersed'

The family of a baby who died in 2002 were told by the pastor that the Funeral Directors had informed him " that you don't usually get anything back." The Form A stated 'Retain if possible. Let Goudies (Funeral Directors) know' . However, the Register records that they were dispersed. Woodside Crematorium, Paisley advise that they contacted the Funeral Directors. The Funeral Directors confirmed to the Investigation that they had no record of the crematorium contacting them about collecting ashes. There is no written evidence to show whether the crematorium contacted either the family or the Funeral Director . What is however clear is that the family were not informed of the existence of ashes and the matter was not adequately pursued by the Funeral Director.

The mother of a non-viable foetus recalled being asked by the Funeral Director (J & W Goudie) in 2006 whether they wanted any remains back and they confirmed that they did. However, after the funeral they were told that " there was nothing because she was so small."

The baby's father did not recall it being raised but confirmed that he was expecting remains. Option (b) which states that the ashes are to be 'Returned to Applicant' has been selected on the Form A (Application for Cremation) and in addition the words 'Yes Return' have been added. However, this has then been scored through with the initials 'N/A' written.

The Funeral Director told the Investigation,

"It was hoped that ashes would be recovered after the cremation but following the process there were no recoverable ashes to return."

In a 2005 case the parents do not recall being told anything about ashes before the cremation of their daughter who was delivered at 20 weeks' gestation. Her parents recalled,

"Nobody spoke to us about ashes until the day of the cremation when we asked. They said there would be nothing left because she was too small. I remember asking the question but I can't remember specifically who it was I asked. It could have been the Funeral Director."

In both cases involving non-viable foetuses, a Form 2 from NHS Greater Glasgow and Clyde requesting a cremation of a pre-viable foetus was signed. This form states 'I understand that there will be no 'identifiable remains' resulting from cremation'. This form was used with bereaved families regardless of which crematorium was to be used and failed to take into account the fact that some crematoria in the Glasgow area regularly returned ashes whilst others seldom did.

At Woodside Crematorium, Paisley, the Cremator Operator told the Investigation that until 2014 he looked for bones in ashes remaining from the cremation and only returned to families those bones. If he could not see any bones, as seems probable in the two cases of non-viable foetuses referred to this Investigation, he did not consider that the residual ash should be returned to the family. He also told the Investigation that on rare occasions all remains including coffin ash were blown away during the cremation process. If there were ashes following these cremations and the Operator considered they did not contain bones, they would have been dispersed in the baby area of the Garden of Remembrance.

A parent of a nine day old baby who was cremated in 2007 told the Investigation,

"I can't remember who it was that told me first that there were no ashes, but all of the midwives seemed to be in agreement. When there was more than one in the room nobody ever turned round and said, 'well actually that's not true'."

Believing that there would be no ashes, this family chose not to attend the funeral,

"… I said 'if there's no ashes, I don't want to know where she was cremated because there's nothing for us. So just send us the bill… and that's that'. We said goodbye to here in the beautiful little room in the hospital, all decorated like a nursery."

However, the Form A has the instruction 'Dispersed within the crematorium grounds'. The Extract from the Register of Cremations advises that the remains were dispersed in the Garden of Remembrance but the parents were not advised of this at the time as the hospital staff had told them there would be no ashes. These parents were therefore denied the opportunity to retain their daughter's ashes.

"What torments me nightly and I end up in tears just about every night and it's because I don't know where she is. If I'd had those ashes to put at the bottom of a tree, I would've known where she was. The fact that somebody cremated her and had her remains and thought nobody cared enough to come to this baby's cremation or get her ashes… when we didn't know there were any ashes. I'm so upset on the one hand and absolutely ragingly angry on the other because what we were told was wrong, and it's too late."

16.10 Conclusions

1. Although training was largely carried out in-house, care was taken to modify procedures to maximise the possibility of obtaining ashes without the use of a baby tray. These methods were successful in the majority of cases. Woodside Crematorium, Paisley are to be commended for the care applied to this aspect of cremation.

2. There was little evidence of any joint training with Funeral Directors or NHS midwives working in this area. Although the Cremator Operator did make an effort to bring Funeral Directors in to the crematorium to demonstrate the ability to retrieve the ashes of infants in Woodside Crematorium, Paisley, 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 and ongoing joint training and joint understanding of their obligations to the parents of these babies.

3. It was clear that Woodside Crematorium Paisley reacted appropriately to the issues emerging from the Mortonhall Investigation and Infant Cremation Commission. Staff exhibited an accurate understanding of the physiology of the bones of foetuses, stillborn babies and infants.

4. There was an absence of any local written instruction or guidance. However this did not impact on the ability of the crematorium to get ashes but could have been of relevance had a change of personnel occurred. This meant that the actual practices employed in the crematoria were not documented and available for inspection by normal quality assurance procedures.

5. Communication between NHS staff, the Funeral Directors and crematorium was not formalised. The Crematorium Manager and Registrar and Chair of the Board attended FBCA and ICCM meetings and there was some evidence of communication taking place in relation to the availability of ashes. 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.

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

7. The procedure for updating records was generally found to be efficient and effective. The co-location of record keeping services and cremation processes may have assisted to ensure that this took place. However, the Cremator Operator recognised that the Register of Cremations would record 'dispersed' even if he considered there to be no remains and had told the administrative staff there were no remains. As he would disperse in the Garden of Remembrance any ash he considered not to contain skeletal remains, on most occasions this record would be accurate. However on the rare occasion that he did not recover anything at all from the cremation, the Register would still record 'dispersed' rather than 'no ashes' or 'no remains'. Although a rare occurrence, this does prevent the Investigation from confirming the location of the ashes of their babies to the parents registered.