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

4 General Conclusions and Recommendations

A number of general conclusions and recommendations follow. Conclusions and recommendations particular to each of the Crematoria follow the individual Chapters on each.

1. The evidence discloses unethical and abhorrent practices at Aberdeen Crematorium over many years, including the cremation of foetuses and babies along with unrelated and unknown adults.

2. A criminal sanction should be created to prohibit the cremation of a non-viable foetus, stillborn baby or infant with an unrelated person unless there is express written consent from the next of kin of the baby. There must also be express written consent from the next of kin of the unrelated person or it must be compliant with the testamentary intention of the unrelated person.

3. The overall regulation of the funeral profession needs to be improved. Funeral Directors as well as Cremation Authorities should be licensed and subject to a statutory regime of regulation and inspection.

4. The Scottish Government should exercise its powers under the Burial and Cremation (Scotland) Act 2016 to regulate the Funeral Directing profession.

5. An Inspectorate of the Funeral Business should be appointed incorporating the current role of the Inspector of Crematoria.

6. The Chief Executives and Senior Management of the Councils and organisations responsible for crematoria and funeral care in Scotland must take full responsibility for securing a forward looking and proactive approach to the management of their businesses and duties. This should include responsibility for ensuring a caring and sensitive culture in their operations and a renewed focus on customer service and standards of care. The parents of many of the families involved in this Investigation have been failed by both crematoria and funeral care organisations over many decades.

7. Minimum standards of training and joint training should be introduced for the cremation of foetuses, stillborn and infant babies. Chief Executives should take responsibility for ensuring all staff are trained and certified to those standards, which should be periodically re-assessed. Such staff should be given opportunities to develop best practice along with funeral professionals and NHS staff.

8. All midwifery students should be trained to deal with the care of parents of deceased babies. There is a particular need to ensure that parents are given time and space to make decisions about the disposal of their baby's remains, that mothers are fit to provide consent and that accurate information is provided about the options available for parents.

9. It was clear that the quality of communication between NHS staff, crematoria staff and Funeral Directors also varied considerably across the country and was subject to confusion and disagreement between the organisations. While the Investigation was told that some crematoria would warn Funeral Directors that ashes could not be guaranteed, this had been understood by Funeral Directors that no ashes were available for foetuses or babies and parents had been advised as much. As with the findings in the Mortonhall Investigation Report, the whole process of communication with bereaved parents about cremation was generally unsatisfactory and muddled, with a small number of notable exceptions.

10. Steps must be taken by all Chief Executives of health, crematoria and funeral organisations to ensure that all staff required to advise parents on cremation or to carry out such cremations are properly briefed. They must have an understanding about the survival of baby bones in cremation where proper care is taken. They must also have an understanding of the fundamental importance to families of having back any small remnant of their baby, including ashes from the baby's clothes, blanket, toy or coffin to help them grieve for their loss.

11. It is incumbent on all senior management in each of these three sectors to lead and secure adequate training, appropriate working practices and a culture of care and sensitivity. Given what is disclosed in this Report, systems must be in place to ensure those services are delivered consistently and are subject to regulation and inspection.

12. The practice of inserting the disposal outcome of the remains of the baby on the Statutory Register of Cremations before the actual cremation had taken place was widespread. In short, what appears to be a record was a prediction and not a record at all. This rendered many records wholly unreliable and meaningless as a statutory record of the actual outcome of the cremation. There was significant evidence that in many cases across the country the outcome recorded was in fact only the instruction for the disposal of ashes and that this was not updated with the actual outcome.

As at Mortonhall, prior to the computerised systems being introduced, most crematoria did not record in manual registers that there were 'no remains' even though they stated this to be the case. Most often the words 'dispersed in the Garden of Rest or Remembrance' would appear.

This casual and careless approach to a statutory obligation is of considerable concern. Steps now need to be taken to rectify these inaccuracies and to ensure this obligation is treated with the solemnity it deserves. The statutory requirement to maintain such records implicitly contains a duty to do so conscientiously and truthfully.

13. Evidence was discovered of Funeral Directors and crematoria holding on to baby ashes for many years on their premises without advising parents until the intervention of this Investigation. Crematoria and Funeral Directors must be vigilant to secure the return of ashes to parents or next of kin where the parents or next of kin have applied for the return of ashes. Ashes should also be offered where any of the circumstances described in this report may apply to parents who may be unaware that the ashes are still being held either at the crematorium or at the Funeral Director's premises.

14. Many parents relied wholly on the advice given by NHS staff and accepted in good faith the advice that there would be no ashes to be recovered from the cremation of their baby. This misleading information deprived many parents in Scotland of the opportunity to recover the ashes of their babies. Such advice and guidance to parents needs to be accurate and set out in different formats to take into account the impact of grief on the ability of the parents to absorb information given on one occasion. Most importantly, parents must also be given the time and space to make their decision.

15. This Report identifies incidences where babies have been cremated with an unknown, unrelated adult and/or their ashes have been disposed of without the knowledge of parents. Steps should be taken by the Chief Executives of organisations responsible for such crematoria to consult affected parents about an appropriate memorial.