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

7 Cardross Crematorium

7.1 Introduction

The Investigation was asked to look at one case from 1994 in relation to Cardross Crematorium. The family did not receive ashes for their baby. Through their own efforts they were able to find out when and where their son's ashes had been dispersed.

Cardross Crematorium opened in 1960. It is managed by Argyll and Bute Council. It is situated in a peaceful rural setting with views over the River Clyde towards the Cowal peninsula just west of the village of Cardross. In the Gardens of Remembrance there are eleven lawn areas. The lawn area in which ashes are scattered or interred is noted in the Register of Cremations. There is a Baby Book of Remembrance.

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. Remains are scattered one week after the cremation takes place. The crematorium has a relatively small number of infant, stillborn and non-viable foetus cremations (Four infant /stillborn babies in 2013 and two non-viable foetuses in 2013). Cardross Crematorium has a relatively small number of cremations in total with approximately 600 per year in recent years.

At the time of the Investigation, Cardross Crematorium was equipped with one Evans Universal 300/2 double-ended, solid hearth gas-fired cremator which was installed in 1997. This was upgraded with new software in 2013 which provided new mechanisms for monitoring and reporting on emissions and infant mode ^[19] . Prior to that Cardross Crematorium had a double-ended Dowson and Mason Cremator with honeycomb hearths.

A baby tray has been used in Cardross Crematorium since 1960. A large size baby tray is now used (24" x 12"). It is used for the cremation of all non-viable foetus, stillborn baby and infant cremations unless the coffin exceeds the tray size. In those circumstances a tray is not required to retain ashes.

7.2 Management

i Structure

Since 2010 Cardross Crematorium has been managed within the Directorate of Environmental Services of Argyll and Bute Council. The Directorate is headed by the Director of Environmental Services under whom there is a Head of Service and beneath that level, an Amenity Services Manager. A Performance Manager reports to the Amenity Services manager and the Crematorium Registrar reports to the Performance Manager.

The post of Crematorium Registrar has overall responsibility for the operational management of Cardross crematorium.

ii Management Approach

The Council operates a plan and performance management framework. The Chief Executive since 2008, Sally Loudon, explained how she kept abreast of issues in the Council,

"(In addition to individual plans) Then you've got team plans, service plan and Departmental and Council plans and then the Community Plan and there's performance indicators against each of those so if I look at say the Development and infrastructure scorecard which gives me the performance information for that particular Department I can drill all the way down to team plans that will tell me if there's any issue.

The other thing that gives assurance is the internal audit. There's health and safety audits and they give more detailed information and then they feature on the scorecard."

More senior managers had limited day-to-day management of the crematorium largely because they believed it operated efficiently. Jim Smith, Head of Services said,

"I got some reports back from Tommy (McLean, Crematorium Registrar) who had been involved with his colleagues but there's no real need to get particularly involved as what we are doing in Argyle and Bute, albeit at a relatively low scale seemed to be operating and running well.

...I've been out on a limited number of occasions with both Tom Murphy (Roads and Amenity Services Manager) and myself to meet with Tommy (McLean) and the four staff members who are based down at the crematorium.

iii Management Response to Mortonhall Investigation Report and Infant Cremation Commission

The Chief Executive visited the crematorium when she first took up post in 2009. It then came to her attention again around the time of the Mortonhall media coverage. She told the Investigation,

"I became re-interested in it after Mortonhall. In fact, it was probably even before the media coverage because the Chief Executive of Edinburgh, Sue Bruce, alerted us as Chief Executives that this was an issue that we might want to go and have a look at within our own areas. So at that point I asked the then Director to make arrangements to go and do an assessment of what was happening and whether the issues that were being expressed in Edinburgh applied here. So there was an internal review of a management review."

The internal review was tasked with looking at whether there were remains available for non-viable foetuses, stillborn babies and infants and whether the parents knew that there might not be remains available. The Chief Executive confirmed that,

"The answer to both of those was yes there were remains available apart from in three instances over the last twenty-two years and that the parents had signed to say that they understood that perhaps there wouldn't have been any remains."

Pippa Milne, Executive Director, Argyll & Bute Council who had previously worked at City of Edinburgh Council, (though not in the Crematorium) and so was aware of the issues with Mortonhall explained,

"When there's been external stuff we do an external audit- certainly in this one it was to seek our own reassurance even though we hadn't had a complaint. We hadn't had any external contact raising issues for us so based on my discussions with the team there didn't appear to be anything that indicated there was a problem. It was about the relatives' sensitivity and of the issue nationally so it was really to give us that assurance if we had had something coming out of the internal audit we might have then taken a view to do something different but it would have to have been something quite significant or a real issue of complaint and something that called into question our ability either through the skills to do that audit, or of being so sensitive in terms of a potential wrongdoing by the Council and the early indications weren't that we had issues like that to be concerned about."

iv Commissioned Audit

The Chief Executive of Edinburgh Council had alerted Argyll and Bute Council to the issues in Mortonhall in 2012. An Internal Audit Report was produced in August 2014, some four months after the Mortonhall Investigation Report was published. The internal audit was carried out by Argyll and Bute's in-house audit team. The level of assurance found was 'substantial' which the internal auditors defined as meaning " Internal control, Governance and the Management of Risk have displayed a mixture of little residual risk, but other elements of residual risk are slightly above an acceptable level and need to be addressed within a reasonable timescale."

The background to the audit was the public concern expressed in 2012 over the accuracy of information given to bereaved parents about the existence or non-existence and final resting place of the ashes of their babies who had been cremated arising from historical practices at Mortonhall Crematorium in Edinburgh. The audit is an internal Council document.

The main objectives of the audit were described as,

• To review current policies, guidance and practice in relation to the handling of all recoverable remains (≤1 year old)
• To review current policies, guidance and practice in relation to the handling of all recoverable remains. (General Population)
• To ascertain whether parents and other bereaved relatives receive clear and consistent advice and information about the disposal of such remains and have their wishes adhered to; and that any such remains are treated sensitively and compassionately.
• To review the report published by Lord Bonomy taking cognisance of recommendations where relevant.
• To review administrative protocols including cash handling, billing, invoicing, record keeping, security and storage of records.

The audit, which included a walk through the procedures, found that in the last twenty-two years there had been fourteen cremations of non-viable foetuses with ashes recovered in all but three instances. Ashes were recovered from all sixteen stillborn babies and ten babies of less than one year from the same period.

In relation to the three occasions when ashes were not recovered parents had been notified that there would be no 'identifiable remains' resulting from the cremation and had signed disclaimers confirming this. The case referred to the Investigation is not one of these three.

Tommy McLean, Crematorium Registrar, speaking of those three occasions, told the Investigation,

"I reckon at least two of them were around the time when we got the new cremator fitted...On the new cremator, I'm thinking that the first time we went to use the tray we realised we were experiencing difficulties on how we were going to get the tray out of the cremator once the cremation had took place, because it sits at a far, far warmer temperature. I think there's a chance we may have cremated them not using a tray"

The audit found that,

"infant trays are used to aid the recovery of ashes, however there have been some instances where the casket has been too big to fit into the tray therefore arrangements have been made to purchase bigger trays."

The size of the tray had not however impacted on the ability to retrieve infant ashes at Cardross Crematorium from larger caskets.

7.3 Policy, Guidance and Training

i Written Policy

Written policy existed in the form of manufacturer's operating manuals and also procedures which Tommy McLean, Crematorium Registrar, said were,

"Just to cover the duties from the start at the front if you're doing chapel duty and then from the start of the process if you're a Cremator Operator in the back (Cremating area)."

A complete Service Manual was not however drawn up until July 2015 which referred to Argyll and Bute Council Policy on burial and cremation, Argyll and Bute Council Rules for Cremation, Associated Work Instructions.

Some of the Cremator Operators had completed training courses in Rotherham Crematorium and Linn Crematorium. Others were trained by the superintendents and then examined by the FBCA. One reported having carried out 100 cremations before doing his examination.

None of the external training was reported as having covered the cremation of non-viable foetuses, stillborn babies or infants.

7.4 Cremation Process and Equipment

i Equipment

Cardross has had a baby tray since 1960 and have recently purchased a bigger one. Protective gear in the form of suits, jackets, aprons visors and gloves are used when handling the baby tray.

A Cremator Operator told the Investigation,

"...There's always been a baby tray and its always been used to my knowledge. If there is anything going to be left it's going to be in there so we try to make sure if we can, if at all possible, where it is just a thimble full, where it is a cup full, an egg cup full, we'll return it to the family and let them know."

ii Cremation Process

At the time of the cremation of the baby referred to the Investigation the old Dowson and Mason twin flux cremators were in use. It was explained by the Superintendent that the cremator ran at a cooler temperature and required greater manual intervention. The volatile airs injected into the cremator were a lot less severe than in the newer cremators. If a tray for the ashes was not used the Superintendent believed ashes were not recoverable. The Crematorium Registrar explained,

"If you didn't use a tray you could lose whatever was in it (cremator) very quickly because it works on a system where there was two chambers. There was the top half where you done the cremation, but there were holes almost six inches in diameter that went through into a bottom chamber where the cooling would take place plus there were your flues so any air coming in, if you didn't use a tray, whatever was there would just be blasted through the holes."

Since the cremators were replaced the practice is to carry out the non-viable foetus, stillborn baby or infant cremations last thing in the day so that the tray can be left to cool overnight. The remains are then cremulated ^[20] the following day. What is left is not always cremulated. The Superintendent explained in relation to cremulation,

"Depending on what's left, if it's a white powder which could be residue coming from the coffin, it will dissolve or break up really, really quickly into powder, so there probably wouldn't be the need to cremulate.".

iii Definition of Remains

None of the Cremator Operators at Cardross had a defined age under which they understood ashes were not available. Staff members used the terms 'ashes' and 'remains' interchangeably. The Crematorium Registrar told the Investigation,

"I think of it as just the remains that are left when we're raking out the cremation, it's whatever 's in the cremator chamber after the cremation process is finished. I have definitely seen little bones for stillborn, for a young child. I don't think I have for a Non-viable foetus, but remember out of the number of cremations that we've done I personally myself have maybe only cremated two or three or four Non-viable foetuses."

Another Cremator Operator said of non-viable foetuses,

"Basically all that's left is the remains of the cremation process. What's there could be dust, could be bits of wood, there still is something. I've done two this year and we've had remains left. You maybe would get it into maybe not as much as half a mug (two inches) sort of thing. Maybe sometimes you maybe get an eggcup full, there is always...at least something. "

The Chief Executive of Argyll and Bute Council told the Investigation

"My understanding is that how you define ashes or remains has never really been an issue at the crematorium here because it's always been the overall remains we are talking about and parents are clear on that and that if the parents want whatever's left as a kind of memorial they can get them. We had never separated the remains from the ashes part of it"

7.5 Administration and Record Keeping

Official administration and record keeping is all done on site at Cardross Crematorium. The Crematorium Registrar and a Cremator Operator maintain the records with some support from an administrator on a part-time basis. Funeral bookings are made by Funeral Directors and booked into the diary system and on to the BACAS ^[21] system (the computer record keeping system).

After the cremation of the ashes the card that had been generated to travel with the coffin is sent back to the office and the records are updated with the details of the disposal of the ashes. The Crematorium Registrar told the Investigation,

"It would only be once the scattering of ashes or the caskets being removed by the family or the Undertakers the card then gets presented back to the office. We'll then update the records to state the ashes were removed on such a date or they were scattered on whatever lawn area it would be."

Although the disposal instructions are inserted at the outset he explained,

"But on the system, there's an actual other bit of the disposal section that once the disposals took place you log back in and state the date and when it happened, where it happened."

The superintendent completes the information on BACAS on a daily basis. If there is a change of mind in relation to the ashes a signed letter is sought from the applicant authorising the change and a hold is put on the ashes in the meantime.

7.6 Communication

i Communication between Funeral Directors and the crematorium

Cardross uses an additional form for the cremation of non-viable foetuses in addition to the Form A (Application for Cremation). This form, which can be completed by either the family or the Funeral Director, requires a signed acknowledgement that there may not be ashes following the cremation of a non-viable foetus. It states,

"I/We acknowledge that it may not be possible to recover any remains following the cremation and that if this application has been made on behalf of parent(s) that this possibility has been made known to them"

Cardross Crematorium confirmed to the Investigation that this form is still in use at the time of writing.

It is policy at Cardross Crematorium policy is to check that the instruction for disposal of ashes for all babies has been signed by the parent. Cardross Crematorium do not have direct contact with the NHS.

ii Contact with Families

Staff at Cardross Crematorium advised that they did not have much direct contact with families except when a family member would telephone in relation to the location of ashes after the cremation or where they attend the scattering of the ashes.

7.7 impact of Mortonhall Investigation and the Infant Cremation Commission

Although the delay in requesting an internal audit is difficult to understand it meant that the auditors could review the crematorium in the light of the findings in the Mortonhall Investigation Report and the Infant Cremation Commission recommendations. The audit found that Cardross Crematorium already met some of the recommendations and that,

"Crematorium staff are familiar with and are considering how to progress the many recommendations within the Lord Bonomy Report."

Specific recommendations in the report included the completion of a service manual detailing procedures for all aspects of the service, the purchase of a larger baby tray and the sending of notices to applicants confirming that ashes have been scattered, when they were scattered and by whom.

7.8 Findings for Individual Cases

One baby cremated at Cardross was referred to this Investigation. The baby was stillborn and was cremated in 1994. The parents told the Investigation they were told by someone from the hospital that there would not be any ashes. They did not know what the role was of the staff member who assisted them with making the funeral arrangements. The Investigation ascertained that she was a social worker attached to the maternity unit but that she has long since retired. This social worker liaised with the Funeral Director on the family's behalf and they had no contact with him. The parents do not recall signing a form giving an instruction about ashes. They insist that they would not have signed a form saying someone else could scatter the ashes, particularly as they had been told there would not be any.

The Form A is signed by the baby's father but he told the Investigation he did not complete the ashes instruction. Section 16 of the form which deals with the instruction for the disposal of ashes is completed to say 'scattered' but this is clearly in the Funeral Director's writing.

This instruction for disposal of the ashes appears to have been completed at the same time as the date and time of service as it is in blue ink, while the Applicant's signature is in black ink like the particulars on the first page.

It is possible that the social worker brought the form to the Funeral Director's office after the father had signed it at home with her (as he has told the Investigation) and at that stage neither the date and time of the service nor the instruction for ashes had been completed. The Funeral Director would need to obtain the date and time of the funeral directly from the crematorium. The Funeral Director does not appear to have had any recourse to the family with regards to the instruction for ashes.

The Funeral Director Gordon Glen told the Investigation that he would have told the social worker that they "could not be certain if there would be ashes or not." He said that when he was arranging a funeral directly with a family he would always take an instruction for ashes in case there were any as Cardross Crematorium would not have accepted a Form A without an instruction for the ashes. He explained that he would have discussed with the family the issue of uncertainty about ashes and then taken an instruction before asking the Applicant to sign the Form A. However, in this case he had no contact with the family. The family have said that they were told definitively that there would not be any ashes by the hospital social worker.

The result of the instruction on the Form A was that this baby's ashes were not returned to the parents but were scattered in the crematorium gardens in accordance with the instruction. The baby's mother contacted Cardross Crematorium in February 2015 and at a meeting was told her son's ashes had been scattered. In November 2015 she returned to the crematorium and was shown exactly where in the Crematorium gardens the ashes are scattered.

This caused the family considerable distress. The mother tried to make sense of it,

"And why would they then allow a stranger to take your child's ashes and go and scatter them without your knowledge? It makes you feel like you've abandoned your little child, it makes you feel like you've abandoned that baby, walked out of that crematorium and just forgotten. Maybe they're desensitised to it?"

7.9 Conclusions

1. Although training was largely carried out in-house, care was taken to maximise the possibility of obtaining ashes by the modification of procedures and the use of a baby tray. These methods were successful in the majority of cases. Unlike other crematoria, Cardross sought a solution to handling issues around the baby tray. Once they realised that they were no longer retrieving ashes consistently without it they took action to re-introduce it. Cardross Crematorium is to be commended for the care applied to this aspect of cremation.

2. There was no evidence of any joint training with Funeral Directors or NHS midwives working in this area. 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.

3. The procedure for the updating of records was efficient and effective. The co-location of record keeping services and cremation processes may have assisted to ensure that this took place.

4. The Investigation found evidence of a strong team with solid management.