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

8 Craigton Crematorium

8.1 Introduction

A total of fourteen cremations of infants or babies conducted at Craigton Crematorium were referred to the Investigation. The earliest of those cremations took place in 1990 and the most recent in 2007.

Craigton Crematorium is the trading name for Funeral Services Ltd, a part of Co-Operative Group Ltd. The crematorium is situated in Glasgow on Berryknowes Road in Cardonald.

Craigton Crematorium opened more than 50 years ago and has one service chapel seating more than 100, an area in which Books of Remembrance are displayed and is surrounded by Gardens of Remembrance which include a Children's Memorial Garden. In 2013 the crematorium carried out 909 adult cremations. In 2013 the crematorium also carried out seven individual cremations of non-viable foetuses.

The crematorium has arrangements with local Funeral Directors and the NHS for the disposal of non-viable foetuses through shared cremation with other non-viable foetuses. In 2013 3,535 foetuses were cremated in shared cremations. There were no cremations of children or stillborn babies in 2013.

8.2 Management

The Investigation was provided with a chart setting out the senior management structure. This showed a vertical line at the head of which is the Co-operative Group Chief Executive with the Head of Consumer Services next. The Funeralcare Managing Director, the National Operations Director and the Head of Support Operations follow, before the Bereavement Services Manager and the Crematorium Manager.

There have been a number of changes to the roles and responsibilities of those managers with direct responsibility for the running of the crematorium.

Harry Tosh, who started at Craigton Crematorium in 2002, was appointed Superintendent in 2007. Harry Tosh has been in post as Manager and Registrar since 2008 when the role of Superintendent merged with that of Manager.

John Williamson, Head of Operations for Scotland and Northern Ireland, told the Investigation that until 2013 the crematoria were managed within geographical regions rather than as a group. As Harry Tosh's line manager he had monthly one to one meetings and was in frequent contact by phone. There were annual appraisals and quarterly reviews. Senior Managers above his Operations Manager level were not actively involved in overseeing Craigton Crematorium at all unless there were exceptional circumstances such as the issues at Mortonhall Crematorium coming to light, or requests for major capital expenditure which go through a Strategy Group.

8.3 Policy, Guidance and Training

Harry Tosh, Manager and Registrar, told the Investigation that, until January 2013, it was Craigton Crematorium policy to follow the Federation of Burial and Cremation Authorities ( FBCA) guidance on the definition of remains and to check ashes for skeletal remains.

Harry Tosh was aware of the then differing positions of the Institute of Cemetery and Crematoria Management ( ICCM) and Federation of Burial and Cremation Authorities ( FBCA) about the definition of recoverable remains (ashes). At Craigton, a visual check for bone would be carried out by Cremator Operators to determine if ashes should be returned to families. If visible skeletal remains were found, everything would be returned to families who had requested ashes. If no visible skeletal remains were found, the ash would not be returned to families but would be scattered in the Garden of Remembrance as 'residue'. John Williamson, Head of Operations Scotland and Northern Ireland, told the Investigation that at the time, prior to the Mortonhall Investigation, he had no difficulty with adopting this position as he considered it consistent with the practice for adult cremations where what is returned is skeletal remains. He now fully accepts the new definition applied across Scotland.

A long serving Cremator Operator was asked about the training he received during the period with which this Investigation is concerned. He told the Investigation,

"I started in August 1991 as a trainee crematorium assistant …we had to go to a training crematorium which was the Linn Crematorium in Glasgow at the time. The training took a fortnight. At the end of the fortnight you were asked questions. We had to do a cremation. Their cremators were different from ours… when I came back to work on our own cremators here it was just watching and being told what to do by the people who were operating the cremators at the time. In those days we were called Funeral Service Operatives ( FSOs). We did the cremating, the garden and chapel duties. It's much the same now but we have a qualification. The qualification for the crematorium technician came in around about the time I was starting in 1991, I think. Before then you didn't need a qualification, you were just a gardener who also cremated. That's how it worked in most crematoria."

Asked whether he had undergone any subsequent training, the Cremator Operator explained how in 1992, with the arrival of new cremators, he and his colleagues,

"were trained to operate them by Evans technicians. It used to be called Evans, now it's Facultatieve Technologies. That was the initial training and then as we were going along we learned things. I can't remember exactly when, but I did an advanced training with Evans and went down to Leeds for it where their headquarters are. I think it was a three-day course, which made me an advanced crematorium technician."

Facultatieve confirmed that they used to run this course. It was about understanding emissions, monitoring and maintenance of the cremators.

The Investigation enquired whether Craigton Crematorium has any documents containing written policy or procedures. In his reply the Manager referred to Cremator Operators relying on the FBCA Code of Cremation Practice, the ICCM Charter for the Bereaved - Guiding Principles for Burial and Cremation and the Facultatieve Operating Manual. A series of documents under the heading Way of Working provides guidance to staff, including on providing mourners with a dignified experience and ensuring that the crematorium is run efficiently. It does not refer specifically to dealing with the cremations of non-viable foetuses, stillborn babies or infants.

8.4 Cremation Process and Equipment

Staff available to be interviewed by the Investigation were able to speak about operational and working practices back to 1991. One of the cases referred to the Investigation dated back to 1990 and there are no individuals who can speak to this specific year from an operational perspective.

Craigton aimed to operate in such a way as to maximise the recovery of such remains. This included, in the case of foetuses and babies, using metal trays since 1993, cremating using residual heat and carrying out a visual inspection of the remains following cremation to check for bone material. Harry Tosh reported that despite their best intentions the process did not always produce remains which Cremator Operators could identify as bones, in which case families were informed of this at the time.

It was confirmed by David Eagle, Regional Operations Manager for Glasgow Co-operative Funeral Care and previously Funeral Home Hub Manager for Bellshill, that remains from babies were returned to families in some cases. He told the Investigation,

"Craigton was like Maryhill, it was a case of ask and we shall see. There was no guarantee but it was a matter of 'ask if there's ashes to be available then we will let you know'."

According to Harry Tosh, the policy about the definition of ashes changed in early January 2013. Thereafter,

"if the family want remains back, we will give what's left after the cremation."

This change in policy followed the emergence of the adverse publicity about Mortonhall Crematorium. John Williamson, Head of Operations Scotland and Northern Ireland, told the Investigation that senior managers in the Co-operative Group had met to discuss the position at Craigton Crematorium in light of the media coverage of Mortonhall. The Managing Director took the decision to change the policy at Craigton immediately and to start returning ashes to families regardless of the presence of visible skeletal remains.

A Cremator Operator described how a conversation with a parent had highlighted the need for a change of approach away from his understanding of the FBCA interpretation. He said,

"I had stuck rigidly to the rules and it wasn't until one of the mums told me as long as she knew her baby had been in it, that's what she wanted… up to that point, I honestly had never considered it. I put my hands up to that, I hadn't. I stuck regularly to the line if there isn't human remains, if I don't see human remains, then I'm not going to give somebody a lump of burnt wood and pretend to them that it's human remains."

Dr Julie Roberts, Forensic Anthropologist, has explained that in very young foetuses it may take considerable forensic expertise to recognise bones which are, nonetheless, there.

The Investigation enquired how, in practice, anything remaining following a baby cremation was checked for skeletal remains. Harry Tosh, Manager and Registrar, explained,

"our procedures at that time were that we always did look to see if there were identifiable remains, if there weren't any identifiable remains we would let the family know…Early January 2013 onwards if the family want remains back, we will give what's left after the cremation."

A Cremator Operator explained the procedure that he had routinely followed. He said,

"I was always taught that ashes are human remains and that was how we always work. At the end of the cremation we looked for human remains in what was left in the tray. If that wasn't human remains and the instruction had been a 'retain' then I would inform the office that there was or there wasn't remains."

The same Cremator Operator explained the procedure if humans remains could be identified. He told the Investigation,

"If I could identify bones we gave the parents everything that was in the tray. You couldn't possibly remove just the human remains and return only those."

Referring to the stage in the gestation period at which he had found human remains, the Cremator Operator told the Investigation,

"I'm sure I found them in twenty-four week babies… and younger than that."

Dr Julie Roberts, Forensic Anthropologist and expert witness to both the Mortonhall Investigation and this Investigation ^[22] has confirmed that bones from cremated foetuses as young as 17 weeks' gestation can and do survive the cremation process. The Cremator Operator would not, however, have known the precise age of those non-viable foetuses he was cremating, as this is not part of the information with which he is routinely provided.

The Investigation enquired whether any cremations of more than one body at a time were carried out in the cremators at Craigton. It is lawful to dispose of non-viable foetuses with other non-viable foetuses through shared cremation, and this practice is carried out at Craigton. The Cremator Operator described his experience of shared non-viable foetus cremations in which twenty foetuses at a time would be cremated inside a box in the baby tray.

i Impact of Cremation Equipment

The Investigation explored the impact of working practices on the services delivered particularly in relation to the equipment, including the use of baby trays, and the policies applied.

Almost all of the cremations that take place at Craigton crematorium are of adults and many of the features of an adult cremation are replicated during the course of a baby cremation ^[23] . Different modifications of the procedures for cremation of non-viable foetuses, stillborn babies and infants were described by the Cremator Operator.

ii Cremators

A Cremator Operator told the Investigation that when he joined Craigton Crematorium in 1991,

"We had an old Dowson and Mason [cremator] which was operated by levers and valves. They had been put in in 1957 so we didn't have the same legislation that SEPA (Scottish Environmental Protection Agency) have now introduced."

He explained the practicalities of operating the old machines which were double-ended and double-hearthed.

"With the double hearth you had your top hearth and it was wee bricks, we called them 'half-moon' … and they came together and there were holes so when the cremation finished, you knocked the ashes down onto the lower hearth through the holes and then you ashed out from the bottom. You had two small hatches at the back end and you charged from the far end. The two smaller hatches, one took you into the top hearth and the other one took you into the ashing out hearth."

In 1992 Craigton Crematorium was updated with the installation of two single-ended gas-fired Evans 300/2 cremators. The same Cremator Operator explained some of the differences from the previous model,

"With a single hearth, you push the coffin in, the cremation takes place in that chamber and you ashed out from that chamber. It's a flat hearth… We didn't have the room when they put new ones in for a double ended. We were building the new ones while the two others were in situ so there wasn't room to put the new ones where the old ones were."

Software upgrades were installed in 2005 and 2013. The upgrades were primarily to comply with new emissions monitoring guidance from the Scottish Environmental Protection Agency ( SEPA). In 2013 those crematoria having their software upgraded for this purpose were also installed with 'infant mode' at no extra cost. Infant mode is now available ensuring that conditions within the cremator are adjusted to make them more gentle and therefore suitable for the cremation of babies.

Dealing with the impact of the infant mode setting on recovering ashes, the Cremator Operator commented,

"there will always be some remains to scatter, it's such a low temperature with so little air, there will be some, there will be wood ash at least."

He also told the Investigation how babies were cremated before the introduction of a baby tray.

"What we did was we'd have two people charge it and we'd lift the door and sit the baby just at the edge. We've got a wee rake, and we just pushed it in just beyond the door. And then we left it down to residual heat. There wasn't any air on so I think it just burned where it was. Of course there would be remains and we would collect them as well. Even if it was only wood dust we would scatter that. We would treat it the same as if it was human remains."

Dr Clive Chamberlain, a Chartered Engineer, member of the Council of the Combustion Engineering Association and expert witness to the Mortonhall Investigation ^[24] explained in his evidence why such modifications to the cremation process are 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."

iii Baby Trays ^[25]

A baby's small coffin, or box containing a non-viable foetus, may be placed on a steel tray inside the cremator to better contain any ashes and prevent them being lost by being spread throughout the cremator by the force of the air jets. Part 5.13 of this Report discusses the use of a steel tray to greatly improve the likelihood of retrieving remains from an infant cremation.

There are two trays available at Craigton for foetal and infant cremations. The first was introduced in 1993 and the second in 2013. They can accommodate wooden baby coffins up to 18" by 8."

The Cremator Operator told the Investigation that the baby tray had been used ever since it became available. It is now used in conjunction with the cremator's infant mode setting, but before the setting was introduced infant cremations took place as the last cremation of the day. This process, he said, was recommended by Evans, the manufacturer at the time.

In order to insert the tray into the cremator it sits on the end of the trolley, quite close to the cremator. Once the cremator door is open the tray is pushed in gently. As the Cremator Operator explained,

"We don't want it to go in too far because getting it out can be the awkward bit. The tray slips off onto the hearth, we shut the door and we then go over and we select infant mode."

iv Dispersal of Ashes

There are four options in respect of the ashes. They are 'dispersal by crematorium staff with no family attending', 'dispersal with the family in attendance', 'retain for uplift by the Funeral Director' and 'retain for uplift by the applicant'.

As explained in the Mortonhall Investigation Report ^[26] there is overwhelming evidence that foetal bones do survive cremation, at least from seventeen weeks' gestation. However, prior to the evidence of Dr Julie Roberts included in the Mortonhall Investigation Report, no such evidence had been published and the belief that non-viable foetuses do not have bones was prevalent amongst the Scottish Government, the NHS, the FBCA, Funeral Directors' Associations and some staff working in crematoria across the country.

The Investigation looked into what happened to any ashes that were not considered to meet the Federation of Burial and Cremation Authorities ( FBCA) definition of skeletal remains, as well as to those ashes containing bone if their return had not been requested by families.

Explaining the process before 1995 in relation to those ashes in which no bones were identified, Harry Tosh, Craigton's Manager and Registrar, said,

"all remains were dispersed in the back of the crematorium, it's not in the paperwork but if anyone was to come in and ask me, I can tell them exactly where it was."

He was also confident that he could identify specific areas in which ashes containing bone were scattered. He explained,

"Recording in the register where the ashes have been dispersed is something we started doing from 2013. That said, the location of where all the remains have been dispersed has been recorded from way back. They're in the cremator register. We've got five areas G1, G2, G3, G4 and G5. That's how simple it is and we know exactly where those areas are so if the family can say we can let them know exactly where the ashes were dispersed."

He later clarified that the location has been recorded since 2007. This was confirmed by the Investigation when undertaking examination of the Registers of Cremations.

More recently, Harry Tosh explained that the crematorium had developed an area specifically for children.

"We only started dispersing children's remains in the Children's Memorial Garden from January 2013."

This area, he told the Investigation, is,

"specifically for all babies' remains, everything that's left after the cremation process is dispersed round the children's garden. Before that all cremated remains or anything left after the cremation process would be dispersed in whatever area the dispersals took place that week, be it G1, G2, G3, G4 or G5, unless the family specifically asked."

The Cremator Operator confirmed,

"We've got five areas in the garden now where we scatter and we change it every week. We do that mainly so we don't have an accumulation of ashes in any one area. I think we've kept records since about 1994."

Referring to ashes to be 'dispersed' (scattered) Harry Tosh told the Investigation that whereas ashes used to be scattered on the day following the cremation, a thirty days waiting period was introduced from March 2013,

"if it's dispersal we wait thirty days after the service, then disperse the remains."

This provides families with time to re-consider and, where they wish to do so, to change the ashes instruction.

8.5 Administration and Record Keeping

Harry Tosh, the Manager and Registrar, is responsible for record keeping at Craigton Crematorium as well as for the day to day operation of the cremation facility. In relation to record-keeping he is assisted by an administrator.

The paperwork that is processed at the crematorium consists of the forms required for a cremation to take place and completion of Form G, the Register of Cremations. Maintaining a Register is a statutory obligation (except in the case of non-viable foetuses) and involves the recording of the cremation number, date of cremation, date and place of birth, age and gender of the baby, details of the applicant for cremation and disposal method for ashes. John Williamson suggested to the Investigation that the wording on the Form G is ambiguous and does not make it clear that the final resting place of the ashes is what is required to be entered on the form. Instead the wording of the form could be interpreted to mean the intended method of disposal. However, the Cremation (Scotland) Regulations 1935 makes it clear that the wording for the Form G Register of Cremations is 'How ashes were disposed of', and not the intended method of disposal. Therefore this section of the form is clearly intended to be completed after the event, not in anticipation of it.

Since 2009 the Co-Operative's computerised Epitaph system has been used at Craigton Crematorium for booking and recording adult and stillborn baby cremations. The Manager and Registrar, Harry Tosh, explained the process,

"The details from the Form A are normally entered into the electronic Register of Cremations, Epitaph, the day before the service and into the manual register on the day of the service. The reason it's entered into Epitaph the day before the service is because the information on that system is needed to fill in the cremation cards and the rest of it. It's not just a register, it's also an invoicing system so we do that on the day for the invoicing. This means that the instruction on the Form A is entered into Epitaph before the funeral.

The information being entered into the manual register is done on the day of the funeral but it is possible that it will be entered into the register before the cremation has taken place. That's because if there are several funerals it might be the dinner time we're filling in the register so we've still got the afternoon funerals to be done. But what's on Epitaph and what's in the manual register should always be the same"

Once the details are entered on the system, identification cards and labels for the remains are generated.

The paperwork and record keeping in relation to babies, whether born alive or stillborn, is the same for adults and uses the Epitaph system. Individual and shared cremations of non-viable foetuses are not recorded on Epitaph. While there is no legal requirement to keep a record of the cremation of non-viable foetuses the crematorium actually records all shared or individual foetal cremations manually. In one of the cases referred to the Investigation, the cremation of a non-viable foetus was in fact recorded in the main Register of Cremations in 1990. Since 1991 paperwork has been retained for all non-viable foetus cremations and, in the words of Harry Tosh, "a register of sorts" has been kept, separate from the main Register of Cremations. This is made up of two logs, one for individual cremations and the other for shared cremations. Since 2013 shared cremations have been recorded separately.

For shared cremations only, the decision was taken by the crematorium not to enter all the information from the accompanying paperwork onto the register, in order to protect the anonymity of the parent. On dealing with a recent query from the parent of a non-viable foetus Harry Tosh said he had contacted the hospital with the parent's details so they could provide the relevant information that enabled him to tell the parent when the cremation took place. In terms of future recording Harry Tosh added,

"We are currently looking into how we might add NVFs on to Epitaph because there is a place on that system for it. However, for shared cremations we can have about 250 in one day. You can't add every detail in but it is something to look at."

Funeral bookings are made by Funeral Directors, or the hospital, directly with the crematorium.

i Findings on Record Keeping at Craigton

As with Mortonhall the Investigation found Form A, the statutory Application for Cremation, to be the most significant of the cremation paperwork ^[27] . However, in many of the cases looked at by the Investigation although the form was completed in the name of, and signed by, the next of kin, they could not remember signing any forms. This was the experience of the father of three babies who died between 2001 and 2003 shortly after being delivered at about twenty-four weeks' gestation. Two of the babies were cremated at Craigton Crematorium. On seeing the Form A for the baby who died in 2001 this father told the Investigation,

"There's a signature that's clearly mine. That's definitely my handwriting but I have no recollection of signing this form."

In the same case the instructions for the ashes on the reverse of Form A (Section 5) was left blank and the section in the Register of Cremations, where the method of disposal of ashes is recorded, was simply scored through.

The speed with which forms were expected to be completed is a matter of concern to the Investigation. The mother in the same case told the Investigation,

"The forms had to be done right after the delivery."

This situation was confirmed by other parents.

A mother whose daughter died in 2004, having lived for almost three months, firmly believed that the circumstances in which decisions are taken led her to make a decision that she came to regret.

"It's not the right time to be asking and making decisions when people are that distressed. I wasn't, obviously, in the right frame of mind to be dealing with it."

She was even unsure as to how she reached the decision to cremate her daughter.

"I don't know when we had to make the decision that we did. We didn't even know where to start. To be honest we had to get guidance on what you do. And we didn't know where to go - Undertakers or anybody - because we had never ever thought we would have to organise a funeral. I don't know how we actually came about getting [our daughter] cremated. All my dad's family are buried so I don't know why cremation ever came about. As I say I'm totally oblivious to that."

The mother recalled that shortly after the baby's cremation, she and her husband were told by crematorium staff that there were no ashes because babies are " too small". This was information she and her partner accepted until news of Mortonhall emerged. They were advised by their solicitor to report the matter and were subsequently informed by the police that records revealed there had been ashes, which were scattered at Craigton.

The mother told the Investigation,

"Nine years down the line they were able to tell us the plot where her ashes were scattered…"

The Form A, signed by the baby's father and the Co-Operative Funeral Director included the instruction to 'disperse' the ashes. As with many other cases, the Form A has been completed by the Funeral Director rather than the father who is the named applicant. The Register of Cremations recorded the baby's ashes as having been 'scattered'. The mother could not remember any discussion about what she wanted to happen to the ashes, only being told that there were none.

In the belief that her daughter had no remains this mother purchased a rose tree and a plaque at the crematorium in memory of her daughter. Had this baby's ashes been returned to her mother immediately after the cremation, a great deal of distress could have been prevented.

Another mother described a similar experience after her daughter was stillborn in 2007. Having been told there would be no ashes she discovered later that the Instruction for ashes on Form A was 'stillborn baby disperse'. The Register entry read, 'Scatter at Area G2'. She told the Investigation how she learned from the Funeral Director there would be no ashes.

"I noticed urns in the corner and I asked if they did smaller ones in a pink colour for a baby. That's when she said, ''No sorry, we don't recover ashes from a baby so young'. I was really shocked but you take it that this person does this every day, that's her profession, she knows what she's talking about, so I just accepted that."

It is not clear to the Investigation why when Funeral Directors from Co-operative Funeralcare were routinely telling parents there would be no ashes, they would select the option "disperse" for the ashes disposal. This is illogical.

Following the Mortonhall revelations the same mother told the Investigation that she,

"asked someone from Sands (charity) to look into [her] case and it came back that there were ashes and they were dispersed and that's when I started looking into stuff for myself. I felt numb, shocked, I'm devastated that my daughter had just been thrown away like a piece of rubbish. At the crematorium they pointed to a piece of grass where the ashes are scattered or dispersed … How do I know that they're not just picking a piece of grass and saying, 'oh that's where it is?' I can't prove that. I can't say that they are or not."

The parents of a stillborn baby cremated in 2004 also regretted their decision to have their daughter cremated. They told the Investigation there was no mention of ashes until after the cremation, when they were told by the Minister that the crematorium did not give out baby ashes. The mother explained to the Investigation,

"If somebody had said, 'Have a few days to think about it and you won't get any ashes back', I wouldn't have had her cremated."

In this case the ashes instruction section on the reverse of Form A was scored through and the ashes disposal section in the Register of Cremations was left blank, thereby shedding no light on the outcome of this baby's cremation.

This Investigation been unable to discover what instruction was entered onto the Form A in some cases because all records (other than the Register of Cremations) were retained for fifteen years only, in line with the statutory obligation at the time.

Mothers in this situation included one who delivered two stillborn babies at around twenty-seven weeks' gestation in 1990 and 1995. She told the Investigation that she was told by the Funeral Director, Co-operative Funeralcare, on both occasions that there were " no ashes for babies" and no forms remained other than the Register of Cremations. Entries revealed that the ashes of the first baby had in fact been 'Scattered'. Describing her reaction to the Investigation the mother said of the Funeral Director,

"I had no reason to question his response."

She had not, however, entirely accepted what she was told. Following the media coverage about issues arising at Mortonhall Crematorium, she made enquiries and had a phone call from Harry Tosh, Manager and Registrar at Craigton. He informed her there had been ashes for the first of her stillborn sons and they had been scattered. She was invited to Craigton where Harry Tosh showed her the ledgers. On seeing the entry confirming the disposal she told the Investigation, " I was devastated". When asked to describe where the ashes would have been scattered Harry Tosh said they could be " from the boundary, right up to near enough the railway".

The same mother questioned why there were ashes for the first child and not the second for whom the relevant Register entry read, " No identifiable remains". Harry Tosh explained to her that this would have meant there were no visible bone fragments. Any residue would have been scattered.

Speaking to the Investigation, the mother said,

"I was thinking what was the difference? The same gestation and about the same weight, to me it should have been the same in both cases. Either both no identifiable remains or both identifiable remains and scattered… I should have been offered my children's ashes or remains even though it was maybe just coffin ash."

Details from the Form A are entered in the daily diary (a list of all the day's cremations) and onto the individual identification card that accompanies each individual cremation. At the time of the Investigation identification cards were not retained but their retention was under consideration with the aim of providing an additional record, in particular of when and by whom ashes were collected, and to provide continuity. As well as the name of the deceased, the date and the cremation number, the card includes the instruction about ashes, whether they are to be retained or scattered. Sticky labels are used to identify remains and their method of disposal.

As is the case at some other crematoria the accuracy of Form G - the Register of Cremations - is questionable. The reason for this is that the disposal of ashes column in the Register is populated automatically at the time when the cremation is being arranged and details from Form A are being entered on Epitaph. This can lead to the situation described by the Cremator Operator when he told the Investigation,

"If there are no remains but the instruction was scatter, it would say scattered in the register."

An examination of the Registers of Cremations by the Investigation did not find evidence of any ashes collected by families or Funeral Directors in 1990, 1999, 2001 or 2007. A small number of entries of 'retain' were found but as these did not relate to cases referred to the Investigation it was not possible to check if the ashes had in fact been returned to families. It is noteworthy that in 1990 every entry for a baby states 'scattered' and in 1999 every entry states 'no identifiable remains'. In 2001 and 2007 the entries are more varied and include 'retain', 'scatter' and 'N/A'.

It would appear that at Craigton, unlike at some other crematoria, an incomplete Form A did not delay the arrangement of a cremation. The Investigation found no evidence that the absence of Instructions for Ashes at section 5 was followed up by the crematorium with the Funeral Director.

8.6 Communication

Many parents who provided evidence to the Investigation described the incorrect information that they received from hospital staff and Funeral Directors about the availability of babies' ashes. A mother who lost three babies on separate occasions between 2001 and 2003, each born alive at about twenty-four weeks' gestation, two of whom were cremated at Craigton, recalled being told on each occasion by hospital staff that there would be no ashes.

"I remember very clearly there was a discussion about ashes. They said that there's not going to be anything left because they're so little. That is what they said. I don't remember who told me that - whoever was around me."

A father, informed by crematorium staff that there were no ashes when he went to collect them told the Investigation,

"You would never in a million years have thought to question a crematorium."

The need for improved and accurate communication was identified by a mother who had in 1990 and again in 1995 given birth to a stillborn baby of around twenty seven weeks' gestation. She said,

"In surviving grief like this I'd have been much happier having the facts, having the proper information so I could make a proper judgment. I would have liked a bit more time to think about things… having to deal with it the same day that you've just given birth is not the ideal time…"

Another mother who had delivered a stillborn twin at thirty weeks' gestation in 1999 told the Investigation that at some point when organising the funeral, she was told there would be no ashes to collect as the baby was so small. She described her response.

"We presumed that we had the correct information on this matter and trusted implicitly the integrity of the company dealing with our child at this time."

She later discovered that the Form A instructions for ashes was blank and that Register of Cremations recorded there being 'no identifiable remains'.

Commenting on the situation she added,

"It would have helped healing and grieving to have had some ashes to scatter and a special place to think of [our daughter] throughout the years. We were deprived of this chance which is devastating. The thought of our child's ashes being discarded somewhere without our consent or knowledge is morally incomprehensible and extremely upsetting. We deserved the chance to have whatever little ashes there were, and the truth told to us, at this our most vulnerable and lowest point as a family."

Contact with families was generally through Funeral Directors rather than directly with the crematorium.

The Cremator Operator described his contact with families as, ' none whatsoever'. It was, he explained, mainly the office that would have contact " and even that can be through the Undertaker rather than face to face with a client". For many cremation staff the only time they would have contact with bereaved families was at the crematorium on the day of cremation. On such an occasion interaction is minimal and any conversation purely formal.

Referring to the situation where there was no specific instruction from the Funeral Director or family to retain the ashes the Cremator Operator explained,

"We've came across human remains lots of times when there wasn't an instruction to retain. If it wasn't retain then it would be down as a scatter and it would be scattered as an adult cremation… if the instruction was scatter we wouldn't have differentiated if the family wanted the ashes to be scattered - I would assume they meant whether there was human remains or not, they still wanted them scattered."

The Cremator Operator confirms that the relationship between crematorium staff and bereaved families was normally an indirect one. He said,

"If there are no remains but the instruction was scatter, it would say scattered in the register. Whether there was remains or not, the instruction I have is to scatter and I must assume that the family discussed that themselves or with the midwife or the Undertaker and then I must follow the instructions which is the family have requested that the ashes be scattered. I would never have considered for a second it was my place to say, 'well wait a minute, those ashes do you want them?' That would be kind of presumptuous."

John Williamson, Head of Operations Scotland and Northern Ireland, told the Investigation he felt there was still room for improvement in terms of communication between hospitals and Funeral Directors about the wishes of bereaved parents. He told the Investigation that the funeral industry had stepped in to assist when hospitals stopped incinerating foetuses as clinical waste.

It was accepted practice in the past for Funeral Directors to complete the Form A with information passed to them by the hospital rather than the family. The word 'disperse' is used to mean 'ashes not to be returned' and could be completed by the Funeral Director in the absence of a specific instruction from the hospital to return ashes to the families. Meetings are now taking place between the Funeral Directors and the hospital so that it is clearer in future that the hospital has actually asked the families for an instruction for ashes in those cases where they are arranging the funeral on the families' behalf.

8.7 impact of Mortonhall Investigation and the Infant Cremation Commission

Rather than waiting for publication of the Mortonhall Investigation Report in April 2014 the crematorium changed its policy on ashes in January 2013 in relation to babies. This meant it ceased to return only those ashes which they believed contained human remains and instead returned everything left in the tray. In addition, steps were taken to record in the Register of Cremations, as well as manually, the location where ashes were dispersed at the crematorium.

Another change made by the crematorium, also in 2013, was the introduction of a waiting period of thirty days where 'dispersal' or 'scattering' of ashes was requested. This delay was designed to give families time to change their mind and request the return of ashes, before it was too late.

Harry Tosh told the Investigation that as a result of the Mortonhall Investigation Report and the recommendations of the Infant Cremation Commission, rather than disposing of its records after fifteen years Craigton Crematorium is now in the process of " keeping everything as long as we can."

8.8 Findings for Individual Cases

Out of the fourteen Craigton cases, ten had a Form A provided to the Investigation by the crematorium. Of those ten only five included clear Instructions for Ashes with three stating 'disperse', one stating 'scattered' and one stating 'if any [ashes] return'. In the remaining five examples three were left blank, one was scored through, and one stated 'no'. The most recent of these incomplete forms related to cremations in 2004.

8.9 Conclusions

1. It would be inappropriate to criticise Cremator Operators and their managers for following the FBCA guidance at the time, and determining the ultimate disposal of ashes according to whether or not they contained bones. In January 2013 the decision was taken by the senior management to change this policy and return everything remaining in the tray after cremation. This decision was taken in response to publicity surrounding Mortonhall Crematorium and prior to publication of the Mortonhall Investigation Report. The decision demonstrated a willingness to recognise, and react to, the need for change .

2. The situation in which families were told there would be no ashes when in fact there were ashes and these were scattered without the families' knowledge or agreement has been a cause of profound distress to the families. Discovering the truth years later has caused parents deep sadness and renewed pain. The provision of inaccurate and misleading information highlights the need for improved communication between the relevant agencies and for training between crematorium staff, NHS staff and Funeral Directors to ensure consistent and accurate information is provided to families. NHS staff and Funeral Directors also require to have a fundamental understanding of the physiology of foetal bones that allows the bones to survive the cremation process. It is particularly unclear why Funeral Directors should tell parents there would be no ashes, yet they would select the option "disperse" for the ashes disposal. This is illogical.

3. The Investigation has been unable to establish all the facts in every case, because in some cases the fifteen years' document retention period has lapsed and in others forms are incomplete. There was also no legal requirement to maintain a register for non-viable foetuses. When a register was kept, unlike the statutory Register, it did not contain a column for recording the disposal of ashes.

4. The procedure whereby the disposal of ashes is recorded before the cremation has taken place results (as in some other crematoria) in a wholly unreliable record. Rather than being an accurate record of what has taken place, the Register entries are often a predicted outcome and not the actual outcome. Given that the Register is expected to be a permanent record, great care must be taken to ensure it is completed accurately. Otherwise there is a failure to comply with the crematorium's statutory obligations.

5. Since adopting the wider definition of ashes as being 'everything left in the cremator following the removal of any metals', Craigton Crematorium has recovered ashes in every case. It is a requirement since June 2015 for any crematorium in Scotland to report to the Inspector of Crematoria any incidence of non-recovery of ashes from infant or foetal cremation. No crematorium has reported such an incident in that time.

6. It is clear from some of the cases referred to the Investigation that Craigton Crematorium's policy of cremating in such a way as to maximise the retention of ashes was not always successful. One explanation for why there were no remains might be that the Cremator Operators lacked expertise in foetal development and failed to recognise skeletal remains. Summarising her findings Dr Julie Roberts, Forensic Anthropologist and Archaeologist Dr Roberts explained to the Investigation,

"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 new born 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 recognise burnt skeletal remains, and/or individual or corporate management decisions."