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

9 Glasgow City Council Crematoria - Daldowie and Linn

9.1 Introduction

A total of 32 cremations of infants or babies conducted at Glasgow City Council Crematoria were referred to the Investigation. Of those, twenty-two related to cremations carried out at Daldowie and ten to cremations carried out at Linn. The earliest of those cremations took place at Daldowie in 1988 and the most recent in 2013. In relation to Linn the earliest cremation was in 1993 and the most recent was in 2009.

Glasgow City Council manages two crematoria. They are Daldowie Crematorium on Hamilton Road, Uddingston and Linn Crematorium in Lainshaw Drive, Castlemilk.

The Investigation was told that Daldowie and Linn Crematoria opened in 1955 and 1962 respectively, with responsibility for Daldowie transferring from North Lanarkshire to Glasgow City Council in or around 1959. Each crematorium has two chapels on site, an area in which Books of Remembrance are displayed and is surrounded by Gardens of Remembrance.

Daldowie is the busiest of the Glasgow crematoria and carried out 2,585 adult cremations in 2013. In the same year there were four child cremations, 133 cremations of stillborn babies and eight individual cremations of non-viable foetuses.

At Linn there were 1,869 adult cremations in 2013, one child cremation, forty cremations of stillborn babies and thirteen individual cremations of non-viable foetuses. There are no shared cremations where non-viable foetuses are cremated together at Linn or Daldowie. In relation to an allegation by an agency employed Cremator Operator that two non-viable foetuses were cremated in the same cremator on 4 June 2011 at Daldowie, David McGoldrick, a manager with Glasgow City Council appointed to investigate, concluded that there was no case to answer. This date did not correspond with any of the cases referred to the Investigation.

9.2 Management

Daldowie and Linn crematoria are managed by Bereavement Services, a division within Glasgow City Council that also manages the city's Council-owned cemeteries. Since a restructure in 2013 Bereavement Services is part of Public Health. Prior to 2013 it was part of the Parks and Environment department which, for a time, also included Transport.

The Investigation was provided with an organisational structure chart setting out the structure of the management team from 2004. In 2015 the Head of Sustainability, Alastair Brown (in post since 2012) reported to the Assistant Director, the Executive Director and the Chief Executive of the City Council. Alastair Brown's portfolio of responsibilities includes Public Health. Reporting to him is the Public Health Manager Nigel Kerr (in post 2013 - 2015).

Nigel Kerr line managed an Assistant Manager - Bereavement Services/ Public Health, David MacColl (appointed 2013). David MacColl (who is frequently referred to by other witnesses as Bereavement Services Manager) was line manager to the Bereavement and Environmental Services Operations Manager, John Downes (in post since 2010). This management team is responsible for both Daldowie and Linn Crematoria.

Under the senior managers are two separate teams, one based at Daldowie and the other at Linn, responsible for the day to day operation of the crematoria. Each is headed by a Bereavement and Environmental Supervisor (a position often designated Superintendent at other crematoria). They are Christopher O'Neill at Daldowie and John Wright at Linn. Both are assisted by a Bereavement and Environmental Assistant Supervisor.

Over the period spanned by the Investigation's cases the various management roles have, not surprisingly, been carried out by a number of different people. Some of the more senior management have very extensive and diverse areas of responsibility of which the operational side of Bereavement Services forms just one part. Current senior managers were open with the Investigation about their lack of experience of the cremation industry at the time they were appointed. In particular, they claimed no specialist knowledge of infant cremation. Alastair Brown, the Head of Sustainability, told the Investigation,

"I thought the procedure for cremation was the same for adults and children."

It was not the practice for more senior managers, above the level of the Bereavement Services Manager, to attend meetings held by the Federation of Burial and Cremation Authorities ( FBCA) and the Institute of Cemetery and Cremation Management ( ICCM). ^[28]

A picture emerged through interviews with Glasgow City Council managers of the crematoria having long operated in what Alastair Brown, Head of Service, described as a, " historical isolated fashion", where despite societal changes,

"the services just continued to operate in the same way and weren't adapting."

There was evidence of a lack of awareness amongst managers of how practices in Daldowie and Linn differed from crematoria elsewhere in Scotland. The Bereavement Services Operations Manager between 2006 and 2010, Alexander Stewart, who started with the Council as a grave digger in 1978, told the Investigation that after his appointment in 2006,

"My attention was never drawn to the issue about cremation of babies or foetuses. I was aware that babies were being cremated. There were no baby trays then. I wasn't aware of there being different views in different parts of Scotland about ashes being only cremated remains of the bones … it was everything left after the cremation. This included not knowing about the use of steel trays within which an infant coffin or non-viable foetus is placed for cremation in other crematoria."

Alastair Brown, the Head of Sustainability, told the Investigation,

"I was quite surprised at the level of inconsistency between different crematoria. Before December 2012 if you had asked me the question I would have expected that most crematoria would have operated in a similar fashion to ours."

Likewise, John Wright, the Linn Crematorium Supervisor, admitted he,

"was not aware until after Mortonhall that in Seafield in Edinburgh they were able to recover remains by adjusting the heating and all sorts of things. Official sharing of information would be something that the managers would probably have."

The Investigation was told that cremation of babies was not discussed at management meetings. Kenneth Boyle, Head of Parks 2004 - 2009, became aware of a general problem not specific to babies or non-viable foetuses involving the,

"totally unacceptable situation in regards to the timeous collection of ashes…My opinion was that a timescale should be set on the retention of remains on behalf of Undertakers. A range of actions would be triggered if remains were not collected at the end of the time allocated."

The critical issue of the cremation of foetuses and babies and whether or not remains were recovered and returned to parents does not seem to have been discussed at all until after the revelations in the media about Mortonhall Crematorium in Edinburgh became public in December 2012. As Alastair Brown, Head of Service since 2012 explained,

"My experience is that people tend to deal with things when there's a problem. It's almost like we wait until there is a crisis and then we deal with it and this might be a good example…Bereavement Services operated within local authorities. They were working okay. They didn't seem to be causing any problems and therefore people just let them continue to work in the same way."

9.3 Policy, Guidance and Training

Witnesses interviewed for the Investigation were able to speak to working practices at Daldowie and Linn going back to the mid 1990s. Therefore, this Report focuses on practices from that time to the present day and cannot comment on working practices employed at Daldowie and Linn before the 1990s. One of the cases referred to the Investigation dates back to 1988 and we were unable to speak to individuals who can tell us about to this period from an operations perspective.

Prior to changes introduced following publication of the Mortonhall Investigation Report in April 2014, Glasgow City Council relied upon the FBCA for guidance on what constituted cremated remains and therefore should be returned to families after the cremation process is complete. Alastair Brown, Head of Service since 2012, explained that accordingly only, ' skeletal remains' or ' calcified bones' and 'not any residue from the coffin or anything else' would be returned. Any residual ashes considered not to contain skeletal remains, referred to in these crematoria as 'fly ash' or 'residue' was interred at Daldowie or scattered at Linn.

The Investigation was informed by Cremator Operators at both Daldowie and Linn that prior to the publication of the Mortonhall Investigation Report they were never issued with written procedures other than the manufacturers' manuals for the cremating equipment. John Wright, the Supervisor at Linn told the Investigation there were,

"No particular written guidelines or instructions in relation to any functioning of the crematorium."

Stevie Scott, who was appointed Head of Parks in 2009, told the Investigation that based on the use of a typed sheet with checks in the form of tick boxes known as the 'Instructions to Cremate' cremation card, " I would be confident that there was a procedure". Nigel Kerr was also of the view that the absence of written guidance was not a problem, telling the Investigation that,

"whilst there might not have been any written procedures there was the Federation of Burial and Cremation Authorities guideline which they [the Cremator Operators] followed to the letter."

Although the FBCA training materials that Operators follow in order to become qualified have, since 2004, referred specifically to 'Cremations of infants or of foetal remains', no Operator that spoke to the Investigation recalled it being mentioned during their in-house training ^[29] .

During the period with which this Investigation is concerned the longest serving member of Glasgow City Council's Bereavement Services management was Lucille Furie. She joined Cemeteries and Crematoria (later re-named Bereavement Services) in 1985 as the Office Supervisor and was promoted to Cemeteries and Crematoria Officer in 1997, later becoming Bereavement Services Manager, a post she held until she left Glasgow City Council in December 2012. She was subsequently appointed Manager at Glasgow Crematorium (Maryhill), referred to elsewhere in this Report.

The senior managers who spoke to the Investigation placed significant reliance upon Lucille Furie. According to Kenneth Boyle, Head of Parks (2004-2009), her position in Glasgow City Council meant,

"She had control of supervisory and administration staff, as well as staff at the crematoria and some burial grounds."

The Group Manager for Public Health and Bereavement Services, Nigel Kerr, recalled holding a series of meetings with Lucille Furie and her team following his appointment in November 2012 until she left on 18 December 2012, with the aim of learning as much as possible before her expertise was lost to the Council.

Kenneth Boyle's successor, Stevie Scott, recalled that Lucille Furie represented Glasgow City Council on the 15 February 2011 at a meeting of the Scottish Parliament concerning disposal of non-viable foetal remains. He expressed the view that,

"Anything on the cremation of babies, how you would cremate a baby or any training or any knowledge about that, I would have expected to come from Lucille."

According to Stevie Scott, Lucille Furie, as Bereavement Services Manager, had " direct responsibility" for the Supervisors from both Daldowie and Linn, although this was disputed by Lucille Furie herself who told the Investigation that the crematoria operational staff only reported directly to her until 1997, when a restructure resulted in their reporting to an Operations Manager.

Lucille Furie also disputed Stevie Scott's contention that she was an " expert" in her field. She explained,

"I've been involved in this since 1985. I've got a good oversight. I'm the Federation Secretary for Scotland and the longest standing chair for the ICCM, but that does not make me an expert."

Asked about the level of involvement exercised by senior management, Alexander Stewart, the Bereavement Services Operations Manager (2006 - 2010) who reported to Lucille Furie, told the Investigation,

"As to seeing senior management around the crematoria, to be honest above Lucille, no. They wouldn't come in to visit unless there was a serious problem. Lucille was more or less it in terms of senior management."

Despite his job title suggesting that he managed operations, and in particular cremations, Alexander Stewart's evidence was that his role bore little relation to the practicalities of cremating and more to managing the Operators carrying out the cremations. It might be expected that such a role would require knowledge of the tasks being carried out by staff, particularly since risk management was also included in his responsibilities. He told the Investigation,

"I didn't participate in any Federation matters… I was more operations, I was the eyes and ears outside. Lucille would have dealt with that sort of stuff… I wasn't certified and I've never done any cremations. I ended up dealing with the sickness levels, absence levels, risk assessments. My remit was that anything above that, the problem would have been Lucille's. She was the senior manager."

Crematorium Supervisors are responsible for the day to day running of the crematoria, overseen by the Operations Manager. John Wright (the Supervisor at Linn) described being responsible for,

"the process here at this crematorium, from the families arriving at the door until they take their ashes away."

The Supervisors are also responsible for managing the Cremator Operators, who are known as Bereavement and Environmental Technicians at Daldowie and Linn. For consistency these staff are referred to as Cremator Operators throughout this Report. In 2015, according to information provided to the Investigation by Glasgow City Council, there were four Cremator Operators at Daldowie and three at Linn.

All of the Daldowie and Linn Cremator Operators interviewed by the Investigation referred to their training as being " in house" and " on the job". In order to qualify they had each undertaken the FBCA training programme, requiring them to keep a record of fifty cremations and to be assessed at work by a Federation representative. In all cases these assessments related to the cremation of adults and not infants. The Cremator Operators told the Investigation that once qualified they received no further training, including refresher training, and no personal appraisals to ensure they followed best practice.

When it came to the cremation of foetuses and babies, Cremator Operators learned from their more experienced peers or Supervisor rather than from formal training. Notions of policy and practice were derived by word of mouth. One of the Daldowie Cremator Operators recalled being trained by his Supervisor to use the baby tray when it was introduced in 2014.

Cremator Operators applied the Federation's definition of cremated remains being only 'skeletal remains' by sifting through what was left after the cremation process in order to establish the existence, or otherwise, of bones. This was confirmed by Christopher O'Neill, the Supervisor at Daldowie (and formerly a Cremator Operator at Linn). He described " looking to see if there's any kind of bone fragments" in what was left after non-viable foetus cremations. Commenting from personal experience, he told the Investigation, " I've cremated NVFs and never found any bone fragments".

There was a range of opinion among the Glasgow Cremator Operators interviewed by the Investigation about what remained after cremation. One Operator who has worked at Daldowie and Linn told the Investigation,

"Usually if it's an NVF there wouldn't be any ashes, there wouldn't be anything left at all."

Another Cremator Operator who has cremated at Daldowie since the 1990s said that prior to the publication of the Mortonhall Investigation Report, and the resultant changes, his practice with non-viable foetuses was to,

"rake it down as usual and then once the ash cool was done I'd checked the ash-cool can and physically check it to see if there were any remains there or not. At that point I would hardly ever get remains from an NVF. That's because the remains you get back are bones and NVFs generally speaking don't have bones. After the cremation of NVFs I would always get the ash from the coffin."

The same Operator described what used to happen when he could not detect bones,

"If I'd found no bones or saw no bones I've cremulated what was there and just scatter them if there were no remains. If there was something, even if it was coffin ash, it got cremulated. If there were bones I'd cremulate the bones and separately cremulate the coffin ash… When I got coffin ash it was just dispersed. I wouldn't have thought the families got a chance to get back that coffin ash."

Another Cremator Operator, with considerable experience of cremating at Linn, Daldowie and Maryhill told the Investigation that his in-house training,

"didn't involve the distinction between remains and ashes."

In his view this was a significant gap. Commenting on how the situation might be improved the same Cremator Operator suggested,

"There was no uniform opinion so maybe that's needed… not leaving it open to interpretation."

This comment tends to suggest that at the time of the interview this Operator had not been briefed on the recommendation already made in the Mortonhall Investigation Report and also included in the Infant Cremation Commission Report ^[30] that specified that 'ashes' should be defined as,

"all that is left in the cremator at the end of the cremation process and following the removal of any metal."

Describing non-viable foetus cremations carried out on the hearth without a tray, the same Operator revealed,

"There is something to be found every time you pull that door up, even with an NVF. I'm not saying bones, I'm saying 'something'. At Daldowie I always got remains, same as at Linn. So I was always able to put something in a container to be taken away or to be scattered."

Overall, however, the received wisdom at Daldowie and Linn was that there would be nothing recovered after cremation of a non-viable foetus. This conflicts with the evidence of Dr Julie Roberts, Forensic Anthropologist and expert witness to this and the earlier Mortonhall Investigation. Dr Roberts identified that skeletal elements are recognisable " from as early as seventeen weeks' gestation". Despite this being part of the Mortonhall Investigation Report this information does not appear to have been communicated by management to Cremator Operators in Glasgow or elsewhere.

The belief that there would be no ashes from a non-viable foetus was shared by Glasgow City Council's administrative staff, responsible for the crematoria's paperwork. The Administrative Officer told the Investigation,

"We were always told by Lucille [Furie], an NVF had no remains."

A Clerical Assistant confirmed having been given the same information,

"With NVFs …as far as I was aware there wouldn't be any remains left after the cremation took place."

The Cremator Operators and their Supervisors were asked by the Investigation whether they had ever cremated more than one body at a time in the cremators at Daldowie or Linn. One of the Daldowie Cremator Operators, with experience going back to 1997, replied,

"When I've cremated NVFs it has only ever been one at a time, except one occasion when it was twins in a box. I don't open the boxes so I only know what's in the box from what they tell me."

All Daldowie and Linn staff maintained they had only ever carried out individual cremations. Although it would have been lawful to dispose of non-viable foetuses through shared cremation with other non-viable foetuses, this did not take place at Linn or Daldowie and there was no contract with the NHS for disposal of non-viable foetuses. Nor, the Investigation heard, had a non-viable foetus or baby ever been cremated with an unrelated adult.

9.4 Cremation Process and 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.

Most of the cremations that take place at Daldowie and Linn crematoria are of adults and many of the features of an adult cremation are replicated during the course of a baby cremation ^[31] .

i Cremators

At the time of the Investigation both Daldowie and Linn Crematoria were equipped with Facultatieve Technologies gas-fired cremators. At Daldowie three 300/2 cremators were installed in 1995 and a further two in 1997.

A software reporting upgrade was implemented in April 2013 and included for the first time 'infant mode'. Facultatieve described infant mode as,

"The infant profile is set such that very low levels of combustion air are applied; this reduces turbulence and retains more ashes. Also the main or ignition burner is effectively disabled again to reduce the effect of turbulence. We recommend that the infant mode is used on any charges below the age of five years'.

At Linn a 300 cremator was installed in 1989 followed by three 300/2 models in 1992, 1993 and 1997. An upgrade to the 300 machines in the early 1990s related to the secondary chamber. As at Daldowie the upgrade was implemented in April 2013 and included infant mode. There is a difference between the Daldowie cremators and those at Linn. At Linn the hearth is ' smooth and level' while at Daldowie the cremators have a lip which is about five inches deep and, ' lets flame get underneath'.

The cremators were primarily designed for adult cremations with the coffin charged (inserted) at one end through a large door. At Linn an automatic charging (coffin insertion) facility is available to transfer the coffin from the trolley and position it in the cremator. Coffins at Daldowie require manual charging and positioning in the cremator.

After the cremation the Operator places a rake through a much smaller door at the opposite end of the machine, where there is a spy-hole through which the Operator can observe the progress of the cremation. The ashes are raked into an ashes cooling pan underneath this rear door.

According to John Wright, Supervisor at Linn, the machines are ' very much automated' with Operators having only limited discretion with regard to how they operate the cremator.

However David MacColl, Assistant Manager for Bereavement Services and Public Health, expressed the view that Operators have a wide discretion for manual intervention. He suggested,

"If an Operator using the machine correctly can control the air, can control the cremator, they can manage the cremation to ensure that the disturbance, and the issues that cause that scattering of remains inside the cremator, is controlled."

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

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

Such manual intervention was found to be very successful over many years at Seafield and Warriston crematoria where it was described to the Mortonhall Investigation.

Dr Clive Chamberlain, a Chartered Engineer, member of the Council of the Combustion Engineering Association and expert witness to the Mortonhall Investigation ^[32] 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."

The Investigation was told by Managers and Cremator Operators that by 2015 the cremators at Daldowie and Linn were long overdue an update. Only two out of the four Linn cremators were in operation, and only three out of six at Daldowie. Stevie Scott told the Investigation he had been concerned at the age and condition of the cremators when he became Head of Parks back in 2009. How long this situation had existed is unclear. However, a Cremator Operator employed at Linn between 2004 and 2011 confirmed that all the Linn cremators were fully functional during his time there.

On a site visit in January 2016 the Investigation was shown that the installation of new machines at both Daldowie and Linn was well underway, with some of the new equipment already operational.

Nigel Kerr, Group Manager for Public Health and Bereavement Services 2013 - 2015, told the Investigation that the new cremators would be far more efficient than the old models and would improve the retention of ashes. While there is evidence from other crematoria that infants' ashes could be obtained without using a baby tray, David MacColl was of the view that this was partly explained by some crematoria, including South Lanarkshire where he worked previously, having better equipment.

"I can qualify some of Glasgow's position by saying that the cremators at South Lanarkshire were brand new FT3 cremators which were single enders which carry out the process. Because you've only got one aperture, which is a bigger aperture, you're not raking it from a small space, you have full door space and you can open the door properly. They're better."

There are however examples of several crematoria in this Report returning ashes to next of kin for many decades both with and without baby trays and using older cremator equipment.

ii Baby Trays ^[33]

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 dispersed throughout the cremator by the force of the air jets.

The Report of the Infant Cremation Commission (June 2014) recommended that,

''The Cremation Authorities which have rejected the use of trays for baby cremations on health and safety grounds should urgently consider, in light of the experience of others, the introduction of a local protocol to allow trays to be used in a way that will expose no one to undue risk."

The Investigation was interested in whether baby trays had been used for infant cremation at Daldowie and Linn crematoria. Lucille Furie, the Glasgow City Council Bereavement Services Manager until December 2012, informed the Investigation that she introduced baby trays to Glasgow City Council crematoria in 1997/98. She recalled that the successful retention of ashes which resulted from use of trays led to the introduction of special containers suitable for holding baby ashes. Lucille Furie was aware that at some stage the baby trays were withdrawn,

"probably not much after that, by the Operations Manager as he felt it was a health and safety risk. I don't know whether it was several months later or longer than that when I became aware that the tray had been withdrawn. I think it came filtering back through to me that it was removed on health and safety grounds, that although the tray had been made available, they didn't feel that there was a sufficient risk assessment and work practice and ethics for it."

The Investigation accepts that the use of a baby tray is not without risk if it is removed through the large charging door while the cremator is still at a high temperature. Facultatieve Technologies have however been making trays for this purpose since the 1960s. The need for extreme care to minimise the risk to Cremator Operators of being burned, was accepted by Facultatieve in their operation and maintenance manual. This explained,

"Before withdrawal of the tray the cremator should be allowed to cool sufficiently to prevent the possibility of injury to the Operator, and it may be best to leave the cremated remains in the cremator until the following morning."

Dr Clive Chamberlain, referred to above ^[34] identified the risks of using a tray. Describing the removal of the tray from the cremator at the end of the cremation he explained,

"If this has to be done with the cremator at working temperature… this is more difficult and more risky than the usual raking operation into the 'ashing chamber' of the cremator."

The Investigation has not been provided with any Health and Safety or other records or reports relating to the use of the tray prior to the publication of the Mortonhall Investigation Report. Nor have any more definite dates during which the tray was in use been made available. Furthermore the Investigation was not told of any steps being taken by either the crematorium, or the professional associations, to find out how use of the tray could be made safer.

The use of a tray in Daldowie and Linn before the publication of the Mortonhall Investigation Report was not something of which all senior management was aware. Kenneth Boyle, Head of Parks 2004 - 2009, told the Investigation,

"I was not aware of an infant tray at Daldowie which was said to have buckled and been removed from service for a period…. I can say with 100% certainty I was not aware of this happening…. If there was talk about having an infant tray it would, should, have come to me to sign off at some point I'm sure. I would hate to think that such a change was, or could, have been made without management knowledge…"

Nigel Kerr, Group Manager responsible for Bereavement Services from October 2012 to 2015 had heard about the tray and told the Investigation,

"I was aware of the historical discussions before my time. I believe that due to heat and it was stainless steel it did buckle. It was difficult to remove safely. I think that was one of the main reasons that it wasn't used."

A Cremator Operator with experience of cremating at Daldowie and Linn referred to the use of a tray pre-2009, but commented it was " dangerous."

A Cremator Operator at Daldowie between 2007-2011 recalled,

"I'm sure there was a tray at Daldowie but I don't remember using it or it was warped, and I don't think it was ever replaced, certainly not when I was there."

According to Christopher O'Neill, the Supervisor at Daldowie, who worked as a Cremator Operator at Linn between 1997 and 2011, a tray was used at Linn,

"for a short period … years ago. It was taken away for health and safety reasons… I can't remember anything about ashes or remains being recovered from the tray here."

However, his colleague who worked at Linn from 2004 to 2011 clearly recalled that a tray,

"was there when I started and it continued for the time I was there. I learned to use the tray as part of my training."

This evidence suggests a baby tray was physically present and available for use during this period.

The inconsistent evidence concerning the use of a baby tray at Daldowie and Linn is difficult to explain. An explanation for the conflicting accounts may simply be that the decision whether or not to use the tray was left to individual Operators. As the same Cremator Operator explained,

"The use of the tray stopped probably about a year and a half after I started. During the last five years before I left I didn't use the tray. I never used it at Daldowie… I couldn't say if there was a tray at Daldowie… I stopped using a tray because it was dangerous. It was a personal decision. I just felt as if the tray never helped. Basically it was just a matter for me to say I'm not using this any more and that's it. I would say that the others had stopped as well. The manager did not have a say in it… when we stopped using it the supervisor, John Wright, asked why we weren't using the tray. I said to him I think it's dangerous. He didn't say anything. Whether there was a conversation with the other cremation technicians I can't honestly say. We just stopped using it. I found it useless to tell you the truth."

John Wright has no recollection of such a conversation.

A Cremator Operator with experience of working at Daldowie and Linn since about 2003 was critical of the quality of the baby trays provided by Glasgow City Council. They did not compare favourably with those he had used since moving to Maryhill in 2014.

''Going back to my time at Daldowie … there wasn't always a tray available… the reason why a tray might not be available was because the trays from the Council warped quite badly and so I think health and safety put a stop to them. There was not replacements brought in…The norm [ at Daldowie and Linn], was there were trays in the building and they would be used up to the point where they would be unsafe. That was during my time, and I would say going back to when I first moved into the Linn [2002/2003] that the tray was already in the building, so that was the practice. That practice stopped through health and safety or through the fact that they warped and they weren't replaced…They didn't try different types of trays at Daldowie and Linn. It was kind of left."

The same Cremator Operator recalled his use of trays at Linn. He told the Investigation,

"Back when I was at the Linn, when the tray was in operation, I cremated babies and stillbirths in the tray but I don't really think the tray was used all that much. It might have been a year and then you were back to manually entering the babies… At the Linn we manually put the trays in, I don't think we used the automatic charger. I don't think the trays were that bad, warped wise, but as soon as something tried to push it in it would spin because it was wobbly."

On the reintroduction of the baby tray the same Cremator Operator told the Investigation,

"The tray came back into use when I was at Daldowie roughly the same time Mortonhall was in the newspapers…The trays they introduced were slightly different from the old ones, a bit heavier but basically the same."

Following the publication of the Mortonhall Investigation Report trays were re-introduced in both of the Glasgow City Council crematoria in October 2014. Christopher O'Neill, the Supervisor at Daldowie since 2011 told the Investigation that there had been difficulties with the trays, leading to a need to test different types. He was however able to comment on current usage and confirmed,

"At Daldowie we now use the tray at all times for NVFs and babies as long as the size can fit into the actual tray. Families just want to get something. We're told to brush everything in and cremulate it and it's disposed of in accordance with whatever the instructions might be."

David MacColl the Bereavement Services Manager with extensive experience of cremating outside Glasgow told the Investigation,

"I had a process in South Lanarkshire where we would do the cremation last thing at night … and then the remains are taken out and left on a trolley overnight and nobody would be on the premises because these trays would pop and crack and, nothing to do with remains, but because of the steel used."

On a site visit in January 2016 the Investigation was shown the new trolley purchased by Glasgow City Council for use with trays. David MacColl explained that the trolley was designed to operate in conjunction with the new cremators in order to reduce the risk of harm to Operators charging the tray, and to provide a safe place for the tray to cool after its removal from the cremator.

iii Dispersal of Ashes

As explained in the Mortonhall Investigation Report there is overwhelming evidence that foetal bones do survive cremation, at least from seventeen weeks' gestation. Yet, as the Mortonhall Investigation Report also identified, a belief that non-viable foetuses did not have bones sufficiently developed and calcified to survive cremation was prevalent among the Scottish Government, the NHS, the FBCA, Funeral Directors' Associations and crematoria staff.

As stated above, Glasgow City Council adhered to FBCA guidance whereby only those ashes that contained skeletal remains were considered cremated remains. Based on this understanding only those remains that contained identifiable skeletal remains were returned by the Council to families following cremation.

The Supervisor at Linn, John Wright, explained the process that Cremator Operators followed. He said that when cremating non-viable foetuses, before the introduction of infant mode,

"the boys were trained to reduce the airs to as small as possible and after the cremation was finished they would rake out and look for cremated remains… It would be bones we were looking for. Now and again we found what we would distinguish as bones and if there were any bones then they would have been cremulated and it would just have been given back to the family… The rest of the residue would be brick ash and metals from the coffin which we would still bury in the cemetery. If there's nothing left then that would be 'no remains' and I would fill in the Register that there were no remains in that cremation."

In her evidence to the Investigation Lucille Furie, who had started as the Office Supervisor with Glasgow City Council in 1985 and rose to the position of Bereavement Services Manager, was adamant that she had been willing to return to parents whatever was left following cremation. She explained,

"My understanding in the early days was there would be no resulting ashes from babies potentially up to a year."

She reported that she had,

"felt it was actually important, that if there was ash material there it could be recovered if the family were asking for it… I felt it was important to try to recover what they [Cremator Operators] could."

Lucille Furie emphasised to the Investigation that the absence of bone did not prevent families in Glasgow receiving ashes, explaining,

"If anything was recovered then I made it clear at the point in time, I don't care whether it's fly ash, brick ash, coffin ash, if the families want something then we should make every effort to try to recover something. I know that previous Federation standards wanted a distinction between bone ash and obviously other material that could be collected. Some people stuck specifically to Federation standards and that was absolutely fine, that's what their training entailed."

Lucille Furie explained to the Investigation that the environment in which crematoria operate today is very different from when she joined the industry.

"Going back to the late 1980s and early 1990s we were participating in something that wasn't regulated. We had asked for regulation. It wasn't forthcoming and we also took the advice from a Chief Medical Officer to give us a determination on the availability of ash post cremation. Not forensic scientists and so forth, we didn't have access to that back in the 1980s and 1990s. And up until that time infant remains were being consigned to hospital incinerators, so anything that we did had to be better than simply consigning an infant in a hospital incinerator."

Lucille Furie disapproved of Cremator Operators physically handling babies' ashes searching for bones. She explained,

"At that point they didn't know that there may well be bones in there because they couldn't recognise them and I'd have been horrified if I'd seen any of the staff sifting by hand to try and recover infant remains. We're not supposed to violate the body and that to me is just ridiculous. It's whatever's in the container would be transferred over for the compaction element."

Lucille Furie also made it clear that she made a " distinction" between those families requesting remains and those that did not.

"If they weren't asking then it'd make a different scenario."

The Investigation took this to mean that only those families who specifically requested remains would receive any. Those parents who had been informed, usually by Funeral Directors or NHS staff that there would be no ashes and therefore on that basis had not given an instruction to retain them, would not have the ashes returned to them because of the absence of the necessary request.

While it is possible that Lucille Furie did not know what NHS staff and Funeral Directors were telling families, the Investigation found that NHS staff and Funeral Directors were telling families in a significant number of cases that there would be no ashes. Through this misinformation, families were deprived of the opportunity to obtain ashes because of the reliance of the crematoria on the instruction information contained on the Form A. The instruction section of the form was often completed by the Funeral Director without the knowledge of the family.

Lucille Furie's introduction of trays for baby cremation in 1997/98 confirms her willingness to return ashes whether or not they contained bone. While she did not expect skeletal remains to result from the cremation of a non-viable foetus she nevertheless expected there might be something to return and therefore introduced baby urns, bags and other containers suitable for storing the small amounts that resulted.

It is clear from the evidence that Lucille Furie's stated position on the return to families of babies' ashes regardless of the presence of bone, was not shared or understood by many of the Cremator Operators and their Supervisors. She recalled instructing staff to,

"deal with infants here on an individual basis", before adding by way of a caveat "as much as I could instruct staff that don't report to me."

Lucille Furie denied that she had direct management responsibility for the Cremator Operators and their Supervisors. As mentioned above, she told the Investigation,

"From 1997 the crematoria operational staff didn't directly report to me. They reported to their own operations manager."

However, as also reported above, the Operations Manager Alexander Stewart did not consider that his remit included the practicalities of cremating.

The Investigation enquired what happened to ashes in which no bone was identified. Asked about residue that was not thought to contain bones, if there was no instruction to return to the family, Lucille Furie told the Investigation,

"What they did was to dispose of that in the Garden of Remembrance. Nothing was thrown out. It would be scattered…"

The Cremator Operators and their managers were asked to describe the procedure where there was a specific instruction to 'scatter' ashes which they considered contained skeletal remains. One recalled that at Daldowie, before publication of the Mortonhall Investigation Report, scattering usually took place in the grounds of the crematorium on the morning following the cremation. The exception was when the cremation was on a Saturday when it would be done on the following Monday. He explained how the grounds resembled a thistle with tree lines for the bristles at the top. A different tree line was used each week,

"so you can actually pinpoint a glade or a tree line for a certain week and you can do that historically, right back to when they started doing that scheme."

The Investigation also asked what happened to any 'residue' or 'fly ash' that was considered not to meet the FBCA definition of 'skeletal remains'. The Supervisor at Daldowie, Christopher O'Neill remembered in the absence of evidence of bone any non-viable foetus,

"residue that was left I put with the containers we put metal joints and things like that in and we interred it in the place for collection of metal pins and hip joints and things."

This is very similar to the arrangements referred to in the Mortonhall Investigation Report and is a matter of concern.

A Cremator Operator from Daldowie, recalling the practice preceding the publication of the Mortonhall Investigation Report in 2014, told the Investigation,

"Ashes are just whatever is left over, and remains are human remains - the bones."

According to him, in the absence of obvious bones, the procedure was to " just scatter" the residue.

On a site visit to Daldowie by the Investigation in January 2016 the relevant area where metals and 'fly ash' were interred was identified by David MacColl as being the edge of Glade 10.

The Investigation enquired about the equivalent practices at Linn. A former Cremator Operator, who worked at Linn from 2002/3 to 2009 told the Investigation that an instruction to 'scatter' would be carried out in,

"a particular place, the Garden of Remembrance at the Linn, such that every morning you would go out. Any ashes to be scattered, it was done the next day after the cremation… If somebody said, 'where's my baby's ashes?' You could say pretty much 'there'."

John Wright, the Supervisor at Linn, told the Investigation that before baby trays were introduced following the publication of the Mortonhall Investigation Report in 2014, in the absence of any identifiable bones, everything left at the end of the baby cremation was buried in the cemetery. When asked to describe where, he said,

"I would struggle to pinpoint… it's quite a large area. It's in the crematorium where the cemetery and the crematorium are joined together."

On a site visit to Linn in January 2016 the Investigation was told by David MacColl that according to his staff the relevant area where metals and 'fly ash' had been interred was in section D4 of the Garden of Remembrance.

In an email to the Investigation David MacColl confirmed that practices at Daldowie and Linn differed. He understood from those who had been there at the time that at Linn metals were interred and 'fly ash' scattered, while at Daldowie metals and 'fly ash' were interred.

Cremator Operators routinely decided whether or not bones were present following a cremation, without any training on the recognition of bones in the early stages of gestation. Given the evidence of the expert witness Dr Julie Roberts, Forensic Anthropologist, about the presence of bone in cremated remains of foetuses from seventeen weeks' gestation, this is a concern. Furthermore, as the above evidence shows, their accounts of how residue was disposed of are inconsistent, giving rise to continuing uncertainty for families.

'Dispersal' is recorded as the outcome for many of the cases at Daldowie and Linn. Where there is a specific date alongside the word 'dispersal' this refers to a dispersal of what was considered by crematorium staff to be cremated remains. Where however there is no date, records are not reliable enough to know whether that is because the record was not updated or because the ashes were considered 'fly ash' and treated accordingly as described above. For those cases registered with the Investigation and where only the word 'dispersal' appears on the Register of Cremations, the records are not accurate enough to provide any certainty. This is described further below.

9.5 Administration and Record Keeping

It is the role of the Bereavement Service's administrative team to receive and process the necessary forms before a cremation takes place at Daldowie and Linn Crematoria and to complete Form G, the Register of Cremations. Maintaining a Register is a statutory obligation (apart from for non-viable foetuses) involving the recording of the cremation number, date of cremation, date and place of birth, age and gender of the baby, applicant for cremation and disposal method/final resting place. Previously typed manually, the Register of Cremations has been computerised since July 1995.

At the relevant dates of the cases referred to the Investigation there was no legal requirement to keep a record of cremations of non-viable foetuses. However, a non-statutory Register has been kept at Daldowie and Linn since before 1996.

Funeral bookings are made by Funeral Directors, or the hospital, directly with the administrative team. Previously based at offices at 20 Trongate the team moved to an office at Daldowie Crematorium in 2014. It is led by an Administrative Officer who, under a previous structure, reported to the then Bereavement Services Manager. Since a restructure, she is no longer line managed within Bereavement Services but reports to Customer Business Support.

The administration and booking database is the Gower system, Epilog.

i Findings on Record Keeping by Glasgow City Council

As with Mortonhall the Investigation found Form A, the statutory Application for Cremation, to be the most significant of the cremation paperwork in informing all other records and as the basis for all action taken ^[35] . However, in many of the cases investigated the form was completed in the name of, and signed by, the next of kin although they explained that they had not in fact completed the form and were unaware of its contents. Many parents could not remember signing any forms. They included a father whose son was stillborn in 1997 who said,

"It's my signature at the bottom, to the right of the date. I don't remember signing it. I don't remember being present when any part of it was filled in."

A mother who had undergone a medical termination of pregnancy in 2004 acknowledged that,

"On the day of the [medical] procedure I signed forms regarding her cremation. I do not remember signing them."

Many parents felt they had not been in a fit state to decide funeral arrangements so soon after the trauma of losing a baby. The mother of a baby who died at one day old in 2006 described the impact of losing a child.

"I don't think your cognitive skills are working at that point. I remember when we went to the Registry Office we were asked in hours and minutes how long our son was alive for. Now we're both relatively intelligent people who can count and we sat there for twenty minutes in floods of tears and we could not work out that he was alive for 33 hours and 9 minutes."

A couple whose daughter was cremated at Daldowie in 2006 noted that they had both signed Form A, the Application for Cremation, one day after their daughter was stillborn and when the mother was still recovering from a Caesarean Section. The mother recalled,

"I was lying in bed at the time. The nurse went through it with us. She wrote in the various bits and pieces in the form. There's no mention in there at all about ashes or what's to happen to them. There was no discussion about that. Page 2 is headed up Particulars to be Supplied by the Funeral Director. None of that page was completed at the hospital by us or by the nurse in our presence."

The baby's father described his feelings the first time he saw the reverse of the form at a meeting with Glasgow City Council.

"When I turned over that piece of paper at the Council Chambers and seen all the detail on the back I was in shock because we had never seen it before. Under Part 5 it says that ashes are to be interred or dispersed in the Garden of Remembrance at the crematorium."

The couple were also shown the Register of Cremations which revealed that without their knowledge the ashes were dispersed at Daldowie Crematorium the day after the cremation. The father explained,

"If we had seen question 5 on the back of Form A and were told we were getting ashes we could have had something. We would have had a chance to deal with it, but the fact is that we never got a chance to deal with it. If we had been given the option we would have wanted the ashes back, of course, even if what had been left was coffin ash. Because you've at least got something whereas now we have nothing and that choice was taken away. You might not be able to get proper ashes from your baby but you'll have some remembrance - something to keep."

This family has been unable to find out where their daughter's ashes were dispersed. " They've never told us." In October 2015, the Investigation was able to inform this family where their daughter's ashes had been scattered.

The Investigation interviewed Evelyn Frame, the Chief Midwife for Glasgow and Clyde since 2013. She was asked how soon a discussion about cremation or burial might take place and whether it sometimes happened before the baby's delivery. She said,

"The subject may be raised before the delivery but it's predominantly because women once they've delivered, and they're fine, they want to go home. The majority of them would have normal deliveries, and pretty quickly actually, and they just wanted to go home as soon as possible. So we were really keen that everything was agreed. I suppose on reflection they didn't get a lot of time to consider… I think probably going forward we should allow them more time. Because you were sitting in with a woman who was in labour so you could be sitting in with them for hours and hours so we did raise it. That's how we were taught to do it."

A Labour Ward Sister, who qualified as a midwife in the early 1980s, told the Investigation,

"you start to talk about these things with a mum before the baby had actually been delivered to try and give them a bit of warning to think about it and maybe even discuss it with other family members."

A couple whose son died in 2001 within a few days of his birth opted to make their own funeral arrangements rather than relying on the hospital. They were critical of the speed with which decisions needed to be made and told the Investigation,

"If we'd had a bit longer we might have had a chance to talk to each other more and work out for ourselves what we wanted to do."

With more time and information they believed they might have decided against cremation. Like others these parents were unaware of the crucial Instructions for Ashes on the back of Form A. They described how the Funeral Director had completed the form,

"upside down to us and turned it round for us to sign. We didn't know there was a second page that deals with the ashes."

The positioning of the instructions for ashes on the back of Form A and the requirement for the section to be signed only by the Funeral Director, and not by the next of kin, was a matter of deep regret to another family whose daughter was stillborn in 2009. They explained,

"As the bereaved your power over the individual to be cremated is removed because you don't get to fill in the second side of the form. There's no requirement for you to sign it."

Having been advised by a woman in the Funeral Directors' office that there were no ashes " in these cases", subsequent enquiries revealed that there had been ashes, which were scattered at Linn Crematorium. At a meeting with Glasgow City Council the parents were shown the back of Form A signed by the Funeral Director. 'Disperse' had been entered by option (ii) 'dispersed in garden of remembrance without family attending '.

The parents told the Investigation,

"We were absolutely devastated because we were told there wouldn't be any ashes and that instruction was not ours."

Following this revelation,

" We went along imagining some nice rose garden, something that would be fitting. But she'd been scattered … in this expanse of grass that forms the driveway to the Linn. So, for us to go and visit her is to stand on a patch of grass with cars coming and going."

In an email the Lead Midwife assured the mother that the instruction to scatter did not come from the hospital. She said,

"It was our understanding from the Funeral Directors that no ashes were available with a stillborn baby…No ashes has been in our common domain for all of my practising career which is over 35 years… No midwife wrote on the back of the A form. It was made clear from the Undertakers that if there was no instruction on the back of the form re the ashes then the default was to scatter in the memorial garden."

Describing her feelings about who was responsible, the mother told the Investigation,

"It's the Co-Op that I probably lay the greatest blame with. [Regional Manager] has repeatedly said, 'My staff are trained to say there may be ashes, there may not be ashes depending on the heat in the crematoria and the size of the baby', which is fine but their person didn't do this… The Co-Op misrepresenting our directions on the form and their ability to do so led to that situation from our perspective… A phone call at any stage would have essentially prevented it."

The Investigation spoke to the Funeral Director whose name appeared on the reverse of the Form A in this case. The instruction for the ashes to be dispersed was in his handwriting. He explained that it was his usual practice when completing an instruction for a family that wanted ashes to write 'return, if any'. However, in this case although he had collected the baby from the hospital he had not had any contact with the family and had not taken their instructions. When completing the reverse of Form A he relied upon the Co-op's internal funeral arrangements form, which included the instruction for ashes, that had previously been completed by a colleague who had spoken to the family on the telephone to arrange the date and time of the cremation. The front of Form A had been completed at the hospital.

Examination of this case during this Investigation revealed that the arrangements for cremation involved three separate sections of the Co-op. The Funeral Director who organised the funeral on the phone with the parents and completed the funeral arrangements form was based at one branch. The Funeral Director who relied upon the information already obtained to complete the reverse of Form A was based elsewhere. The family's only face to face contact had been with a third person at a branch local to them which they visited to hand in the Certificate of Stillbirth. It was there that they recalled asking how they would get the ashes back and being told that there would be none.

The Investigation requested a copy of the funeral arrangements form, but was told it was no longer available. The complexity of the Co-Op's internal processes and the lack of continuity of service to this family has resulted in the family being deprived of their baby's ashes and the consequent trauma of learning this so many years later.

This family was not unique in directing blame at the Funeral Director. The parents of a baby who died soon after birth in 2006, told the Investigation they had been informed by the Funeral Director there would be no ashes only to discover by chance that there had been, and they were scattered. The mother told the Investigation,

"My issue was with the Undertaker, it's not particularly with Daldowie. They were faced with a pretty clear instruction which says, 'dispersal'. There should have been safeguarding in place that somebody could have contacted us and said, 'can we just make sure?' but obviously with a very clear instruction that's why it was done the day after the funeral."

The Investigation contacted the Funeral Director in this case. Asked about his expectation of infants' ashes being recovered at Daldowie, he informed the Investigation in a written response that it was the crematorium staff who dictated whether there were ashes or not. In the 2006 case he said he would have explained that Daldowie Crematorium would not guarantee that there would be any ashes because of the gestation of the baby.

More generally, details from the Form A were used to populate the daily running order (a list of all the day's cremations) and on to the individual detail card, which is an A4 sheet that accompanies each individual cremation throughout the cremation process. It is headed 'Instructions to Cremate' and is called a 'details card' or a 'cremation card' in Glasgow.

Glasgow City Council administrative staff are trained to double check every form to ensure there are no errors, especially in relation to spelling of names and other personal details. Despite this the Investigation found several examples of names being spelt incorrectly, which added to the distress of families examining the paperwork in the course of the Investigation.

It is clearly essential that the Instructions for Ashes are passed to the crematorium by the administrative team so they can be carried out. The Investigation asked what would happen if this particular section on the Form A was incomplete. The Glasgow Bereavement Services Administrative Officer explained that if the disposal section was blank they would phone the Funeral Director and request that the instruction be faxed over.

Inspection of the official Register of Cremation entries revealed, as at Mortonhall, that the outcomes of cremations had been entered on the Register prior to the cremations taking place, meaning that the Register commonly consisted of a predicted outcome rather than a record of the outcome. In other words, it is not a record at all. The situation is further confused by the inclusion in the same column of the Daldowie Register of the date of registration of death. In one example from 2003 involving a stillborn baby the Register entry 'taken away' included a date twelve days before the cremation took place. During this Investigation, when families saw the words 'dispersal' or 'taken away' in the same column as a date which precedes the date of cremation it has caused them great confusion and concern. The Investigation has provided families with a detailed explanation for this, as it relates to their baby, in individual reports.

Glasgow City Council staff explained that when they input the Form A details onto the computer system, the Register of Cremations is automatically populated with those details and the Form A ashes instruction becomes the recorded outcome.

Following the cremation process, and after the ashes have been disposed of, the system described to the Investigation was that the individual detail card is returned to the administrative team from the crematorium, with the actual disposal method recorded on it by the crematorium staff, confirmed with a signature. The administrative team then have the opportunity to update the database using the information on the detail card. The Investigation heard that while it had been routine for register entries to be checked weekly by a member of the administrative team, this process was stopped due to financial pressures. In any event the purpose of the check was said mainly to be aimed at identifying and correcting typing errors rather than to ensuring that the ashes disposal column was correct.

The Investigation learned that no-one checked that all the detail cards are returned to the office, nor that the predicted outcome relating to the ashes disposal on the Register of Cremation matches the actual outcome. This means the Registers for Daldowie and Linn are a wholly unreliable record in relation to the cremation of babies.

This is illustrated in the case of a stillborn baby from 2009. The words 'Infant return to CWS [Funeral Directors]' had been added to Section 5, the Instruction for Ashes on Form A. This was apparently interpreted as a request for any ashes to be returned to the Funeral Directors and was summarised as 'taken away' on the computer booking system. This in turn populated the Form G - Register of Cremations - with the identical entry. The Investigation was able to inspect the baby's Cremation Card from Daldowie on which the entry 'taken away' had been scored out and replaced with the handwritten entry 'no remains'. No corresponding amendment to the Register of Cremations was made, meaning the record did not reflect the actual outcome. This would infer either the detail card in this case was not returned to the administrative staff or that it was returned but the disposal outcome was not corrected by them.

Nor was this an isolated example. In an earlier case from 2005 'Taken away' was entered on the Daldowie Register of Cremations, suggesting that there had been ashes and they had been collected from the crematorium. However, on the baby's Cremation Card the printed instruction 'Taken away' was scored out and replaced with a handwritten 'no remains' and the date. This correction had also not been made to the Register.

In a case from 2003 'Taken away' was entered on the Daldowie Register of Cremations, suggesting that there had been ashes and they had been collected from the crematorium. However, no Cremation Card was made available to the Investigation so unlike the two cases mentioned above the Investigation was not initially able to rule out that there had in fact been ashes collected from this baby. The parents had already told the Investigation that they did not have the ashes and that the crematorium had warned them that there may not be ashes. However, in this case the Investigation subsequently discovered that the ashes were still with the Funeral Director, Jonathan Harvey Ltd. The Investigation informed the family in this case and arranged for the ashes to be returned to them the same day.

The Investigation asked both the Funeral Director and NHS Greater Glasgow & Clyde for an explanation. Evelyn Frame, the current Chief Midwife for Greater Glasgow & Clyde, informed the Investigation that at the relevant time the contractual arrangement with the Funeral Director meant that all communication with bereaved families would go through the hospital. The Funeral Director would have no direct contact with the family. Neither the NHS nor Jonathan Harvey Ltd were able to provide the Investigation with documentary evidence to explain the chain of events that resulted in this wholly unacceptable and, for the parents, deeply distressing situation.

Due to the absence of such documentary evidence, it is not possible to identify precisely how this situation arose, but it is clear that this family was badly let down by a lack of communication between the agencies entrusted with the sensitive handling of their baby. In particular, it can only be assumed that there was no follow up by either the NHS or the Funeral Director to ensure the satisfactory completion of this important task which should have been carried out with professionalism and in a manner that provided the family with support in such difficult circumstances.

As a result of this case, and very shortly before publication of this Report, this Investigation asked Jonathan Harvey Ltd to check their storage facility for any other baby ashes being held on their premises. The Funeral Director has reported eleven sets of ashes of babies who are not part of this Investigation, dating as far back as 1999, still being held on their premises. These cremations were similarly organised by hospitals. The Investigation has referred these cases to the Inspector of Crematoria for further investigation.

As the Register for Cremations was completed in advance, entries in a number of cases referred to the Investigation were found to be wholly inaccurate and misleading.

Prior to the publication of the Mortonhall Investigation Report in 2014 Glasgow City Council record-keeping and administrative staff accepted the entry 'no remains' on the Form A in the instructions for ashes section. This meant that the Register was populated with the same entry before the cremation had even taken place. This practice was criticised by Cremator Operators. As one explained to the Investigation,

"whether there are remains was a grey area because how does somebody in an office or the person in charge know that there would be no remains?"

Following the Mortonhall Investigation Report, the entry 'no remains' is no longer available as a disposal option at Daldowie and Linn Crematoria.

The Investigation found that, unlike Mortonhall, there was no systematic change of recording of disposal outcomes with the introduction of an electronic Register rather than a manual system. At Daldowie Crematorium in the 1980s the Registers suggest that ashes were obtained more often than not with entries in the Register most likely to be 'dispersed in garden' with a date of dispersal also recorded. This started to change in the 1990s with 'no remains' featuring in both the manual Register and the computerised Register.

At Linn, entries in the manual Register varied between 'no ashes', 'no remains' and 'dispersed in the garden' in the 1990s.

9.6 Communication

Many parents who provided evidence to the Investigation described the misleading information that they received from hospital staff and Funeral Directors about the availability of ashes. For many the impact of misleading information was devastating. The following is an example provided by a family whose baby was stillborn in 2001. They were told by a member of staff at the Funeral Directors that,

"With a baby's cremation there won't be any ashes because the bones are so soft the cremation process would basically just obliterate anything that was there."

Yet in relation to the same baby the instructions for disposal of the ashes on a hospital form assumes there will be ashes and states, 'please dispose of as Undertaker sees fit', a request about which the parents were not consulted. In the official Register of Cremations 'dispersal' is recorded as the final method of disposal and an email from Glasgow City Council to the family explains the ashes were strewn in the crematorium grounds after being held for one month at Daldowie.

Responding to this the baby's father told the Investigation,

"That really, really upset me just knowing that unceremoniously his remains were dumped up there… I dare say they will say it was quite dignified … but I'm not going to take their word for it, after all we have been lied to once telling me there would be no remains. If they tell me it was dignified, no, once bitten twice shy."

The same baby's mother expressed her frustration at the difficulty in identifying who exactly was responsible for the misleading and inaccurate information.

"It just seems to be that if you asked the Undertakers they seemed to say they were getting it from the hospital, the hospital were saying they were getting it from the crematoria, the crematoria were saying, 'Oh it was the hospital' so it's a vicious circle and nobody will put their hands up."

Families enduring the loss of a baby have no option but to put their trust in those they perceive as professionals, in particular the Funeral Directors. This is hardly surprising given the pressures to which families are subject, and their vulnerability at such a difficult time. In one such case the family of a twin who died a day after birth at twenty-six weeks' gestation in 2011 told the Investigation that they were informed by an employee of the Funeral Directors that there would be almost certainly nothing of their son following the cremation. They said she told them,

"even if there was something, they couldn't guarantee it would be him. The proposal was put to us that if there was anything left it would be scattered in the garden of remembrance. You trust these people as the experts. We were not in a position to query it. So it was agreed if there was anything left it would be scattered."

In this case the Register of Cremation disposal section says,

"dispersal if any, family do not wish to have them."

The Investigation interviewed the Funeral Director who met the family and signed the Form A in this case. She said,

"That conversation definitely does not sound familiar to me. I would never ever say to a family that the ashes they would get would not be their loved one because we've witnessed through the training in a cremation and I can guarantee that any ashes that a family do get back are their beloved member of their family."

In relation to the part about there almost certainly being nothing of the baby following the cremation the Funeral Director said,

"I would just say normally there might not be because the baby's so small but I would ask if there was any, would they like them returned."

It is not possible to reconcile the very different accounts provided by the parents and the Funeral Director in this case. Although the meeting took place several years ago, it was clearly a very dramatic event in the lives of the parents. The same cannot be said for the Funeral Director who was asked by the Investigation to recollect one of many cases some five years later. Accordingly, the very explicit and detailed recollection given by the parents is more likely to be reliable after this passage of time.

Andrew Brown, the Regional Manager of Co-op Funeral Care, explained,

"It's never been our position that we would categorically tell a family that there will be no ashes. Looking back… there was always a bit of uncertainty about the possibility of ashes following the cremation of a NVF or a baby… there were some crematoria where we more frequently had the ashes returned, and others where there were occasions where we were told literally that there are no cremated remains."

Comparing the availability of ashes at Daldowie and Linn with other crematoria he said it was,

"a bit more hit and miss - with Daldowie probably …the least likely for us to get ashes returned."

Gerard Boyle, the Regional Manager for Dignity Funerals Ltd in Scotland, had a similar view.

"We wouldn't speak to the Cremator Operators as a matter of course. Our dealings were with the staff who took bookings. So where they [the staff] got their information, or whether that was what they were told to say, I'm not sure… I don't think we ever questioned that information."

Referring to Glasgow City Council, he recalled,

"Daldowie and Linn it was almost a matter of course [to be told] 'remember there won't be any ashes' and that was the information that we passed on to the family… I do remember them saying if it was a particularly young child, 'Oh the bones wouldn't have formed properly' and the bones would have been more cartilaginous tissue so that there wouldn't be anything."

The father of a son who died at one day old in 2006 described the pressure he was under at the time. As well as trying to support his wife and look after their other child,

"You've got these people coming in and out the house, you've got folk phoning you and you're thinking, 'Right, I need to get down the Undertakers.' You needed to get it done. It wasn't, 'I wonder how this goes, I wonder what I do'. It's just, 'I need to get this done, I'll go down and do it'. The Undertaker's the person who deals with all that, he tells you what to do. You sign something and off you go."

He thought it highly probable he would have signed forms without reading them. Explaining that the Funeral Directors were a local firm that their family had used in the past, his wife told the Investigation,

"That's why we chose them. I wish we were stronger to ask more questions. I wish we had got more involved. I wish all these things but at the time we didn't, we trusted the professionals."

An issue that the Glasgow City Council Public Health Manager Nigel Kerr identified soon after his appointment in 2012 was the lack of any meaningful communication between the crematoria, NHS maternity staff, the Funeral Directors and families. The role of the crematoria was simply to,

"get all the paperwork from them and follow instructions."

A Funeral Director who had started in 1999 told the Investigation,

"Earlier in my career we were always told by the manager at the time there was no ashes for a baby under the age of two."

On later developments she said,

"We were never told officially from management that that policy changed over the years, but speaking to other crematorium staff about ashes, they would maybe say that they could get a small amount. That's why you started putting down on your form 'if any please return to family' and always explained to the family that they may not get any. So that's what we always do."

The Investigation interviewed a Funeral Director who was involved in the case involving a family whose baby died in 2001. She recounted the advice she gave,

"I explained that there wasn't any ashes for a baby that was four days old. The lady had asked why that was and I had said the bones are too soft in a wee baby and that was the end of the conversation really. That was my understanding, that there weren't ashes for babies. The cut-off point in terms of the age or gestation was usually up to two year old. There were no ashes because the cremators at that time were very hot. They've reduced the temperatures now. That was at Daldowie."

Asked where this information came from the Funeral Director, who had twenty-five years in the industry, said,

"That information come from the [Co-op] Manager at that time … and the Funeral Director who was training me ... One's dead and the other's retired a while ago. They explained that the bones were too soft for ashes because when they went into the cremator when the bones came out they were put into a cremulator and crushed down and that's what families get, the crushed bone. There wasn't any from a wee baby.

I never heard of other crematoria where they were getting ashes for babies. Nor did I ever hear it challenged that you might get ashes. So that belief was carried on for really quite a long time."

A Midwife who qualified in the early 1980s, and had been a Labour Ward Sister for twenty years, told the Investigation,

"Looking back, from the 1990's and the 2000's we were always told that there weren't any ashes. If the parents chose to have their baby cremated then we passed on to them that there wouldn't be any ashes. There wouldn't be any remains and you used to discuss that with them to help them make the decision regarding burial or cremation but that was one of the things that you told them."

She told the Investigation she had never thought to question this information until the news from Mortonhall Crematorium became public knowledge.

Kenneth Boyle, Head of Parks between 2004 and 2009 was adamant that,

"No declaration where parents were told they would not be provided with their child's ashes, was authorised by me during my tenure as Head of Parks."

On a site visit to Daldowie with Lucille Furie, Kenneth Boyle's successor Stevie Scott specifically asked about babies' ashes.

"The response I got was that there was basically nothing in terms of remains…If there was anything left and if it was requested they would return it back to the Undertaker but... they were quite specific, in that nine times out of ten because of the size of it there was actually nothing in terms of remains…If the ashes were not requested the normal procedure would be, whether it be a child or an adult, to scatter within the Memorial Gardens within both crematoria. They're the only two options - return or scatter."

David Eagle, Regional Operations Manager for Glasgow Co-operative Funeral Care and previously Funeral Home Hub Manager for Bellshill told the Investigation that he had questioned the failure of Daldowie and Linn to provide ashes.

"With the two Glasgow City Council Crematoria in Daldowie and Linn it was a blanket 'No' when I started within the business. 'There won't be any available'. So we would ask, 'could there be any?' and there were occasions where we would say, 'Well if we can get them at Maryhill or at Craigton, why can we not get them there?' But generally the rule of thumb was there would be none. There were occasions where a family may wish to go to the Linn or Daldowie but if they wished ashes back we would then suggest that they go to one of these other crematoria as an alternative, to have a better opportunity to get ashes back. So this was the situation round about September '99 from memory, when I started within the business."

This is the only instance in which the Investigation heard that Funeral Directors would suggest a different choice of crematorium to bereaved families seeking ashes.

Explaining to whom his questions were addressed David Eagle told the Investigation,

"My questions for Cremator Technicians or Operators would have taken place in individual cases where we were asking about ashes. You'd be asking if they could obtain ashes or you would be asking, generally, the booking office probably or the Crematorium Registrar. So it may well have been a 'phone call to the Linn directly. The way their booking system works and worked in the past was there'd be one office that they would book everything through, a diary so to speak, but the crematorium would be a different location. So maybe you would contact Daldowie or the Linn's Registrar directly to ask them the question as opposed to the booking office but it could have been either to be perfectly honest.

The situation I've described carried on really until after the Mortonhall report I would say pretty much… Prior to being in this role I was in Bellshill so I was in South Lanarkshire and Lanarkshire. So it was probably more apparent, when I went into that role, that the likes of South Lanarkshire crematorium would offer baby ashes all the time. And that's when it really started coming to light, probably prior to the Mortonhall."

David Eagle's experience did not correspond with Lucille Furie's. She told the Investigation,

"If the Undertakers listened to me over the years then they should have understood the position for Daldowie and Linn that there was an effort to get some form of ashes."

A Cremator Operator with experience of cremating at Daldowie and Linn (from approximately 2002 - 2014) told the Investigation,

"I have heard of the suggestion that you would never get remains from a child under eighteen months. This is going back to when I was in the office. There was a distinct difference between what the people in the office thought, and was told was right, and what is the reality…That idea grew arms and legs. What you know is that it was allowed to continue by certain folk… who knows when myths start but certainly it was allowed to be a myth."

The same Operator was of the view that the message developed from a failure in communication between the Council, Funeral Directors and the hospitals.

"So it would be the three things that has broke down there. It's come from them all but you can't actually point the finger at someone and go, that's your fault."

Lucille Furie's opinion on communication between the different organisations was that there was, ' a vacuum of information'. Although the clerical staff could see that a particular Funeral Director kept inserting ' no remains' on Applications for Cremation Forms, they would only know it was wrong if crematoria staff were to inform them that ashes were produced. She believed that there was no deliberate intention to misinform and both sides were simply following their own process. However,

"at some point in time the grey matter hasn't actually connected in between.

What was actually happening I think was that the funeral industry was saying to midwives, there will be no ashes in young babies. Black and white, just like that."

David Eagle was also of the view that there was no deliberate intention to mislead families. He told the Investigation,

"One of the things, having been a manager in the business for a number of years and knowing the various people across the business, both from a Co-Op perspective and outwith, I don't think there's ever been any malice towards any client in terms of not receiving ashes. It's not a case of, 'Ah well tough, you're not going to get any ashes because I don't want you to'. I don't think it's in anyone's makeup within this industry to go down that route. It's very much whatever we can do we want to do for every single client."

While the Investigation found no evidence of malice, it remains the case that over many years mythology about the non-availability of ashes and wholesale inaccuracy of record keeping continued without appropriate training and auditing. This led to misinformation and in a number of cases families being misled and deprived of the opportunity to choose their baby's final resting place. This was a collective failure to address the issue by all the responsible agencies including hospital staff, Funeral Directors and Glasgow City Council senior managers.

Lucille Furie informed the Investigation that, in order to resolve the issue,

"A couple of years before I left Glasgow, I introduced training for the admin persons in the cremation process, to make sure they understand it."

One family, whose son was stillborn in 1994, was informed by the Funeral Director,

"It's really unusual to cremate a baby and you never get any ashes back, they are too small."

The family told the Investigation that being given this information the day before the cremation added another layer of grief to something that was already impossible to bear. Their experience left them with suspicions about the activities of the funeral industry.

"I feel our Undertaker told the crematorium staff no remains were expected and so they didn't check for any. I believe this because how else could our Undertaker state categorically on two separate occasions there would be no remains unless he knew for sure there would be none because there was an unwritten agreement not to look for any ashes in babies' cremations."

The same parents questioned the role of Funeral Directors, telling the Investigation,

"We feel the Undertaker's role in this scandal needs to be closely looked at as in our experience paperwork was dispensed with to lessen workloads leaving parents like us with no say in major aspects of our child's funeral."

Other families also speculated that Funeral Directors withheld information out of the misguided notion that they were somehow protecting the parents from additional distress. One father who lost a new born baby in 2006 explained,

"I think looking back on it with hindsight that the whole profession wants to make it as painless as possible and makes so many assumptions and actually, it hasn't worked in our favour. Maybe they should get you to take this form away, have a read of it, make sure you're happy with everything and come back tomorrow or the next day. I know you can't leave it sitting there for a fortnight, but if they'd maybe said something like that, yes you might have gone away and said, ok, I'd better have a look at what's going on."

This may not be a solution for all bereaved families as some rely on the Funeral Directors to provide them with accurate information about options, complete forms for them and comply with their wishes.

A bereaved mother criticised the lack of regulation surrounding the funeral industry noting,

"My issue with Undertakers is that they are their own bosses. They're not answerable to anybody."

This family questioned whether commercial competition between crematoria prevented them sharing information which might have led to more consistent and positive outcomes in relation to ashes. The father who, following publication of the two Reports ^[36] addressing these issues, had volunteered on a working group exploring questions around ashes told the Investigation,

"we've got people there from two or three different crematoria and we were talking about whether we could get some sort of combined database, but they don't talk to each other and that's really about competition, because they don't want to be in contact with each other. They'll pay each other the professional courtesy of 'hi' and whatever but they were saying, no, we have our own way of doing things."

Drawing on his own experience the father commented that,

"There has to be transparency too and at every level, from the hospitals to the ministers, to the priests, to the Undertakers. The post of the Inspector for Cremations will be welcomed, but I think there should be something similar for Undertakers because I don't think they're answerable and I think some of them think they're infallible."

The Linn Supervisor and others reported that their contact with families was generally through Funeral Directors. For many crematorium staff the only time they would have contact with bereaved families was at the funeral service. On such an occasion interaction is minimal and any conversation of a largely formal nature.

In a letter dated 25 March 2013 Glasgow City Council's then Chief Executive, George Black, responded to Nicola Sturgeon MSP concerning two of her constituents whose baby had been stillborn in 2009. In this letter George Black explained the position in Glasgow as follows,

"You will be aware that no one from the Council deals directly with the applicant for a cremation. In this case the form was countersigned by the midwife at the hospital and the instructions for how the cremation is to be carried out are given by the Funeral Director.

Council staff are therefore not able to explain directly to bereaved parents that there might not be any remains after cremation, or to ask them directly whether they want to collect any remains we are able to recover. I think it is reasonable that it continues to be the responsibility of the hospital or the Funeral Director."

Despite the changes following the Mortonhall Investigation Report which mean that ashes are always returned following cremation, the Investigation was told by Glasgow City Council administrative staff of a form still in circulation and from the main Glasgow hospitals that included a declaration signed by parents stating,

"I understand there will be no identifiable remains."

The Chief Midwife confirmed to the Investigation in May 2016 that this form had been withdrawn.

Although the Investigation heard repeatedly that if families requested their baby's ashes they would get them, the fact that NHS professionals and Funeral Directors believed none would be available and said as much to families led to few requests being made. Meanwhile the embedded and unquestioned procedures at the crematoria simply continued and crematorium staff disposed of the ashes or residue by scattering or interring them without questioning whether they were genuinely unwanted.

The family who was told by the Funeral Director in 2001 that there would be no ashes because,

"babies' bones are too soft",

subsequently discovered from the Register of Cremations that there was a dispersal of their baby's remains in January 2002. Nobody informed them afterwards and instead the remains were kept for a month and then dispersed. In their view,

"We should absolutely have been told that there was something left. It would have made life a lot easier… even if it was only coffin ash we would have wanted that because it's the essence of your child, their last resting place, there could be fragments. It's important."

The Investigation was told of an occasion when ashes were recovered following a predicted outcome of 'no remains'. The Assistant Supervisor at Linn described what happened saying,

"one occasion that I've seen John Wright actually change [the ashes disposal on the individual details card] from 'no remains' to 'there was remains' and he got in touch with, I think the Co-op head office at Castlemilk and notified them that there was remains."

When asked whether he recalled the incident John Wright said,

"I do seem to recall that there was a time I changed the detail card from no remains to remains recovered. I can't recall the service details but would have contacted the Funeral Director, most likely being CWS head office or Castlemilk."

This would seem to be an isolated incident and Glasgow City Council was unable to determine the identity of the baby.

Although the requirement for crematorium staff to repeatedly check details was engrained in the way they performed their roles, there was no corresponding requirement to double check, when ashes were obtained, whether the family would welcome their return. Instead the prevailing attitude, expressed by one Cremator Operator to the Investigation, was,

"It's not up to us to chase people up and say, 'do you want to change your mind?'."

If there is a clear instruction on the Form A to disperse there would be no reason for crematorium staff to doubt that.

9.7 impact of Mortonhall Investigation and the Infant Cremation Commission

Glasgow City Council's Chief Executive responded to the Mortonhall media coverage in December 2012, and to its inability to respond to a Freedom of Information request from the BBC, by asking the Council's Internal Audit to provide assurances on the practices the Council had adopted. The undated document, headed 'Internal Audit - Review of Cremation Records for non-viable foetuses, stillborn babies and infants under twenty-four months' looked at 2,385 records going back fifteen years, checking the families' ashes instructions against what the Council did in each case. The audit published a number of 'Observations'. These included the need for Application Forms to be clearer as to who is signing them and in what capacity and for the ashes instructions to be properly completed. Responsibility for this, the audit declared, rests with Funeral Directors.

The audit identified one letter issued to a family after the ashes had been disposed of explaining that the remains were dispersed because there were no clear instructions on the Application Form and no other instructions had been received from the family or the Funeral Director. In this case the remains had been retained for 55 days before dispersal without reference to the family.

In relation to non-viable foetuses the audit found,

"there has been a general presumption conveyed in the wording of the Application for Cremation form completed by registered qualified medical practitioners and the parent(s) that there will be no remains recovered following cremation. This presumption is not supported by the findings of the review which indicates remains are recovered in a small percentage of cases."

The audit declared,

"The probability of recovering remains from still-born babies and infants up to twenty-four months is greater than 75%",

and recommended that,

"the wording on the Application for Cremation of Non-Viable Foetuses should be changed immediately to provide a more accurate reflection of position including replacing the statement of understanding that there will be no identifiable remains resulting from the cremation."

In May 2013 the audit was forwarded to the Infant Cremation Commission. The findings of the audit are diminished however as this Investigation found that the system of record keeping rendered the records they were examining unreliable as described above.

Following the publication of the Mortonhall Investigation Report, written Cremation Operational Processes were published by Glasgow City Council in December 2014. These require that,

"where the cremation is of a non-viable foetus, stillborn child or baby of up to one year old, the steel baby tray must be used."

The same document also provides guidance on the disposal of 'fly ash' (defined here as ' ash arising from the cremulation process and accumulating in the transfer station'). This must be,

"strewn in the garden of remembrance in the glade in current use", this activity "to be carried out with the same dignity applied when scattering identified remains."

Guidance on the Scattering of Remains, whether Attended or Unattended is also included in this document. The return of remains to families is, however, not addressed.

Another response to the publicity generated by the Mortonhall Investigation Report and the Infant Cremation Commission Report ^[37] was the undertaking of a comprehensive Risk Assessment of the role of Daldowie and Linn Crematoria Technicians. This is a standard Risk Assessment form and is not specifically tailored to the subject of infant and foetal cremation. The Subject Area of Assessment entered on the form is Daldowie and Linn Crematoria Technicians. The risk assessment was published by Glasgow City Council Land and Environmental Services on 24 February 2015 and includes a number of 'Actions to be Taken' including the upgrading of cremators and consideration of the use of more personal protection equipment.

For families who have opted for cremation following the loss of a baby or non-viable foetus, the most significant impact of the Mortonhall Investigation Report and of the Infant Cremation Commission is that they now have a far greater chance of receiving ashes than previously. Since June 2015 no crematorium in Scotland has reported to the Inspector that they failed to retrieve ashes from an infant or foetal cremation.

Even before the re-introduction of baby trays in October 2014, publicity surrounding the Mortonhall Investigation Report raised awareness amongst managers that bones from non-viable foetuses and babies survive cremation. John Wright, the Superintendent of Linn Crematorium, told the Investigation,

"After the Mortonhall I started going down and double-checked [for bones] … they all insist that I come down and double check for their own protection…… once the Mortonhall Report came out…… that's when I started going down and double-checking."

However, since the Mortonhall Investigation Report recommended that everything left after cremation other than metals be returned to families, it is unclear why Operators would start to look for bones at that stage. This is particularly so given the expert evidence of the Forensic Anthropologist Dr Julie Roberts that it may be difficult for untrained eyes to recognize small bones within the ash material.

On the re-introduction of baby trays in October 2014 David MacColl, the Bereavement Services Manager, told the Investigation that,

"in relation to the guidance about the tray, and the emotion side of it, staff have now been through a training process. There's an information sheet and an operation process that they go through. Now we always get remains, and we are duty bound to report to Bert Swanson [Inspector of Crematoria] if we don't. We haven't reported anything to date to say we haven't received remains."

This was confirmed by the Inspector.

As Alastair Brown (currently the Head of Sustainability but with responsibility for Bereavement Services since 2012) explained to the Investigation,

"Our record of returning ashes is probably fairly consistent over fifteen, twenty years and when the Mortonhall Report came out we changed our practice so we started to say okay we will use the trays because quite clearly the report thought that's what we should do. So we changed it and now we get not quite 100% but we do return ashes almost in all cases."

Alastair Brown was also confident that staff were " more switched on now."

Nigel Kerr attributed the introduction and use of baby trays at Daldowie and Linn since October 2014 to the recommendations of the Infant Cremation Commission. As a result,

"everything from the cremation process is being collected and that's being fed back to the Funeral Directors and so I'm hoping that they are giving a message to families."

The Investigation considers it vital for Council managers to engage with Funeral Directors to ensure this is happening.

The Daldowie Supervisor, Christopher O'Neill, told the Investigation,

"Families just want to get something. We're told to brush everything in and cremulate it and it's disposed of in accordance with whatever the instructions might be."

The Linn Assistant Supervisor explained another significant change in relation to the available options for disposal of ashes resulting from the Mortonhall Investigation Report,

"Overnight it changed from 'no remains' to 'dispersal' or 'take away' which we always followed for adults for all the time I've been there."

Yet another change in procedure relates to the cremation of non-viable foetuses as explained by the Bereavement Services Administrative Officer to the Investigation.

"Now if there are no ashes instructions for an NVF we phone the Funeral Director. In the past we would not…"

Since publication of the Mortonhall Investigation Report and the Infant Cremation Commission Report there has been an increase in the sharing of information between Glasgow City Council and its partners. Evelyn Frame, the Chief Midwife for Glasgow and Clyde since 2013 described attending meetings with David MacColl, Bereavement Services Manager for Glasgow City Council.

"I've obviously had discussions with the midwives in Glasgow and their understanding was that there would be no ashes and that that discussion would have been had by the Funeral Director. We have subsequently changed our patient information leaflet to include the part about ashes. The midwives now have that discussion, saying there could be ashes but they can't say whether or not there will be and that that has to be a question for the Funeral Directors."

9.8 Findings for Individual Cases

Of the twenty-two cases registered from Daldowie, eleven were recorded as 'no remains'.

Three were recorded as 'taken away' but only one of these was actually taken away. In the other two cases the Register of Cremations had not been updated following the cremation to reflect the amended outcome of 'no remains' on the cremation card.

One case from 1997 was left entirely blank.

Five cases were recorded as 'dispersal' with no date of dispersal added.

Two cases were recorded as 'dispersal' with a date of dispersal added.

Of the ten cases registered from Linn Crematorium, four cases were recorded as 'no remains'. Four were recorded as 'dispersal' with no date added to the Register. Two were recorded as 'dispersal' with a date added.

As discussed in the section on Record Keeping, the Investigation found that where a date of dispersal had been added to the Register this was evidence that the initial instruction for ashes had been updated and the ashes had been dispersed. However, the absence of a date could mean either that the original instruction had not been updated or that the ashes had been categorised by the Cremator Operator as 'residue' and scattered or interred along with other residue and metals.

9.9 Conclusions

1. The Investigation noted the absence of consistent information emanating from the crematoria, Funeral Directors and NHS staff concerning the availability of ashes. Many parents were told by the NHS staff and Funeral Directors, on whom they relied, that there would be no ashes. To discover subsequently, sometimes after many years, that there were ashes and that they were scattered or interred in the crematorium grounds without the parents' knowledge or consent has caused deep distress.

The absence of any effective communication about the cremation of non-viable foetuses, stillborn babies and infants between Glasgow City Council, NHS professionals, Funeral Directors and families resulted in an inconsistency of approach and understanding of the actual position. This has significantly contributed to a state of affairs in which families have been deprived over many years of the opportunity to have ashes returned.

2. It is of serious concern that the mothers of the babies referred to this Investigation were unable to give informed consent to the cremation of their child, in some cases because of the persistent effects of sedating medication or strong pain relief. Some were recovering from surgery and all were suffering considerable grief. Steps should be taken to ensure that any form to be completed by any patient after a foetal loss, stillbirth or infant death is explained to the mother at a time when they are fully able to understand that to which they are consenting. Likewise, those suffering the unexpected loss of a non-viable foetus or baby must be given adequate time and consideration to make a decision about the cremation of their child.

3. With the FBCA guidance at the time advising that cremated remains consisted only of skeletal remains g0?it is understandable that Cremator Operators and their managers determined the ultimate disposal of babies' ashes according to whether or not they believed they contained bones. Conflicting messages from the FBCA and ICCM contributed to different crematoria following inconsistent practices. Lucille Furie was adamant in her evidence that she was willing to adopt a wider definition of ashes than that of the FBCA and return to families whatever was left after cremation regardless of whether it contained identifiable human remains. Yet the evidence from the Cremator Operators and their Supervisors suggested that this message was not understood by all, let alone acted upon. This apparent breakdown in communication between the crematorium's management structure and its workforce was further exacerbated by the absence of local written policy and guidance. As a result, Cremator Operators apparently decided for themselves whether they would, for example, use a tray when cremating babies, based on their personal opinion of the risks involved. Furthermore, while Lucille Furie expressed distaste at the idea of Cremator Operators sifting through babies' ashes to identify bone, this procedure was one which they themselves regarded as normal.

4. The Investigation into individual cases has been significantly hampered by the inaccuracy of the Register of Cremations at Glasgow City Council as it relates to these cases. The procedure of recording the outcome of the process before the cremation actually takes place resulted in the Register being unreliable in many cases. Rather than being an accurate record, entries often consist simply of an instruction or predicted outcome. Given that the completion and maintenance of the Register is a statutory obligation, except in relation to non-viable foetuses, steps must be taken to ensure it is an accurate and reliable source of information.

5. Like Mortonhall Crematorium, Glasgow City Council's Bereavement Services worked in almost complete isolation from the rest of the Council and from other crematoria. In the words of one Cremator Operator, who in nearly twenty years of cremation work had no contact with Operators from elsewhere,

"We're kept like mushrooms here. I don't even know what is happening with the Council never mind anything else."

The Investigation is concerned at the lack of knowledge about the working practices of other crematoria and the absence of any willingness to share good practice. This was illustrated by the reluctance, even after publication of the Mortonhall Investigation Report, to consult other crematoria concerning their use of baby trays. As John Downes, the Bereavement and Environmental Operations Manager explained,

"I don't think we've spoken to any other crematoria that were using trays to see what they were using. We wouldn't have done that at that time. You go, 'let's not be getting out and chapping on their doors and asking this'. We've worked independently."

This isolation contributed not only to a failure to resolve issues such as the satisfactory use of the tray but also to recognise and adapt to societal changes relating to bereavement, including most importantly the obligation to address the needs of parents which have been neglected and ignored over many years in these cases.

6. The absence of any local written procedures and the reliance on learning 'on the job', without any appraisal system or quality assurance of the methods adopted, meant there was no identified best practice against which to measure performance. The Investigation notes the absence of any refresher training for Cremator Operators and their Supervisors, following initial FBCA certification, and is concerned that this contributed to ongoing practices being embedded as the norm without any recognition of the need to improve and develop. However, this situation was not unique to Glasgow and was identified in a number of other crematoria investigated. While the introduction of specialist training in this area by the FBCA and the ICCM is to be warmly welcomed it is not a substitute for local training and reinforcement of appropriate working practices. Glasgow City Council must take responsibility for taking this forward and securing a change in culture at its crematoria.

7. The absence from Glasgow City Council's senior management's agenda of cremation of non-viable foetuses and babies until the situation at Mortonhall became public knowledge is also a cause for concern. The evidence in this Report suggests that senior managers were remote and uninformed about the operation of the crematoria as it relates to babies and infants. Furthermore, there was no strategic direction or development of the service in relation to babies and infants. The absence of any local written working practices for the cremation process for non-viable foetuses and babies is an additional significant barrier to this Investigation's ability to establish what was happening at the crematoria during the relevant time period. Likewise, the absence of any management record of the introduction of a tray and its abandonment is a significant gap.

8. The Investigation is concerned that in Glasgow and elsewhere the use of the baby tray was not monitored. As a result, reliance has had to be placed on the memories of Cremator Operators and their Supervisors after the passage of some time. While the evidence suggests that a baby tray was available from the late 1990s until as late as 2011, because its use was apparently left to individual Cremator Operator's discretion, it is impossible to identify with certainty those cremations where a tray was used.

9. It is of concern, too, that following publication of the Mortonhall Investigation Report, staff were not briefed about the expert evidence of Forensic Anthropologist Dr Julie Roberts' findings about the existence of bones in non-viable foetuses. During the interviews with Cremator Operators it was clear that they still had no understanding of the physiological development of foetuses and the existence of bones following cremation from seventeen weeks' gestation onwards. The expert report by Dr Roberts states,

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