Section 11 - Training and Other Ways of Improving Practice
11.1 The importance of training all involved in the aftermath of baby and infant death and in all aspects of the cremation process was mentioned in various submissions to the Commission.
Training of Crematorium Staff
11.2 Both the FBCA and the ICCM have training schemes which lead to certification of successful candidates as technicians. That training is referred to in PG Note 5/2(12). In terms of paragraph 5.48 Cremation Authorities are encouraged to set up an environmental management system (EMS) for the general operation of their crematoria. Para 5.49 provides specifically as follows:
"Staff at all levels need the necessary training and instruction in their duties relating to control of the process and emissions to air. In order to minimise risk of emissions, particular emphasis should be given to control procedures during start‑up, shut down and abnormal conditions.
Training may often sensibly be addressed in the EMS referred to above. The Cremation Technicians Training Scheme operated by the Institute of Cemetery and Cremation Management should be adequate for this purpose, as should the Training and Examination Scheme for Cremation Technicians which is run by the Federation of Burial and Cremation Authorities."
11.3 The FBCA Training and Examination Scheme for Crematorium Technicians (TEST) specifies its purpose as being to supplement the technician's training in procedures appropriate for the competent operation of cremators, compliance with the appropriate Regulations and Codes of Practice and to prepare the technician for practical examination in cremator operation. Examination success results in the issue of a certificate of proficiency in cremator operation. The TEST training is normally undertaken in‑house, with the tuition being given by a trained and experienced operator who acts as mentor to the candidate. The candidate has to complete a minimum of 50 cremations, under supervision, and log details of every fifth cremation on a prescribed form before being examined.
11.4 In addition to undertaking practical training and recording details of these cremations, the candidate must also study course notes and, at the candidate's own pace, answer questions at the end of each section of the course. An FBCA examiner conducts a practical examination at the workplace crematorium. That examination is designed to ensure that the candidate understands the principle of combustion, works to the FBCA Code of Cremation Practice and understands the health and safety factors of the technician's role. The examiner has access to the candidate's responses to the course note questions and should tailor the examination process to ensure that relevant factors are dealt with and any areas of apparent weakness are examined closely to ensure that the candidate is able to operate the equipment in a safe and ethical manner. Any candidate failing to reach the required level of competence will fail the examination and will be required to undergo further training prior to retaking the practical examination. Recently that has occurred on two occasions.
11.5 The ICCM Crematorium Technicians Training Scheme (CTTS) leads to the award of the BTEC (Business and Technology Education Council) Intermediate Certificate for ICCM Crematorium Technical Operations, which is a nationally recognised level two qualification. To achieve the qualification candidates must pass all of the three sections that make up the unit entitled Crematorium Operations:
1) the functioning of a modern cremator;
2) starting up and closing down procedures;
3) the process for dealing with cremated remains.
As in the case of the FBCA, the candidate's training is supervised by a mentor who will usually be the candidate's line manager at the workplace crematorium who is already suitably qualified and experienced.
11.6 As the candidate works through the course instruction notes (study pack) 6 assignments must be completed, including maintaining a log of cremations that the candidate has carried out. When all 6 have been completed, the mentor arranges for a short multiple choice test of 20 questions and a cremation observed by an ICCM assessor at the workplace crematorium. The work book in which the assignments have been completed, the test paper, and the assessor's notes of the observed cremation are then passed to the ICCM National Office to be assessed and verified. The successful candidate is awarded the BTEC certificate.
11.7 The ICCM scheme also provides for the technician to advance to a higher level and obtain an advanced certificate at BTEC level 3. Under the scheme old qualifications can be updated and converted to a BTEC level 3 qualification. The ICCM training scheme is administered from a training centre, the performance of which is audited annually by Edexcel. The Edexcel appointed auditor inspects systems and procedures and examines a random sample of candidates' work and examiners' report forms. Should a lowering of standards or quality be identified, then that can result in Edexcel accreditation of the training centre being withdrawn.
11.8 The significance of risk management in crematoria has been recognised by the recent introduction of a qualification accredited by City and Guilds to level 3 which is awarded following successful completion of an ICCM training programme entitled "Controlling Risk in Crematoria". This qualification, together with other ICCM City and Guilds accredited qualifications for cemetery operators, is audited annually by City and Guilds along the same principles as those outlined above for Edexcel.
11.9 All ICCM staff are qualified trainers and assessors through City and Guilds and undergo technical verification annually. That involves a City and Guilds representative observing ICCM staff undertake an assessment at a live course. Once again, should any lowering of standards or quality be identified, the assessor's qualification is withdrawn pending further training and subsequent verification.
11.10 While both the Institute and the Federation have invested considerable effort and resources in the development of training and testing schemes for trainee technicians, little guidance is provided on baby and infant cremation. The FBCA training and testing notes give minimal guidance on the procedures and techniques for baby cremations, mentioning only the use of trays and the practice of overnight cremation while the ICCM training notes do not mention the subject at all.
11.11 With that in mind a set of course notes specifically relating to baby and infant cremations has been drafted to be added to course material, additional paragraphs have been prepared for inclusion in the Assessor Guidance Note used by assessors observing the conduct of cremations, and also a new element relating to the conduct of baby and infant cremations has been drafted to supplement the list of competences that the assessor should be looking for in the course of observed cremation. The ICCM intends to review these proposed additions to their scheme in the light of the report of this Commission with a view to introducing a revised training scheme taking specific account of the variations in practice that are appropriate in conducting baby and infant cremations. The FBCA has also indicated that they will review their training and testing scheme in light of this report.
11.12 The Commission note the steps already taken by the ICCM to prepare revisions of its technician training scheme and the intention of both the ICCM and the FBCA to revise their training schemes in light of this Report. The Commission consider that the time is ripe for both the Institute and the Federation to review their respective current technician training programmes with a view to providing adequate guidance on best practice for the recovery of ashes in baby and infant cremations, and so recommend.
11.13 A major problem running through the dealings that Funeral Directors, cremation staff and healthcare staff have with bereaved families is their inability to provide informed advice about the ashes that will be recovered. As an example, the current training scheme for crematorium technicians does not include any guidance that would provide the technician with a better understanding about the nature of the contents of the cremator tray at the end of a cremation. While there will plainly be occasions when it will not be possible to identify bony fragments or other remains of the baby, guidance and training on the physiological results of the cremation process would better equip the technician to provide information, and therefore greater comfort, to families who seek that reassurance. The ICCM has advised the Commission that it recognises that training and educational courses should include, as a fundamental element, training and guidance for their members on helping bereaved families who want more than simply routine information about the cremation process. The Commission recommend that the ICCM and the FBCA should engage an expert, such as Dr Roberts, to advise on the compilation of a suitable training module for inclusion in their respective crematorium technician training schemes, and should include, in their training programmes, guidance on dealing sensitively and transparently with families in providing them with information.
11.14 It is also important that any published Guidance documents accurately reflect the knowledge and information now available about the recovery of ashes in baby cremations. Dr Roberts suggested that the FBCA should review all Guidance documents to provide clear and fully informed guidance on the prospects of ashes being recovered based on information about skeletal maturity rather than gestational age per se. We endorse that suggestion and recommend that the FBCA carry out such a review, taking particular note of the terms of the reports by Dr Roberts at Annex E.
11.15 It is appropriate to mention one particular matter that caused the Commission concern. Under both schemes the technician's training is largely provided and supervised by an experienced operator or technician within that establishment. When the problems of baby and infant cremations first came to light in December 2012, there were significant variations in practice in baby and infant cremations at different crematoria over the country, reflected in the responses to the Commission's crematoria questionnaire. These variations are fewer now than they were at the start of the Commission's work. However some remain. They reflect differences in local practice which exist for reasons which may or may not be justified. That highlights the danger of the perpetuation of unsatisfactory practice within local establishments when training is largely the responsibility of those who follow that local practice. In addition, during the training period the trainee technician may have few opportunities to carry out a baby or infant cremation.
11.16 Against that background the Commission recommend that both the Institute and the Federation should introduce an external monitoring scheme for newly-qualified technicians, whereby they would not be certified competent to conduct baby and infant cremation unsupervised unless they had in the period of two years following certification carried out two under supervision to the satisfaction of an ICCM or FBCA examiner, to ensure that in these most sensitive of cases best practice is being followed by the newly-qualified technician.
11.17 The ICCM also offer members a Diploma in Cemetery and Crematorium Management that is accredited to HNC standard. It consists of eight discrete units of study as follows:
1) Cemetery Management
2) Crematorium Management
3) Cemetery and Crematorium Law
4) Managing Financial Resources and Decisions
5) Organisations and Behaviour
6) Managing Activities to Achieve Results
7) Human Resource Management
8) Administrative Services
At the initial stage there are three different certificates available depending on the career aspirations of the member, ie (1) certificate in cemetery management, (2) certificate in crematorium management, and (3) certificate in office management. The ICCM recommend that certificate level qualifications should be obtained by all service managers in the industry. Thereafter staff can proceed to obtain the ICCM diploma, usually over a period of 5 years. It is also possible for a member to continue their studies to HND and degree level with other qualification providers. The Unit points accrued from completing the ICCM Diploma count towards qualifications.
11.18 At present no part of the ICCM management training scheme deals with the subject of baby and infant cremation. Some issues relating to baby and infant cremation are inevitably dealt with in the course of studying the units relating to crematorium management and crematorium law. However, the whole circumstances which gave rise to the Mortonhall Investigation and this Commission demonstrate the need in any management training scheme for crematorium staff to address the particularly sensitive subject of baby and infant cremation, which involves cremation staff (i) dealing with personnel they may not routinely deal with in other cremations, such as maternity and gynaecology staff, (ii) meeting and assisting the families who are endeavouring to cope with a loss made all the more distressing because it is all that has come of events from which so much joy was anticipated, and (iii) undertaking technical cremation practices specially tailored to provide a gentler cremation. The Commission therefore recommend that the ICCM should revise their management training scheme to include an element dealing with baby and infant cremation which would be an essential part of study for the certificate in crematorium management.
11.19 It is not uncommon for persons with direct management responsibility for the operation of a crematorium to have no qualification in crematorium management. To ensure that full effect is given to the foregoing recommendation, the Commission also recommend that those with that direct management responsibility should hold either a qualification in crematorium management or the FBCA certificate of proficiency in cremator operation or the ICCM intermediate certificate for crematorium technical operations.
11.20 The ICCM also has a continuing professional development (CPD) scheme for members to enable them to keep up to date on new developments in the industry. Since one of the lessons of this review is that the state of knowledge improves with the passage of time, the Commission consider the provision of a training programme for continuing professional development of staff to be necessary to ensure that their work is always carried out in accordance with current best practice. The Commission therefore recommend that the FBCA should devise and introduce a CPD training programme. This Report and the MIR demonstrate that there is already much knowledge and guidance on good practice available to be disseminated
Training of Funeral Directors
11.21 Funeral Directors largely rely on Cremation Authorities and their staff for their understanding of the various aspects of cremation practice and in particular the likelihood of recovery of ashes. Training of Funeral Directors does not address these issues. As a result the funeral director has often been the one who conveyed misleading information about ashes to parents. The professional organisation for individual Funeral Directors is the British Institute of Funeral Directors (BIFD). To obtain full membership requires the applicant to have obtained the Diploma in Funeral Directing (DipFD). That is a qualification awarded by the National Association of Funeral Directors (NAFD), the trade body of which the majority of funeral director businesses are members. For the past 30 years the DipFD course was taught by BIFD tutors but the candidates were tested by examiners from the NAFD which was responsible for awarding the diploma. There has recently been a review of this arrangement and both bodies are in the process of establishing their own individual training programmes, examinations and qualifications, in each case in association with a university.
11.22 There are other training facilities. The National Society of Allied and Independent Funeral Directors (SAIF) provides vocational training through the medium of the Independent Funeral Directors College. In addition one of the largest funeral director businesses, Co‑operative Funeral Care, provides National Vocational Qualification (NVQ) training at the Co‑operative College.
11.23 Funeral director training addresses subjects such as dealing with the bereaved, handling the necessary paperwork, and arranging a funeral, as well as technical details about the construction of coffins and what may or may not be placed in a coffin. The action taken in relation to the ashes actually recovered is also dealt with, including interring, scattering and retention. However, funeral director training does not address the process of cremation and its impact on the body.
11.24 So far as the likelihood of recovery of ashes is concerned, Funeral Directors rely on and take their lead from the ICCM and the FBCA and quote their advice and the information they have obtained from the local crematorium when discussing with bereaved families the options for laying their babies to rest. The Commission understand that, in the absence of information to the contrary, a funeral director would normally advise that ashes may not be recovered following the cremation of a baby and would mention the alternative of burial. Among the submissions received by the Commission are cases where Funeral Directors made more definite statements to the effect that ashes are not recovered in baby cremations, including some where it has now come to light that there were ashes, as occurred in the Mortonhall cases.
11.25 As in the case of those involved in cremation, a lack of consistency in the use of language by Funeral Directors reflects not only uncertainty, but also differences of opinion, about what the applicant for cremation ought to receive at the end of the cremation. Yet again the need for clarification of Regulation 17 of the 1935 Regulations, as dealt with earlier in this Report, is demonstrated.
11.26 The importance of the part played by Funeral Directors in ensuring that bereaved clients experiencing the most distressing of bereavements understand clearly the options available to them and the implications of cremation cannot be overstated. It is, therefore, vital that their professional associations, trade organisations, and those involved in the funeral directing business in general, particularly those running large undertaking businesses, should pay close attention to the terms of both reports, the expert evidence referred to therein and any changes in practice and guidance that may be determined by the ICCM and FBCA following the work of this Commission and the Mortonhall Investigation. Those bodies which provide training programmes should review them in the light of any legislative changes affecting the cremation of non‑viable babies and stillborn babies, as well as the various changes to the forms in use and the registration process. They should also, as part of that review, devise a training module designed to give Funeral Directors an understanding of the cremation process, its effect on the body, and prospects of the recovery of ashes in baby and infant cremations.
Ensuring Best Practice in the Funeral and Cremation Industry
11.27 As Dame Elish pointed out in the MIR at page 539, it is one thing to recommend action, but quite another to ensure that the recommendation is implemented. Ideally the implementation of recommendations for changes in practice should be overseen by the governing body of the trade or profession affected. In the case of the cremation industry, all but one Cremation Authority in Scotland are members of either the ICCM, or the FBCA, or both, each of which works to a professional charter or code. Both organisations require technicians to be trained. It is gratifying to note that both are committed to ensuring implementation of the recommendations of the Commission. The position is somewhat different in the case of Funeral Directors. About 80% of funeral director businesses are members of the NAFD, about 10% of the National Society of Associated Independent Funeral Directors (SAIF), both of which have codes of practice. However, about 10% are affiliated to no trade or professional organisation. While the organisations referred to have codes of practice, there are no requirements or enforceable conditions that apply to all Cremation Authorities or Funeral Directors in relation to the arranging or conducting of a funeral involving cremation. While there is no reason to anticipate resistance to implementation of the Commission's recommendations, there is equally no mechanism for overseeing their implementation.
11.28 Against that background it is the view of the Commission that it is appropriate for the Scottish Government to consider establishing a National Committee to oversee implementation of the Commission's recommendations, including those applicable to Funeral Directors and Cremation Authorities and their representative bodies. Such a National Committee could be charged with overseeing the implementation of all the recommendations of this Report, as well as being endowed with wider powers. The Commission will address the terms of the remit of such a Committee later in Section 13 of this Report, after identifying all the areas about which the Commission have specific recommendations.
Training of Healthcare Staff
11.29 In the submissions received, and in the course of the Commission's investigations, training of healthcare staff was referred to in relation to a number of different areas, including ensuring an understanding of the pain and despair of pregnancy loss and infant death, recognising and managing the confused expectations of parents and family, and communicating accurately, sensitively, clearly and consistently with them in guiding them through the process of laying their baby to rest at the same time as they struggle to cope with the associated grief. The Commission see applying these qualities in the communication of information and guidance as a vital element in avoiding the failings and misunderstandings of the past.
11.30 That can only be achieved if those responsible for communicating information, guidance and advice are themselves fully conversant with all aspects of what is involved from the hospital to the crematorium. The acquisition of that understanding and the development of good communication skills to convey that understanding are vital elements in the professional development of all who deal with families affected by baby and infant death. While the MIR deals exclusively with the role of healthcare staff at NHS hospitals and the investigations made by the Commission have been largely confined to NHS Health Board and hospital practices, the recommendations of the Commission apply equally to any other healthcare provider in Scotland to which the work of the Commission is relevant.
11.31 It is clear from the MIR that there was considerable misunderstanding among hospital staff about what could be done at the various crematoria in Edinburgh and even about the cost of privately arranged baby cremations. On the other hand, it was encouraging to note the finding in the MIR that there has undoubtedly been a huge improvement in how the experience of pregnancy loss, stillbirth and neonatal death is managed in hospital. At the same time, in the passage where that progress is reflected, it is also noted that the area of communication is a persistent issue. Much work remains to be done.
11.32 It is widely accepted that some of the most difficult and delicate situations in hospital arise in the context of miscarriage and termination of pregnancy. It is in those situations that the July 2012 Guidance from the CMO and CNO applies. Communications and discussions with Health Boards revealed that some have found it much easier than others to adapt to that Guidance. Systems previously followed in maternity, gynaecology, and mortuary departments have had to be revised. The implementation of the Guidance has been effected in different ways in different boards. NHS Orkney, with no local crematorium of its own, has reached agreements with the Burial Authority and a mainland Cremation Authority; NHS Grampian used the new Guidance to additionally facilitate the updating of all its existing documentation and procedures; NHS Tayside (amongst others) used the Guidance to enhance a pre-existing level of service that already met or exceeded the minimum standards.
11.33 One area in which the experiences of different Boards have varied significantly has been in dealing with parental consent for disposal from a mother who does not wish to discuss the matter or have any regard to the Guidance leaflet offered. Each Health Board has had to make its own arrangements for ensuring that staff are properly instructed in any new procedures introduced. In some Health Boards staff have found difficulty in discussing the disposal options available with mothers who are resistant to engagement in that discussion. One of the larger boards which appears to have succeeded in applying the Guidance in its entirety fairly quickly, including ensuring that the options available for disposal are clearly explained and the appropriate paperwork completed, is NHS Ayrshire and Arran. They may have been assisted by the involvement of Consultant Obstetrician, Dr Marjory MacLean, in the 2010-11 working group which devised the Guidance. The Commission consider that the circumstances surrounding the introduction of that Guidance provide good illustration of the sort of situation where one hospital or Health Board can learn and benefit from the experience of another or others.
11.34 The Commission recognise that it is impossible to prescribe a procedure that will inevitably apply to all communications with a mother at, during and after she undergoes a distressing hospital procedure. Every individual case is likely to present its own particular challenge. The guidance given to staff should recognise that parents should be given the time and space necessary for them to make the right decision about laying their baby to rest. They should not be expected to make such an important decision at a time of physical pain, grief, exhaustion and sedation, combined with emotional turmoil and distress. There are also findings that, in spite of the fact that guidance made provision for decisions to be made days and up to 4 weeks after discharge from hospital, staff failed to follow that guidance. Two points to be particularly borne in mind in the drafting of hospital Guidance are these: (1) the parent should always be clearly advised of the availability of the option of burial; and (2) not every parent will be up to dealing with the issues of cremation, the recovery of ashes and their disposal while still in hospital. Arrangements should be in place at each hospital for ongoing contact with parents where necessary.
11.35 The Commission consider that there should be formal training for healthcare staff, including chaplains, whose duties involve liaising with patients in the context of advising them about, and guiding them through, the possible arrangements that may be made to deal with their pregnancy loss. Each Health Board, as part of continuously improving the quality of the service, should identify staff who will have responsibility for communicating with families about arrangements for disposal and liaising with Funeral Directors and crematoria, and arrange for their education and training as part of their continuing professional development, including in communication skills and understanding the roles and responsibilities of colleagues. The Scottish Government should facilitate the development of appropriate modules to be completed by relevant staff, to include current evidence as to the prospects of recovering ashes in baby and infant cremations such as that contained in the reports of Drs Roberts and Chamberlain and how to communicate information.
Sharing Information, Experience and Knowledge
11.36 A proper understanding of the local situation is of primary importance. Of course it has to be recognised that that would be of little value in a situation where the practice followed was inappropriate, as in Mortonhall. However, in the current climate of increasing awareness of what can be achieved, what is appropriate and where parents have been failed in the past, a full and relevant understanding of the whole position locally from hospital to crematorium should provide positive benefits. That is why the Commission encourage the formation of multi‑disciplinary working groups to exchange information, knowledge, understanding, practice and experience for the benefit of all involved. An example of multi‑disciplinary meetings can be found in Ayrshire and Arran where as many as 40 people may participate. In a submission made to the Commission the group was described as including "all involved in the journey, including local authority personnel, mortuary technicians, midwives, doctors etc". The reference to "local authority" includes the authority as Cremation Authority. These groups or meetings should involve not only those representing and working at local crematoria, but also Funeral Directors who are not usually involved as often. In Ayrshire and Arran the introduction of these meetings has been seen as a positive development. The Commission would encourage the introduction of similar arrangements in other areas, with the local Health Board supporting relevant staff in taking the initiative with a view to understanding, developing and refining local practice and producing information leaflets relevant to the local context. This sort of co‑operation can also promote greater understanding in simple ways, for example by hospital staff visiting the crematorium to observe the cremation process and meeting the cremation technicians, as suggested in the MIR.
11.37 At the outset of the Commission's work a quantity of NHS Guidance documents, information leaflets, and forms used in the management of pregnancy loss from 7 different Health Boards in Scotland were made available to the Commission. In October 2013 the Commission requested all 14 of Scotland's Health Boards to submit copies of all the documentary information and guidance material in use in relation to pregnancy loss and infant death. Examination of the material submitted disclosed significant variations in the way in which important information is conveyed to patients in different Health Board areas but also between different hospitals within the same Health Board. Some documentation had not been updated in light of the July 2012 CMO/CNO Guidance. Some Health Boards rely heavily on pamphlets produced by bereavement support organisations which provide support to mothers and relatives, while others place much less reliance on that material. It was not always clear that full information about the support available on leaving hospital is provided. Since the precise manner and terms in which information is conveyed and the Guidance is provided are for each individual Health Board and other healthcare provider to determine, the Commission also consider that every Health Board and healthcare provider should review all documentary material currently used to convey information and guidance relating to baby and infant loss in light of the terms of this report and the MIR to ensure that all relevant information and guidance is accurate and is communicated clearly and consistently, including in particular information about the prospects of recovering ashes and a reminder of the availability of the option of burial.
11.38 It is likely that some will have been more successful than others in developing clear and consistent documentation. As in the case of the implementation of the July 2012 Guidance, the Commission consider that the way towards ensuring that best practice is identified and applied as widely as possible is for boards to share their practices and experience. One board in its submission to the Commission suggested that leaflets and information books should be produced nationally and the costs shared proportionately among boards. Since consistency in the application of best practice in the country is important the Commission also consider that the Scottish Government should establish a working group comprising a representative from each Health Board and chaired by a Scottish Government official, to review all Guidance documents and information leaflets in use across all Health Boards and other healthcare providers, including those compiled by or in conjunction with bodies such as SANDS UK and the Miscarriage Association, relating to the management of pregnancy loss, infant bereavement and arranging disposal. That should ensure consistency in this guidance and information, and reduce the proliferation of different documents in use.
11.39 In the many medical, scientific, engineering and technical aspects that are a feature of pregnancy loss and infant death, there is constantly potential for development and change. It is incumbent upon those involved in this area of work to ensure that they are aware of developments in equipment, material and practice to ensure that the loss of babies and those enduring the consequential trauma are sensitively dealt with in accordance with the best available practice and given clear and consistent guidance to enable properly informed decisions to be made.