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

Investigation findings and recommendations following an investigation across crematoria in Scotland who did not routinely return ashes to families following the cremation of infants.

15 Mortonhall Crematorium

15.1 Introduction

A total of 43 cases which had not already been investigated by Dame Elish Angiolini were referred to this Investigation. These 43 cases range across the time period 1970 to 2011. Of these, one baby was found to have been buried rather than cremated and two are believed to have been clinically incinerated on hospital premises rather than cremated at Mortonhall or at any other crematorium.

All families who referred babies to the Investigation were invited to submit evidence in person or in writing. In each case these families were offered a copy of the Mortonhall Investigation Report to help them understand the context of what had already been discovered. This Investigation facilitated communication for the families with the City of Edinburgh Council who included them with the families of the previous Mortonhall Investigation in the consultation on options for a memorial and offered them the opportunity to have their baby's name engraved on the wall of the new Memorial Garden at Mortonhall Crematorium.

The evidence given to the Investigation by the families was very familiar and consistent with the findings of the Mortonhall Investigation. Having been told, usually by their Funeral Directors, that there would be no ashes, the manual Register of Cremations routinely recorded 'interred in the Garden of Rest'. With the move to a computerised system, cremations of foetuses and babies were then routinely recorded as 'no remains'. Sadly, the findings of the Mortonhall Investigation Report apply equally to these cases registered with the National Investigation. This information has been communicated to the families who registered with the Investigation.

In the most recent case of a stillborn baby cremated in 2011, the family were told by the Funeral Director that they could collect the ashes because Mortonhall Crematorium had by then introduced a baby tray to maximise the recovery of ashes. This instruction was duly noted on the Application for Cremation (Form A).

After the cremation had taken place the family were informed that in fact there had been no ashes recovered in this instance. The Investigation interviewed the Crematorium Manager and was told he believed it was possible that on this occasion the Cremator Operators placed the baby's coffin directly on the hearth and did not use the baby tray which had only been very recently introduced. One of the Cremator Operators who carried out this cremation is no longer employed by City of Edinburgh Council and was unable to be contacted. The other, who was a trainee at the time, told the Investigation he could not recall this particular case. The family were informed after the cremation that there were no ashes recovered and the Register of Cremations was updated to reflect the actual outcome. Given the evidence of Dr Julie Roberts, that the bones of a stillborn baby would survive the cremation process, it can be inferred that these were lost to the secondary chamber when the cremator was switched on in the morning in readiness for that day's cremations or were left in the cremator and mixed with the ashes of the next person cremated in that cremator.

The Investigation requested a report from the Chief Executive of the City of Edinburgh Council, Andrew Kerr, on the changes implemented since the publication of the Mortonhall Investigation Report in April 2014.

"Following the discovery of potential issues in relation to cremation practices at Mortonhall Crematorium in late 2012, the Council commissioned an independent investigation into practices at the Crematorium regarding the cremation of non-viable foetuses ( NVFs), stillborn and neonatal babies. In April 2014, following receipt of Dame Elish Angiolini's Mortonhall Investigation Report, it was agreed at the City of Edinburgh Council's meeting of 26 June 2014 that the twenty-two recommendations contained in the report would be accepted and taken forward by the Council and other relevant agencies.

To take this work forward, a Multi-Agency Working Group was convened by the Chief Executive, and met regularly, allowing the opportunity for affected parents and stakeholders to have scrutiny of improvements, multi-agency discussion and feedback on actions undertaken to inform and develop the way forward. This forum was facilitated to provide reassurance to affected parents that good progress was being made on the actions and that these were being delivered within the required timescales. This Group has requested that Council give consideration to ensuring long term service improvements and joint working by continuing its role through bi-annual meetings and a further report to Full Council in June 2016.

The implementation team, which was led by a Senior Manager and includes officers seconded to support the delivery of the action plan, staff at Mortonhall and officers from across the Council, have continued to work jointly in embedding the recommended culture change at Mortonhall Crematorium. This work has also involved developing improved working practices with partners and stakeholders to ensure an informed and supportive approach from the range of service providers who meet directly with the bereaved. All staff have played a key role in local implementation of changes to working practices arising from the investigation and actions, supporting the development of an engaged, legislatively compliant service demonstrating best practice.

Working cremation practices at Mortonhall were revised with immediate effect following receipt of the recommendations, to ensure compliance with the actions required. As a specific example, the practice of overnight cremation of infants at Mortonhall formally ceased in May 2014, and relevant agencies informed of this change in practice. This followed the change in practice introduced in 2011 whereby Operators adopted the use of cremation trays for the cremation of NVFs, stillborn and neonatal babies.

In order to provide a clearly articulated public statement of revised operational practices, a Cremation Services Policy Document was approved by the Council in February 2015. This Policy Document has been made available to members of the public, industry and healthcare professionals and key elements of this document will be incorporated into wider service information which is currently under development. This document incorporates guidance agreed at National level, sets out the range and quality of service that the bereaved can expect from services delivered at Mortonhall Crematorium, and outlines a commitment from us to deliver cremation services to the specified standards.

In connection with this, Senior and Service Managers are attending regular meetings with NHS Lothian and representatives of the funeral industry to develop greater shared clarity of understanding around the choices available to parents when faced with the loss of a child, and to develop a clear end-to-end understanding of each stage of the process by all stakeholders. This clarity will ensure that all practitioners are aware of operational practices at Mortonhall Crematorium, and therefore enable them to provide informed support to parents at a difficult time.

The Federation of Burial and Cremation Authorities ( FBCA) and Institute of Crematorium and Cemetery Management ( ICCM) have agreed to adopt recommendations of Lord Bonomy's report and have developed updated training and guidance. The FBCA's Training and Examination Scheme for Cremation Technicians now incorporates specific elements dealing with baby, infant and foetus cremations. Mortonhall Crematorium is among the first in Scotland whose staff have successfully undertaken update modules in infant cremations, which has involved monitored assessments carried out through site visits to other crematoria in Scotland. Currently these modules have been completed by four members of staff, with the remaining staff due to complete these during the next delivery phase offered by the provider.

Senior officer input to the Scottish Government's National Committee on Infant Cremation, and its various sub groups, has enabled the City of Edinburgh Council to maintain a proactive role in the review and development of good practice and legislation across Scotland.

The Council has continued to work with affected parents and collaboratively with Stillbirth and Neonatal Death Society ( SANDS) Lothians and Simpson's Memory Box Appeal ( SiMBA) in regards to improving the landscaping around Mortonhall, and the design and location of a fitting memorial to babies affected by historical practices at Mortonhall. Following a number of consultations and meetings involving affected parents around the potential location, style and design of any memorial options, it was agreed by parents that a memorial should be developed at Mortonhall recognising the significant feedback received in support of this. It was also agreed that, in acknowledgement of feedback received from parents who would find it difficult to return to Mortonhall, that a second memorial be developed in an alternative location. The team worked closely with the designer and other contractors in progressing and refining the design for Mortonhall Crematorium to ensure this remains tailored to the wishes of parents. Positive progress in this regard enabled the garden to be completed and opened in early December 2015. The Memorial Garden offers a secluded space for affected parents and families to remember their loved ones.

Parents who did not wish to return to Mortonhall also requested that a further memorial location be identified. Based on feedback from parents the preferred location for the alternative memorial is Princes Street Gardens, and good progress is being made in relation to the commissioning of a suitable memorial in this space.

As part of a recently agreed Improvement Programme, £1.9 million of investment will allow for the refurbishment of the customer and operational aspects of the building and installation of replacement cremation equipment, with work to enhance the reception area and waiting room environment expected to take place later in 2016.

Regular communication has been maintained with affected parents throughout the programme. As part of a joint approach between SANDS Lothians and SiMBA and the Council, parents have been invited to participate in ongoing consultation around the design and location of memorials. Close liaison with these partner charities has ensured clear joint understanding of key messages. Parents have received regular letter and email updates to ensure they are aware of progress, and a number of meetings have been arranged to enable wider discussion of options and facilitate shared agreement around the way forward. The team has provided regular written and telephone support in responding to individual queries from affected parents. These have ensured that parents contacting the Council are updated on progress, while at the same time providing a sympathetic response to those parents who require additional reassurance and emotional support.

The City of Edinburgh Council, in conjunction with industry representatives and agreed Scottish Government Codes of Practice, has developed an approach to the cremation of babies and infants that is designed to maximise the recovery of ashes at all times. This includes the use of a cremation tray designed to retain ashes, and the maintenance of operational conditions that will maximise the recovery of any ashes during the process of cremation.

Cremations of babies and infants are carried out at the end of the working day when all other activities have ceased, allowing the onsite staff to be vigilant during the cremation process, and to take action to adjust operational conditions when necessary in order to maximise the recovery of ashes.

These actions have enabled staff to recover ashes for the cremations of all babies and infants since the revised practices were formally introduced in 2014.

All City of Edinburgh Council staff responsible for carrying out cremations of babies and infants continue to undergo training to ensure they have the relevant skills for this highly sensitive process, and the Council is committed to ensuring that the service provided by staff at Mortonhall is of the highest standard"

15.2 Conclusions

It is clear that the City of Edinburgh Council and their partners have listened to the findings of the Mortonhall Investigation and implemented changes that aim to ensure that mistakes made historically are not repeated. Sadly this comes too late for the cases referred to this Investigation. The conclusion drawn by the Mortonhall Investigation, that families will be left with a lifetime of uncertainty about their baby's final resting place applies equally to these cases.


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