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.

17 Seafield and Warriston Crematoria

17.1 Introduction

Situated in Edinburgh, Seafield and Warriston crematoria are both privately run by Edinburgh Crematorium Ltd. Warriston Crematorium carried out its first cremation in October 1929 and Seafield in May 1939.

A total of eleven babies registered with the National Investigation were found to have been cremated at Warriston or Seafield spanning the period 1971 to 2006. In contrast to other crematoria investigated, the records for these babies all stated that ashes had been dispersed following cremation.

17.2 Cremation Process and Equipment

The detail of how foetal and infant cremations are carried out at Seafield and Warriston was covered in detail in the Mortonhall Investigation and described in the Report. The Registers of Cremation record that remains have always been recovered from these cremations whether or not a baby tray has been used.

Edinburgh Crematorium Manager Jim Nickerson told the Investigation,

"After the Mortonhall issue broke, I thought I should check to make sure that this always had been the policy and always been the case with us, so I started going back through the early registers. I found the first stillborn child that we ever did was in 1934 and the ashes were given back in an urn to the applicant. I then looked at every decade to find other children where the ashes had been given back and I found that every decade after that, we had given ashes back at some point. The majority are still dispersals because that was the custom at the time, but I can always find one at least where we had given them back so I'm confident that throughout the whole time that Warriston Crematorium has existed, that we've given ashes back when asked."

17.3 Administration and Record Keeping

The majority of the cases registered with the Investigation were more than fifteen years old and therefore the only record available was the Register of Cremations. It is a statutory obligation to keep all other records for fifteen years only. In all but one case the Register stated that the ashes had been dispersed in the Garden of Remembrance. In one case from 2006 the Register stated that the ashes had been 'retained'.

Seafield and Warriston crematoria have for many years operated a system whereby Funeral Directors have to sign for any ashes they collect from the crematorium. Initially such signatures might only be the name of the company but by 2006, the signatures were required to be those of individuals. The Investigation was therefore able to find the name of the Funeral Director who had signed the ashes out in 2006 and follow this up. The Investigation discovered that the baby's ashes were in fact still being held by the Funeral Director, eight and a half years after the cremation took place. The Investigation directed that these ashes should be immediately returned to the family.

17.4 Communication

i Communication with Families

One of the issues for families registered with the Investigation appears to be that some Funeral Directors working in Edinburgh understood the position to be that there would be no ashes and informed the families of that position. As established by the Mortonhall Investigation, Funeral Directors were informed by Mortonhall Crematorium that there were no ashes following cremation of foetuses and infants. No such communication was issued by Warriston or Seafield crematoria.

The current Superintendent at Warriston Crematorium worked as a Funeral Director before taking up his post at Warriston in 1992. He told the Investigation,

"What I was aware of, as a Funeral Director, was that if you went to Mortonhall, you did not get ashes back. If you went to Warriston or Seafield you would get ashes back. That was my understanding. If I knew that, I can't see why other Funeral Directors weren't aware of that."

The Managing Director of William Purves Funeral Directors confirmed their understanding,

"whilst Mortonhall clearly stated that there would be no ashes from cremations of young infants, Warriston, whilst not guaranteeing there would be any ashes, made every effort to provide ashes and to our knowledge they always did so."

Parents however told the Investigation that they were clearly informed by Funeral Directors that there would be no ashes. One said,

"But the Undertakers were very clear with us. No question. No dubiety. There will be no ashes. It was absolutely clear."

Another had a similar experience,

"we all sat down and went through various details and that was the first time that we were informed much to our surprise, because we did ask for ashes, and it was the Undertaker that first of all says there won't be any ashes. There will be nothing left. It's only a baby."

The mother of a baby who died aged seven months told the Investigation,

"the Undertaker said 'no ashes for a child under two'. Those were his exact words 'No ashes for a child under two"'.

Two families told the Investigation they had checked the position on ashes with Warriston crematorium and that crematorium staff had confirmed there would be no ashes.

The parent of a baby who died in 1977 said,

"I also contacted Warriston to make sure and they said exactly the same, there wouldn't be anything left."

Another parent whose baby died aged four months in 2001 said,

"I asked for ashes and the Funeral Director told me there would be none. On the Monday after the cremation I phoned Warriston and asked if there was any and again was told no"

The current management at Warriston Crematorium cannot explain how this message could have been conveyed to parents by crematorium staff given that they have always recovered ashes.

The family who received their ashes after eight and a half years told the Investigation that the Funeral Director had told them at the time of arranging the funeral that there 'probably' would not be ashes. When they collected the ashes from him, the Funeral Director told the family that he had been passing on what he had been told by the crematorium.

"He went through arrangements and at that time he said 'now you do realise there probably won't be any ashes'. And at our meeting with him last week when we collected the ashes, he did say 'I was warned by Seafield that you don't, that there sometimes aren't ashes' and he said 'I gave you that information as well.'"

In the most recent case of a baby cremated at Warriston in 2005 the mother recalled that the Funeral Director had very strongly given the impression that there would be no ashes following the cremation of her newborn son. She told the Investigation,

"While he did not definitively say 'there will be no ashes' he said it was highly unlikely and we definitely made our decision thinking that there would not be any ashes. He then said 'I would go for dispersal' and because we thought there was not likely to be anything we agreed to that. There was a certain easiness to it, that we wouldn't have to think of what else to do. We didn't know then what dispersal meant and we didn't know that dispersal means different things in different crematoria. I hadn't thought about what it meant very much because I thought it wasn't going to happen. If we had thought there were going to be ashes, we would have thought about what that meant and we probably would have chosen elsewhere to disperse them in our own way. That is my issue, that we didn't get that choice."

17.5 Conclusions

1. The Mortonhall Investigation found that Funeral Directors often gave an instruction for ashes to be dispersed even after telling the family that there would be no ashes. If that was also the case for the families in this Investigation, the crematorium would have followed the instruction on the Form A (Application for Cremation) for the ashes as they do for every cremation they conduct.

2. The overall regulation of the funeral profession needs to be improved. Funeral Directors should be licensed and subject to a statutory regime of regulation and inspection.

3. Steps must be taken by the Chief Executives of Health, Crematoria and Funeral Organisations to ensure that all staff required to advise parents on cremation or to carry out such cremations are properly briefed. They must have an understanding about the survival of baby bones in cremation where proper care is taken. They must also have an understanding about the fundamental importance to families of having back any small remnant of their baby, including ashes from the baby's clothes, blanket, toy or coffin to help them grieve for their loss.

4. The written evidence in the Registers of Cremation supports the crematorium's position that ashes are always recovered. However, with the exception of the most recent case, there is no surviving paperwork which records the instruction that would have been given on the Application for Cremation (Form A). In all cases referred to the Investigation it can be concluded that ashes will have been recovered from cremation and will have been dispersed in the Gardens of Remembrance. The exact location of dispersal is not recorded.


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