2.1 Terms of Reference
On June 17, 2014, the then Minister for Public Health, Michael Mathieson MSP, announced to the Scottish Parliament the establishment of a National Investigation into infant cremations in Scotland. He explained that the Mortonhall Investigation Report by former Lord Advocate, Dame Elish Angiolini QC, published on April 30 2014, provided specific answers to affected families in the Edinburgh area, as well as a number of wider recommendations.
Lord Bonomy's Infant Cremation Commission Report, published by the Scottish Government on June 17, 2014, also provided national recommendations for future improvements. He added that Scottish Ministers acknowledged, however, that families from some other areas of Scotland were still seeking answers.
The current National Investigation, to be led by me, was therefore established to respond to this need. The appointment was made under Section 19 of the Cremation (Scotland) Regulations 1935, with powers to inspect, at any reasonable hour, any registers or documents (all applications, certificates, statutory declarations and other documents) relating to any cremation held by any Cremation Authority in Scotland.
The terms of reference of the Investigation were,
- to investigate the circumstances around the cremation of any infant or baby referred to the Investigation team by bereaved parents or others, including the work of crematoria, hospitals and NHS Boards and Funeral Directors as necessary;
- to report back to the bereaved parents or others the results of that investigation, particularly in relation to the likelihood of there having been ashes following the cremation, and the whereabouts, if known, of any such ashes;
- to conduct a more general investigation into practices and operations at any specific crematorium where case-specific investigations give rise to more general concerns;
- to report back to the Minister at the conclusion of the National Investigation with a summary of the work undertaken and the key findings.
2.2 Structure of the Report
This Report is divided into separate Chapters about each of the Crematoria under investigation with findings, conclusions and recommendations particular to the individual crematorium included in the individual chapter. An overview of the general issues emerging, so far as they relate to these 14 crematoria follows this introduction, along with a summary of general conclusions and recommendations arising from the Investigation.
A Report by the Forensic Anthropologist, Dr Julie Roberts is annexed to this Report and provides crucial expert evidence. The Report refers to her earlier Report for the Mortonhall Investigation  and confirms, amongst other significant findings, that bones in cremated foetuses from as young as 17 weeks' gestation can and do survive the cremation process. Taking that into consideration alongside the data presented in her report she concludes that,
"It is inconceivable that there would be nothing left of new born babies and infants aged up to 2 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 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."
Furthermore, she explains that in very young foetuses it may take considerable forensic expertise to recognise bones which are, nonetheless, there. They may not be apparent even to experienced Cremator Operators.
In addition to this general report, the next of kin of each baby referred to the Investigation have been provided with copies of any recovered documents and details of the Investigation about their own specific circumstances. Many of those circumstances are also referred to anonymously in the chapters of this report about the relevant crematorium.
As I stated in the Mortonhall Investigation Report, it is important that those who must address these problems and interact with those so badly affected should do so as sensitively as possible. However, a proper professional approach inevitably requires resort to technical and explicit terminology that can appear brutal and insensitive in this very sensitive context. The terms non-viable foetus, stillborn and neonatal baby and infant will be used, as appropriate, within this Report. The term 'baby' is used to describe these four categories when they are referred to collectively and, more generally, as parents and others do not in ordinary conversation refer to expecting a foetus.
To ensure that the issues are properly addressed and are accurately defined, this Report necessarily contains some very distressing evidence and terminology throughout. The expert report by Dr Roberts annexed to the Report is particularly explicit with illustrations included in her Report.
2.3 Methodology of the Investigation
A total of 202 cases were referred to this Investigation involving 14 out of the 29 crematoria across Scotland. The Investigation was therefore a major undertaking. 320 witnesses were interviewed and many hundreds of documents recovered and examined. Each crematorium was visited and relevant staff interviewed. In older cases, many relevant witnesses had retired or passed away and in a number of cases records had been destroyed or weeded after the expiry of the minimum statutory period of 15 years for mandatory retention of such documents. In 11 cases, the families approached the Investigation because at the time of their baby's death they had not received even the most basic information about where their baby had been taken and whether their baby had been buried or cremated. The Investigation was able to establish what had happened in each of these cases and to inform the families of their findings.
The investigation also involved discussions with professional and expert witnesses.
Given the scale of this Investigation I was asked by the Minister to lead a team to carry out the necessary enquiries and preparation of the Report. That team consisted of Claire Soper, the Director of the team, Charlotte Triggs OBE, former Senior Prosecutor with the Crown Prosecution Service, Fiona Donnelly, Solicitor, former Associate Director Institute of Professional Legal Studies, Senior Lecturer Queens University, John Watt, former Area Procurator Fiscal and Marion Collins, former Civil Servant. Victoria Stott, University of Oxford, also provided invaluable research and editorial support to the team.
Amanda Moss BEM, my Executive Assistant at St Hugh's College, Oxford, has also provided great assistance to me throughout the Investigation.
The members of the Investigation team, led by Claire Soper have been outstanding. They have each shown great sensitivity and dedication to what has been a deeply disturbing and distressing major Investigation and I am enormously grateful to each of them for their care, professionalism and expertise.
I would also wish to acknowledge with thanks the cooperation and advice of the Inspector of Crematoria, Robert Swanson, along with the professional and expert witnesses whose evidence is contained in the Report.
Finally, I am deeply grateful to the many parents who participated in this Investigation and who, without exception, showed great courage and dignity in having to revisit the loss of their baby in such sad circumstances. Their evidence will be of great assistance in the prevention of the recurrence of their own experiences for future parents facing the loss of a baby.
Rt Hon Dame Elish Angiolini DBE QC