Report of the Infant Cremation Commission June 2014 ‘We recognise that the events leading to our appointment were and continue to be deeply distressing to many parents and families. To those affected we offer our sincere condolences on the loss of their babies and our profound sympathy for the additional distress caused by the events that followed.’ All Members of the Infant Cremation Commission June 2014 CONTENTS 1. Executive Summary 3 2. Collated Recommendations 5 3. Introduction 13 4. Submissions 19 5. Cremation in Scotland 23 6. Technical Aspects of Cremation 27 7. Ashes 33 8. Securing the Recovery of Ashes 40 9. Regulation of Baby and Infant Cremations 53 10. Registration of Cremation 66 11. Training and Other Ways of Improving Practice 71 12. Memorials 82 13. Implementing the Recommendations 84 1 Annexes: A List of Crematoria in Scotland 87 B Infant Cremation Commission Full List of Members 89 C Infant Cremation Commission Local Investigation Guidance 90 D Joint Opinion of Counsel 92 E Dr Roberts Anthropology and Supplementary Anthropology Reports 100 F Dr Chamberlain Report 143 G Dr Chamberlain Supplementary Note to SEPA and Comments 160 H DEFRA / SEPA Process Guidance Note 5/2(12) 169 I Glasgow Audit Report 221 J Aberdeen Audit Report 229 K CMO & CNO 2012 Guidance on Disposal of Pregnancy Loss 241 L Scottish Government Analysis of CMO & CNO Guidance Implementation 255 M Health Board Documentation Responses Summary 261 N Health Board Arranged Individual Cremations Responses 269 O Crematoria Questionnaire Responses Summary 270 P Residual Heat or ‘Overnight’ Cremation in Scotland 283 Q Numbers of Deaths and Cremations By Age of Baby / Infant 286 R Children’s Memorials in Scotland 287 S Infant Cremation Commission Approved Meeting Minutes 291 Annexes E, F, G, I, J and L reproduced with kind permission from Dr Julie Ann Roberts, Dr Clive Chamberlain, Edinburgh City Council, Glasgow City Council, Aberdeen City Council and the Scottish Government. Enquirers may wish to contact the respective City Council for any updates and details of changes to their cremation processes since the audit reports were issued. 2 SECTION 1 - EXECUTIVE SUMMARY 1.1 Death always evokes grief. To some it brings release and to their families relief from the distress of observing a loved one in decline and pain. For others the grief and distress of suffering untimely bereavement can seem unbearable. That is particularly so for many who suffer the loss of a longed-for and much-loved baby at or before birth or in the early months of life. To learn later of uncertainty about the existence and disposal of their babies’ ashes has compounded the grief, caused further distress to many, and given rise to mixed emotions in others. That highlights the importance of taking steps urgently to ensure that future cremations of babies are handled with sensitivity that has due regard to the duty to lay their remains to rest as and where their families wish. 1.2 The work of the Commission has been confined to the cremation of babies and infants. It may coincidentally have an impact on arrangements for the cremation of older children and adults. However, it must be recognised that there are special features of baby and infant death and cremation of which it is important to be aware in trying to devise systems to avoid repetition of past failures. Perhaps the most significant are the practical result of cremation of a baby and the proper understanding of that by the three separate groups who have roles in arranging and conducting funerals and cremations, namely, healthcare staff, Funeral Directors and crematorium staff. Public concern about the current situation and the need for change was clearly expressed within a submission made by the parent of a baby who died shortly after having been born prematurely: “I feel that it is essential that national standards are established to inform the work of crematoria and that bereaved parents of the future are not left with any doubt about what has happened to the remains of their deceased children. If there are no remains then time should be taken to explain to parents why this might be the case. Parents also need to understand why apparently remains can be retrieved 100% of the time in some crematoria, but almost never in others. The current situation is not acceptable.” 1.3 The aim of the Commission has been to identify where the problems lie and to devise arrangements for cremation which address these problems in order to ensure that those involved have a clear and consistent understanding of the whole process that will enable them to assist families to make informed decisions, have their babies laid to rest as they wish, and have confidence that their wishes have been implemented. In doing so the Commission have been careful not to lose sight of the many examples of good practice already available to tap into, in all areas, and the widespread ethos of aiming to provide a dedicated public service. 1.4 In the Sections which follow, the circumstances which led to the creation of this Commission are set out along with details of the work undertaken in the course of the investigation and a summary of the 57 submissions received. The extent to which cremation is practised in Scotland and how cremation is carried out are explained. At the core of the Report are Sections addressing the nature of “ashes” and the means available to ensure the recovery of ashes in baby and infant cremations. Sections are then devoted to how baby and infant cremation is 3 regulated and the attendant formalities, including the forms to be completed and registration of the outcome. Two important legislative changes proposed are that there should be a statutory definition of “ashes” and statutory regulation of the cremation of babies of less than 24 weeks’ gestation. Since the Commission have identified a fairly widespread lack of appreciation of the impact of the cremation process on babies and infants and a failure to appreciate what the public expectation of cremation is, the subsequent Sections deal with training, education and communication. 1.5 Full consideration of all the material gathered by the Commission in the course of their work has led to the following recommendations which have the support of all members of the Commission. These recommendations are set out below along with reference to the parts of the Report where they are particularly addressed. 4 SECTION 2 - RECOMMENDATIONS 2.1 In legislating, devising policy, drafting information and guidance documents, and making arrangements for and conducting baby cremations, the baby and the interests of the family should be the central focus of attention. Parents and families should be given time and space to reach the correct decision for them. Arrangements should be in place at each hospital for ongoing contact with parents, particularly mothers, where that contact is necessary. (11.34) 2.2 The FBCA in the course of their “critical friend” visits to crematoria and the ICCM in their self-assessment questionnaire should address specifically the conduct of baby cremations and recovery of ashes. (5.6) 2.3 The “ashes” which the Cremation Authority is obliged to give into the charge of the person who applied for the cremation if he so desires should be defined in legislation as “all that is left in the cremator at the end of the cremation process and following the removal of any metal”. That should not preclude the applicant from consenting in advance to the removal of metals, such as coffin nails and artificial joints, and their separate disposal, including as part of a metal recycling scheme. (7.21) 2.4 Cremation Authorities should review their practices immediately to ensure that, in dealing with the “ashes” following cremation, they proceed on the basis that the “ashes” are as defined in the foregoing recommendation. (7.21) 2.5 The Scottish Government should inform their counterparts in England and Wales and Northern Ireland about the changes in legislation in Scotland to enable them to consider clarification of the definition of “ashes” in identical terms. (7.23) 2.6 All Cremation Authorities at whose crematoria ashes are not always recovered should liaise with a crematorium or crematoria where ashes are recovered more regularly to share their experiences and information about their respective practices in order to identify changes in practice that should be introduced immediately with a view to increasing the prospects of recovering ashes. (8.13) 2.7 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. (8.14) 2.8 As an urgent interim measure, the ICCM and the Federation of Burial and Cremation Authorities (FBCA) should form a joint working group, which should also include two lay persons nominated by the Scottish Government and a representative of Facultatieve Industries Ltd, to consider the various practices and techniques currently employed in baby and infant cremation in full-scale cremators with a view to identifying those practices which best promote the prospect of recovery of ashes inclusive of baby remains and compiling Guidance for cremator operators. The working group should identify aspects of the cremation process which could conceivably be changed or improved and into which research ought to be 5 commissioned by the Scottish Government. The working group’s endeavours may be assisted by the fact that the majority of cremators in use in Scotland are produced by the same manufacturer, Facultatieve Technologies Ltd.