THE inquiry into the Mortonhall babies ashes scandal has concluded that there is “overwhelming evidence” that babies’ bones do survive cremation.
• Managers ‘knew that there were ashes after baby cremations but refused to tell parents’.
• Baby ashes ‘mixed in with next adult cremation’.
• “I saw small bones… even a skull cap”
Dame Elish Angiolini’s long-awaited report into why parents were told there were no ashes from stillborn babies, or those which had died at minutes or days old, was officially published by Edinburgh City Council today.
And it includes the harrowing claim that ashes of babies cremated in the evening, were left to be mixed in with the first adult cremation in the morning.
The report, over 600 pages long, details every step of the former Lord Advocate’s 11-month long investigation.
It contains damning evidence that managers at the council-run crematorium knew that there were ashes after baby cremations but refused to tell parents, claiming it would be “too distressing”.
The report also says that long term manager of Mortonhall George Bell and Anne Grannum, a former superintendent - who denies she ever saw baby bones after cremation - had asked the council for a baby cremator to be installed, only to be told this was not financially viable. However there is no record of this request.
Interviews with former and current staff contain the upsetting information that while babies were cremated in the evening as the incinerators were cooler, any ash found in the morning “would be mixed in with the first adult cremation in the morning”.
‘Harder for the families’
One former staff member quoted in the report, Paul Jackson who is now a funeral director, said: “You can’t burn something and have nothing left. I am asked what I saw. I saw small bones… even a skull cap.
“It was not hard to see them, they look different from ashes from the coffin. There isn’t a lot of ash but you can still see bones. Before I saw this myself I was told by Anne Grannum there was nothing left.
“When I showed them to Anne Grannum she said ‘Garden of Remembrance… that’s what happens. I felt pretty bad about that. I heard her say it would be harder for the families but I disagreed, it was harder for them to have nothing.
“It became almost a daily occurrence to see there were remains.”
Dame Elish’s report states that Anne Grannum denies she was ever shown babies bones by staff and had “always believed there were no ashes from babies” and based on that there was “no sustained effort to secure a more effective way of recovering ashes”.
The report says: “Even though Mrs Grannum disputes the evidence of Paul Jackson and Hazel Strachan which I found to be reliable and credible, her acceptance of the description of the instance when she was presented bones from the cremation of a baby is at odds with the rest of her information,
“Her failure over many years to make any enquiry about what was happening at Seafield, where she understood ashes were recovered is also difficult to understand.”
The report also condemns NHS staff and funeral directors for their “inertia” about discovering how Seafield was able to give parents ashes. George Bell even visited Seafield as an examiner but didn’t “question or probe” the success of recovering ashes.
Mixed with adult
Dame Elish says: “Looking at the evidence of the employees at Mortonhall overall, they appear to be and to have been a dedicated and hardworking group…. both George Bell and Anne Grannum were well respected but there appears to have been a blind spot when it came to the cremation of babies and foetuses.
“If the small quantities of ashes produced were not recognised as ashes by Anne Grannum and therefore left in the primary chamber when the equipment was switched on by her each morning, the prospects of discovering the possible location of the disposal of any remains of these babies becomes grim.
“When the cremator operators arrives to see the equipment already switched on and they charged the cremator with the first deceased adult it is likely that some of the delicate remains of the baby from the overnight cremation would be mixed in with the first adult to be cremated that morning.
“Additionally some of the remains could be blown into the flue. These can be trapped and so the flue is hoovered regularly ad the contents vacuumed from these areas into hoover bags.”
These bags are then interred “in a separate area designated by the council adjacent to the skip.”
Dame Elish goes on to state that there is “complete inconsistency” in the rationale of the managers of Mortonhall to explain to parents why there would be no ashes and the contrast to the working practices at Seafield and Warriston - both run privately - is “stark”.
She said: “The outcome of this investigation will cause more pain and distress for most of the parents of the 253 babies who are the subject of this investigation. It cannot be said with certainty what remains of which babies are interred in the Garden.
“Our babies just didn’t matter to them”
“The precise extent to which remains of babies have been mixed in with an adult cremation is also unknown but appears likely extensive
Today, Dorothy Maitland, operations manager of charity Sands Lothians which first discovered the scandal, said that she was “shocked” by what the report contains. The ashes of her own baby Kaelen are, she was told in her own personal report “most likely” buried in the Garden of Remembrance
“I’m not surprised by what Dame Elish has found though,” she added. “You feel that our babies just didn’t matter to them.
“As a family we have to accept that Kaelen is in the Garden of Remembrance but we really still don’t know what to believe. We have to find a way forward now.
“We want to plant a tree at Blackford Pond where we always went as a family but her memorial is at my father’s grave and I get comfort from that. I get no comfort at Mortonhall.”
In total there are 23 recommendations in the report. Edinburgh City Council is recommended to review the management of the crematorium to ensure greater understanding of manager of the processes and procedures of its operation, that there should be robust systems of audit and inspection and that most importantly senior management should lead and support staff in continuing a change of culture and attitude towards the quality of service to next of kin.
Dame Elish also recommends that the council asks the Scottish Government to instruct national research to ascertain the most effective practices for the future to ensure ashes will be recovered for parents and the cremation of nonviable (pre-24 weeks) foetuses should be regulated by legislation.
“Lies and cover-ups”
She also states that unless a crematorium can demonstrate its competence in achieving remains and show consistent sensitivity to parents it should not be allowed to cremate babies.
Edinburgh council is also recommended to change cremation forms to ensure parents are aware of the recovery of ashes procedures.
It also demands that “immediate steps are taken, in consultation with next of kin of babies cremated at Mortonhall and where ashes were not returned, to address to the condition of this land (Garden of Remembrance) and to ensure it conforms to statutory requirement of decency.”
Willie Reid, chairman of the Mortonhall Ashes Action Committee, said: “It’s shocking and just shows the lies and cover ups we’ve been told since day one. It only means if there is no record keeping and they can’t account for any babies’ ashes we need to campaign to the government for a public inquiry.”
“It shows the contempt Mortonhall Crematorium has shown to bereaved parents and to the babies who have sadly died.”
Commission likely to lead to legislation
IT was in the wake of the Dame Elish Angiolini inquiry and amid demands for a full-scale public inquiry that the Public Health Minister Michael Matheson announced that an independent commission would be established to examine the current policies in place for handling the ashes and cremated remains of babies, which could then lead to legislation.
Headed up by former High Court judge Lord Bonomy, pictured, the results of that inquiry will also be made public today. It is expected that his report will call for a complete overhaul of Scots law in regard to how crematoriums deal with babies’ ashes – including those of “non-viable” babies born at less than 24 weeks’ gestation.
It is also expected to suggest that all local authorities provide dedicated areas of remembrance at crematoria as well as a national memorial for all those babies which have been affected by past practices.
Finally, the report is expected to recommend that all crematoria have specialist equipment for the cremation of babies.
City council chief executive Sue Bruce said: “Dame Elish has made many important recommendations, some of which relate directly to working practices at Mortonhall.
“I will be working with council colleagues and elected members to take these forward.
“We will now consult with families and relevant organisations regarding their views on a suitable memorial.
“We must ensure that the highest possible standards are adhered to at Mortonhall and that nothing like this can happen again.”
December 5, 2012: The Evening News first reveals the scandal after being contacted by Dorothy Maitland from Sands (Stillbirth and Neo-natal Death Society) Lothians. The charity had discovered that while parents had been told for decades there would be no ashes from the cremation of tiny babies, there were remains, and these were buried in an unmarked plot rather than given to grieving families.
December 7, 2012: Employees of Mortonhall use spray paint to try and identify where the unmarked graves of the buried ashes are in the crematorium grounds. Parents describe the move as an insult.
December 8, 2012: Edinburgh City Council announces an inquiry into Mortonhall headed by its own head of schools and community services, Mike Rosendale.
December 18, 2012: A petition calling for a public inquiry to be established by the Scottish Government is launched by families affected and garners thousands of signatures. Sands Lothians meets with Justice Minister Kenny MacAskill.
January 11, 2013: The first of eight complaints is made to Police Scotland about the scandal.
January 16, 2013: Edinburgh City Council says it will appoint a senior, independent legal expert to conduct a full inquiry into the Mortonhall scandal.
January 19, 2013: Families create their own action group – Mortonhall Ashes Action Committee, right, – to press for a public inquiry.
January 22, 2013: Dame Elish Angiolini, former Lord Advocate, is appointed to head the Mortonhall inquiry.
March 26, 2013: A Pricewaterhouse-Coopers audit is complete. The two-month forensic analysis uncovered such poor book-keeping that some cremations were not even registered.
April 17, 2013: The Scottish Government announces it will set up the Bonomy Commission to look at the efficacy of legislation surrounding baby cremations.
April 19, 2013: Police Scotland reveals there will be no further action on its part. Dame Elish, right, is able to begin her inquiry.
October 2013: The report’s publication is put back to January so as not to disrupt another Christmas for the families affected.
November 22, 2013: The Infant Cremation Committee, led by Lord Bonomy, reveals that Scots law will be changed to bring in standard procedures for recording the cremation of babies. Advice to parents will also be standardised.
April 14, 2014: Dame Elish Angiolini delivers her report to the council
April 30, 2014: The Mortonhall inquiry report is couriered to parents and then published.