On my lunch hour I scrolled through my usual Twitter feed of parent blogs, medics, music and death related posts.

I learned of the background stories of terrible movies, hidden accounts of discrimination and fun with H.P Lovecraft as the substitute teacher you never knew you should have had.

I also learned that I am lucky to have a box of ashes bearing my sons’ names.

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I learned that I am lucky to know that I have sons.

I am lucky to have physical proof that they existed even if it is now only in powdered form.

To borrow a much maligned phrase I don’t even know how I would be able to cope without that.  I have the luxury of only having to imagine these horrors safe in the knowledge I do have their ashes.

I learned that horrors are not the work of evil but ignorance, denial and arrogance.

That was once you

When our boys died we were told of our options.  We were told about cremation and how small as they were there would be ashes that we could bury, scatter or keep as we saw fit.

We were offered the option of having two sets of ashes within an urn so they could be together but separate having their own identity and name plaque.

We took their ashes home and they are in plain sight not hidden away.  They were there overlooking their sister’s birthday party without shame or embarrassment and people asked about them and we gladly spoke of them.

But not for you

This was not the case for at least 200 families in Scotland.

What started as a piece of research for a book for Sands in 2012 lead to investigations uncovering systematic and historic failure to provide ashes of babies to grieving parents as well as unethical practices showing no regard to the grieving.

It started when the researcher noted a discrepancy between the experiences of parents that had gone for a private cremation and those that had their babies cremated at the local authority crematorium. Why was it that the private crematoria could provide baby ashes but the local authority one couldn’t?

The investigation that followed along with media interest started to gather evidence that this problem was not isolated to one crematorium. More and more families came forward with stories of how they too had been denied the ashes of their children.

This has culminated in the soberly titled ‘Report of the National Cremation Investigation’ by Dame Elish Angiolini. It is a weighty tome as would be expected of an investigation into the practices of Scottish crematoria.

Few of us have the time to read 435 pages of a report about ashes. Wonk as I am, even I haven’t read the full report. It contains detailed descriptions of the process many of us would prefer not to think about and the language can often be harsh.

“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.”

This is not a warning given lightly. I tried to read as much of it as I could but the often graphic descriptions were sometimes too much.

It is rare to read an official report where you can feel the rage vibrating from its words. Reading the accounts and excuses I share that rage. But that rage is as nothing to the righteous fury felt by parents denied their child’s ashes.

These are parents that had lost their children. They, as I did, probably had little knowledge of the details and would have been in no fit state to make big decisions alone. It would seem obvious that in the throes of raw grief that they would have looked to others to help them and find what they could do.

They were told that there would be no ashes from a child less than 18 months old.

They were told this by hospital staff, funeral directors and crematorium staff.

These families were left with nothing.

One family was told that they had lost a boy.  They mourned his death, named him, marked his grave and created traditions and stories about their lost son.

Then they found out that there had been a mistake.  Their lost child was a daughter.

“I’m not ready to change anything yet. I’ve not even changed my tattoo or the name on his headstone. It feels like I have lost two babies instead of one.”

Another family had been told that their child had been cremated but no ashes were recoverable.

During Dame Elisha’s investigation these ashes were found in a cupboard.

These are terrible, heart rending stories.

It’s how it’s always been done

How did this happen? How did it get to the point that so many parents were denied the last ashes of their children? Let’s check the helpful Q&A from Aberdeen City Council.

Why couldn’t Aberdeen Crematorium collect ashes from baby cremations when some other places could?

Other crematoriums used trays to hold baby coffins, and ACC stopped using them about 30 years ago, we believe, due to health and safety reasons for staff. Since this came to light, we have reviewed our processes and now use trays for all cases. Aberdeen Crematorium has recovered ashes from all cremations where a tray has been used.

Here’s a clue. It’s not [expletive deleted] health and safety. What it is a complete failure of culture. A failure to question, to review what is being taught . It’s a depressingly familiar tale of poor practice being taught to staff who then go on to teach new staff and so on.  It’s played out unchecked by management in a little isolated bubble insulated from outside challenge time and time again and still no-one learns.

The alleged health and safety incident has no record.

“He also said that he had found out that they used to get ashes when baby trays were used but that the trays were stopped by ‘Health and Safety’. No evidence of any injury was presented to the Investigation. No records of any Health and Safety reports or intervention relating to the use of a baby tray were provided to the Investigation.”

Despite this coming from Aberdeen a similar story had been told in Edinburgh:

“Mr. George Bell, Bereavement Services Manager at Mortonhall, told the Investigation that a staff member sustained a hand injury using a tray in the 1980s and that a risk assessment was carried out with a member of the Council’s Health and Safety team. The risk to staff was deemed too great and the tray was withdrawn. The Council was unable to provide the Investigation with any records or details of this accident and the subsequent risk assessment.”

All of this heart break, all of this anguish could have been avoided through the use of a simple tray.

Even if there had been a health and safety risk to using a tray due to risk of injury surely a better response would have been to review processes or look for ways to reduce the risk rather than stopping the use of something that has been used successfully by many other crematoria for hundreds of years.

“We have baby urns in the columbarium there. We have a big tower there. It‘s got 3,000 sets of ashes in it and we‘ve got wee baby and stone urns and there‘s ashes in them from a hundred years ago. So they must have had baby trays or something similar to the trays we have even back then because as I say there are ashes in there that are a hundred years old and they‘re baby ashes. So they were able to collect them all that time ago without any modern equipment or anything”.

If I burn my hand on an oven tray do I a) use an oven glove in future or b) throw out the oven tray?

Even when presented with evidence of the furnace manual explaining the proper process was presented it was ignored:

“…I went to Derek (Snow, former superintendent Aberdeen Crematorium) and I says please just tell us how to do it. All I got was ‘we had the baby trays in here years ago, it doesn’t work, we’ll just do this normal’. And that was basically that.

I think basically that Derek was adamant that trays were not the answer because it was so dangerous.”

“I probably did see when reading the Facultatieve manual that there was something about how to cremate babies, but it didn’t resonate with me because we did it differently. In particular, I think it mentioned baby trays and we didn’t use one so I thought it didn’t apply to us.”

The training was in-house and there was no specialist training on infant cremation. If there are no remains, why would there be? It was only after watching a documentary about their workplace that some staff members started to check afterwards to see if there were any remains going as far to do so while their manager was away.

This goes beyond just denying ashes. It is a callous disregard for the parents and children they have lost.

“She also discovered that infant remains were mixed with adults and in many cases families will have gone home with ashes of their loved ones mixed with remains of several babies.”

Even if the staff did believe that there would be remains and that a tray provided by the manufacturer and referenced in the manual and training posed a health and safety risk what they did directly contravened their code of practice as well as basic human decency and compassion..

Once a coffin with its contents has been placed in the cremator, it shall not be touched or interfered with until the process of cremation is completed. On completion the whole of the Cremated Remains shall be collected and shall be disposed of in accordance with the instruction received.

Each coffin given to the care of the Cremation Authority shall be
cremated separately.

Dame Elish is scathing and sweeps away the paltry excuses offered in defence of a complete failure to test the misguided assumption that there would be no remains from children under 2 years old:

“There was, quite simply, no interest in recovering ashes from foetuses and babies and no effort put into attempting to do so, although ashes had been recovered at Aberdeen many years before. The reality is described in detail in this Report and is deeply disturbing. The evidence discloses unethical practices over many years of the cremation of foetuses and babies along with unrelated and unknown adults.”

The insult continues

Since the break of this scandal and the investigations that followed there have been improvements as well as legislation and action on the many recommendations of the report to make sure there is greater scrutiny and accountability.

This offers small comfort to families but there are still calls for further investigation into the events at Aberdeen.

Even after all the reports there are those that still insist that it’s not possible to recover ashes.  Here’s an account of a meeting between two mothers and the Glasgow City Head of Bereavement Services

Mr McColl didn’t know me, I just said I was a friend there to support her. We were talking about babies’ bones and he said in the 25 years he had done that job he has never found remains.

“Then I told him I was one of the mums involved in the inquiry and have read the report, which says you can get ashes from babies as young as 18 weeks, but he said no. I said, no wonder all these parents are still angry if you are still coming out with that after the report.”

There’s more, so much more in this report and the scandal will continue to hurt.  The small consolation is that the action taken in response to these events will help to ensure that this never happens again but there is so much more to be done.

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