The report by Dame Elish Angiolini into the disposal of babies' remains at Mortonhall crematorium in Edinburgh has answered some important questions but, sadly, has left one of the most important unanswered.
When the scandal emerged in 2012 and it was discovered the remains of babies had been buried in a garden of remembrance without the knowledge of the families, parents wanted to know specifically what happened to their own child.
Regrettably, Dame Elish's report concludes it cannot be said with any certainty which babies were interred or where remains were buried. It means that, in the words of the report, the parents will be left with a life of uncertainty about their baby's final resting place.
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In other respects, the report sheds some light on much of what happened at Mortonhall. In particular, it exposes unacceptable practices over many years and a lack of focus on the service to parents. It also reveals the extent to which the crematorium failed to reflect the changes that have taken place in society's attitude to death and bereavement, particularly the death of very young babies. The care of parents in these circumstances has changed beyond recognition in the last 20 years, with a much deeper emphasis on sensitivity and transparency. The managers at Mortonhall remained isolated from these changes.
The report also clears up one of the central issues in the scandal, which was whether the bones of babies could survive the cremation process. Anne Grannum, the former superintendent at Mortonhall, told the investigation she had always believed there were no ashes from babies and it was what parents were told over several decades. But Dame Elish's report is clear: there is overwhelming evidence that foetal bones do survive cremation, at least from 17 weeks' gestation. The fact the policy was not changed at Mortonhall in the face of this evidence is one of the most shocking aspects of the scandal. Perhaps staff at some point did believe no ashes could be retrieved, but there was a lack of interest in looking at whether the service they offered, or the practices they followed, could be changed. Even when it became clear other crematoria were able to recover ashes, Mortonhall persisted with its policy.
Partly, this was because the management remained committed to the way things had always been done: at worst, there was opposition to change; at best, inertia which made change impossible. Much worse was a lack of focus on relatives and a failure to keep them informed. Families should always be the main focus for staff in such a sensitive area.
Mortonhall also appears to have been able to operate without reference to other similar institutions. That cannot be allowed to continue. One of the central recommendations of the report is that there should be robust systems of audit and inspection and these must include standards of service every crematorium is expected to achieve. The standards should reflect changes in technology, culture and working practices; they should be reviewed constantly; and they should apply to all crematoria to avoid any single institution operating according to its own flawed rules.
There is at least the prospect of swift reform. Edinburgh City Council says it will act on Dame Elish's recommendations and a report by former judge Lord Bonomy into how infant remains are dealt with in this country is due next month. Lord Bonomy will recommended the changes needed but Dame Elish's report has highlighted the areas that demand attention: proper record keeping, good supervision and constant review of procedures but, above all, focusing on the needs of the families.