Babies were cremated along with unrelated adults over many years in "unethical and abhorrent practices" at Aberdeen Crematorium, according to a report.
Dame Elish Angiolini looked at more than 200 infant cremation cases across the country following questions raised by the Mortonhall scandal where it emerged the crematorium had secretly buried or scattered the ashes of babies for decades without the knowledge of their families.
Bereaved parents had been told there would be no ashes produced and other local authorities including Aberdeen City Council were subsequently implicated in similar practices.
Dame Elish, the former Lord Advocate, investigated concerns raised by families across the country and found "deeply shocking" practices at Aberdeen Hazelhead Crematorium.
It was found in some cases that an infant coffin was placed at the side of or on top of an unrelated adult coffin and both cremated together.
Many staff had the "extraordinary belief" there would be no recovered ashes from babies up to the age of 18 months despite the fact they were recovered in other crematoriums and scientific evidence.
It was said there were issues around the recovery process of ashes, the ability to recognise skeletal remains and "individual or corporate management decisions".
The National Cremation Investigation report said: "Like Mortonhall, this was a section of the city council working in almost complete isolation without any strategic direction, development or quality control of the service, so far as it related to babies, infants and non-viable foetuses.
"There was little knowledge by senior management of the service provided to the families of these babies. There was insufficient interest taken or leadership shown by management."
Dame Elish found that training was done in-house with no studies of best practice elsewhere and that many staff believed there were no ashes from infant cremations because of "received wisdom from more experienced peers".
The report states: "An additional practice carried out at Aberdeen was described to the investigation.
"This involved raking adult ashes forward at the completion of a cremation and inserting into the same chamber an infant to be cremated while the adult ashes were still present.
"The entire contents of the chamber were then raked into the ash pan to cool. For obvious reasons this process was not recorded.
"It is therefore not possible to identify those unrelated adults and babies to whom this happened."
Dame Elish added: "The cremation of babies along with unknown adults is an unethical and abhorrent practice which will offend the sensibilities of the wider community and cause great distress to those whose babies were cremated there.
"It will also cause profound concern to the next of kin of unrelated adults who may have collected and continue to retain ashes of loved ones cremated at Aberdeen which also contain the ashes of a baby or one or even several non-viable foetuses.
"The understanding that there were no ashes or that they could not be recovered was not explained and is inexplicable."
The investigation found that communication between bereaved parents, NHS staff, crematoria staff and funeral directors was often "muddled" and led to general misunderstandings about the production of ashes.
The investigation looked at 14 crematoriums, praising some such as Cardross for "the care applied" in retrieving baby ashes.
In total, 15 recommendations were made including a law to prevent the mixing of baby ashes with those of another person, proposed criminal sanctions and tighter regulation of crematoria.
The Scottish Government is working on the Burial and Cremation (Scotland) Bill, brought forward from the recommendations of Lord Bonomy's Infant Cremation Commission.
Public health minister Aileen Campbell said: "Some of the historic practices uncovered in this report are unacceptable and, frankly, appalling.
"It is awful that parents who have lost their child in such sad circumstances have had their grief compounded by the actions of those they trusted to support them.
"While I understand it may be little comfort for those who have been affected in the past, much has changed in Scotland since these issues first came to light.
"We have brought forward legislation to overhaul policy and practice in the burial and cremation industry, introduced a new inspection regime for crematoria and worked to improve staff training, particularly in the NHS.
"I am committed though to driving forward further improvement and we will now work to progress any outstanding actions that have been identified by the Investigation."
Aberdeen City Council chief executive Angela Scott said: "It cannot be overestimated how much anguish and hurt parents have experienced due to past practices at Aberdeen Crematorium and on behalf of Aberdeen City Council, I apologise unreservedly to those parents who did not receive their baby's ashes, and to the relatives affected by the practice ended in 2012 of placing baby coffins in the cremator alongside adult coffins.
"The loss of a baby is devastating for parents and their families, and we are deeply sorry for the extra distress our past actions have caused."
Ms Scott added: "I fully concur with Dame Elish's view that some past practices at Aberdeen Crematorium were abhorrent and unethical.
"Many of the report's recommendations are directed specifically at chief executives and I also state now that I will personally ensure that I and my senior management team address each recommendation and ensure that all necessary actions are taken in Aberdeen."
The chief executive said a helpline remains open for families affected - 01224 522255 - and discussions are to take place on a fitting memorial for those involved.
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