A yearlong, independent investigation commissioned by Philadelphia officials over the handling of the remains of victims of the MOVE bombing was unable to determine exactly how or why a box of the victims’ bones languished in the city medical examiner’s office for decades, officials announced Thursday.

Also still unknown is why an office employee, directed to cremate the remains in 2017 without notifying the victims’ next-of-kin, instead disregarded the order. The remains were found in cold storage in the office last year, days after former health commissioner Thomas Farley resigned over his order to cremate them.

At the time, city officials promised answers: “We are getting to the bottom of many different disturbing questions, including why these remains were held for decades, and why they were still held after being directed to be cremated,” Mayor Jim Kenney said in a statement in May 2021.

But, according to Thursday’s report, those answers are still out of reach.

Several key players in the incident, including several former medical examiner’s office employees and the employee who disobeyed the cremation order, refused to speak to investigators from the law firms Dechert and Montgomery, McCracken, Walker & Rhoads. The firms’ 257-page report on their findings, released Thursday afternoon, includes recommendations for improvements in policies and record-keeping in the medical examiner’s office.

Investigators determined the medical examiner’s office should not have considered the bone fragments in their possession as disposable, and should have immediately notified the victims’ families it had the remains.

The report also contends the office is still not fulfilling its obligation to serve as an independent investigative agency in cases of death, and is too understaffed now to effectively investigate homicides in the city. Bias, along with inadequate training and policies, likely played a role in the “grossly inadequate investigation” in 1985, investigators concluded.

The report didn’t go so far as to accuse the people involved nearly 40 years ago as motivated by racism, but said it is likely political pressure or bias played a role.

“It is difficult to believe that all of the omissions and commissions discussed above were made simply through negligence,” the report reads.

The Philadelphia Department of Public Health accepted the report’s 16 recommendations, and said in a statement the current medical examiner would change the death certificates of all 11 people killed in the bombing to identify them as homicide victims, per one of the recommendations.

Lionell Dotson, who is the brother of two of the victims of the 1985 bombing, Katricia and Zanetta Dotson, said the reports demonstrated that the city has not acted in good faith since the 1985 tragedy.

”Throughout this process, Mayor Jim Kenney, the city of Philadelphia and the University of Pennsylvania have asked us to trust them,” Dotson said. “But this report makes it clear that they simply aren’t trustworthy.”

Six adults and five children were killed in the notorious 1985 bombing, when police dropped a bomb on the fortified West Philadelphia house where the MOVE organization was headquartered. The resulting fire killed all but two people in the house and burned down blocks of surrounding rowhomes.

The mistakes from the medical examiner’s office began almost as soon as the flames from the bombing were subdued, the report found. Cranes were used to dig up debris and bodies, damaging them and jeopardizing the forensic investigations that would follow. The medical examiner at the time did not send staff to the scene to ensure bodies were recovered properly — ignoring standard practice.

For months, MOVE families waited to bury their loved ones as medical examiners and anthropologists debated over the identities of the remains. The office’s files and documents on the victims were “incomplete, inconsistent, and, at times, contradictory,” investigators wrote. They kept no logs on which remains were released to funeral homes or cemeteries.

“As a result, we are unable to conclude definitively what remains, if any, were released for the respective victims and actually buried or cremated between May 1985 and September 1986, when the last of the victims’ remains were purportedly formally released to the families,” investigators wrote.

Some of the bones were sent to anthropologists at the University of Pennsylvania, purportedly for help with identifications. But in 2021, families were shocked to learn that the anthropologists had kept, and in some cases displayed in online lectures, bones of at least one of the children killed in the bombing, for more than three decades.

» READ MORE: Penn report on mishandling of MOVE remains faults two scholars for ‘gross insensitivity’

Then, on the 36th anniversary of the bombing last year, came another stunning admission: Then-health commissioner Farley admitted that in 2017, a box of bones and bone fragments from MOVE victims was found in the medical examiner’s office, and that he had ordered it cremated without informing families. Farley resigned; the medical examiner, Sam Gulino, was suspended, and resigned later in 2021.

In 2017, investigators found, a staffer at the ME’s office was sorting through boxes in the “personal effects room” — a disorganized space that held unclaimed belongings of the deceased. There were disputes even among staffers about how old some of the items were — some staffers told investigators there were items dating to the 1970s, while others insisted that the oldest belongings in the room were just 10 years old.

The staffer found one box labeled “MOVE Evidence.” Inside were 11 packages containing what were obviously human remains, including a femur, several jawbones, teeth, and other bone fragments.

By the end of the day, Gulino had been informed of the discovery; within weeks, he was discussing what to do with former deputy health commissioner Caroline Johnson and Farley.

Gulino didn’t bring the box to the meeting with Farley, nor did he tell the health officials about “the exact type or quantity of remains in the box,” according to the report. Farley told investigators he believed the box held a small number of bones. Gulino said that his office didn’t have guidelines for disposing of remains like the kind in the box.

» READ MORE: Questions persist over Philly’s mishandling of MOVE remains

Legally, medical examiners generally don’t need a family’s permission to retain parts of a body for an investigation. But many offices do give families detailed information on what samples need to be taken for an investigation, and consult with them on whether they would like them returned.

That hasn’t generally been the practice at the Philadelphia office. In 2017, Gulino recommended the bones be cremated, “because biohazard disposal processes would not destroy them,” the report read.

Farley agreed. He said in his interview with investigators that he told Gulino to wait six months and cremate the remains without notifying the MOVE families, so as to spare them trauma. But the six-month waiting period served another purpose, the report found.

“Dr. Farley explained that he requested the six-month period to see if [the discovery] became publicly known and would warrant a difference response,” he said. “He told us during his interview that if it were widely known that the bones existed, he would have felt obligated to contact the family.”

After it was reported last year that Penn also had MOVE victims’ remains in its possession, Farley and Gulino did not initially inform city officials about their decision to cremate the remains in 2017, waiting nearly 10 days to submit a memo to superiors about the cremation decision.

Dotson’s attorney Bakari Sellers said the report’s recommendation that the bombing victims’ causes of death be changed to homicide was long past due.

”Katricia and Zanetta Dotson didn’t have an accident. The city killed them,” Sellers said. “If Mayor Kenney wants to make things right, then he should start there. Tell the truth and start treating the victims and their families with basic human decency.”

The authors of the report suggested the document itself would be a good starting point to conclusively identify the remains stored in the box. Investigators were able to tentatively link some to victims, including John Africa and several of the children, but others could not be identified.

The office continues to have a chaotic and poorly catalogued storage system, the report concluded, and needs regular audits of items in storage and specific, detailed labeling for those items. It also needs a policy determining how long remains and personal items should stay in the hands of the office before being released to families. If more stringent record keeping and custody policies had been in place, the report suggested, remains might not have ended up in a Penn professor’s cardboard box for decades.

The office needs more cultural diversity training, the report found, and its authors urged the office to make more clear its independence from other investigative agencies by hiring outside legal counsel, rather than using the city’s legal department.

The Philadelphia Department of Public Health stated in a response to the report that some of the recommendations are already being implemented. “Some will be challenging due to funding constraints,” health officials continued. “We are committed to working with the families of the victims to identify a respectful plan for how to handle the remains.”