Inadequate investigation, bias, and a desire to avoid public scrutiny at the Philadelphia Medical Examiner’s Office all help explain why victim remains from 1985′s MOVE bombing sat in a cardboard box for almost four decades, a city report released Thursday found.

Why they were kept there, and why an order to cremate them was ignored, are among the questions still left unanswered, five years after the box was discovered.

Philadelphia officials promised a thorough investigation of the mishandling of the MOVE remains. On Thursday, independent investigators released a 257-page report of their findings.

» READ MORE: Read the full report on the mishandling of MOVE victims’ remains

Here are six key takeaways from the report:

1. A “grossly inadequate” MOVE investigation in 1985 led to human remains being mishandled.

The Medical Examiner’s Office did not send personnel to the scene on Osage Avenue during the crucial period when the victims’ bodies were recovered, and the city used a crane to uncover debris and bodies, corrupting the scene. There was no independent investigator to document the initial location and condition of the bodies. When the ME got the bodies, initial examinations weren’t properly documented. The office didn’t take timely tissue samples, stored the remains at the wrong temperature, and made conclusions about cause and manner of death that weren’t supported by the evidence.

The “grossly inadequate investigation” in 1985 was in part a result of inadequate policies and training, the report concluded, but bias and political pressure within the office played a role as well.

» READ MORE: Philly releases reports on city’s mishandling of MOVE bombing victims’ remains

2. We still don’t know why the box was at the ME’s Office, or why an order to cremate them was disobeyed.

Several former Medical Examiner’s Office employees, including the employee who disobeyed the cremation order, refused to speak to investigators from the law firms Dechert and Montgomery, McCracken, Walker & Rhoads.

In 2017, investigators found, a staffer at the ME’s office found a box labeled “MOVE Evidence.” Inside were human remains. Then-medical examiner Sam Gulino recommended to then-health commissioner Thomas Farley that the bones be cremated “because biohazard disposal processes would not destroy them,” the report read.

But because the employee who disobeyed the cremation order wouldn’t talk to investigators, it’s unclear why the remains were never cremated. Because of shoddy record-keeping, it’s unclear why they were kept in the first place.

3. We now know exactly what was in the box.

The box contained 11 packages with human remains, including a femur, several jawbones, teeth, and other bone fragments.

Investigators were able to tentatively link some to victims, including John Africa, MOVE’s leader, and several of the five children who died in the bombing, but others could not be identified. Investigators urged city officials to get the identification completed, change the manner of death for all 11 victims from accident to homicide, and revisit the causes of death. In some cases, the listed cause of death was not robustly supported by evidence and should be changed to “unknown.”

4. City officials worried the box’s existence would become public.

Farley 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. (It’s legal for medical examiners to cremate specimens without notifying families, but investigators concluded the Philly medical examiner’s office should not have considered the remains in the box disposable, and should have immediately told the MOVE families it had the remains.)

Farley’s 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 different 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 the University of Pennsylvania also had MOVE victims’ remains in its possession, Farley and Gulino waited nearly 10 days to tell superiors about the 2017 cremation decision.

» READ MORE: Philly health commissioner resigns over cremating MOVE victims without telling family; Kenney apologizes

5. Systemic problems at the Medical Examiner’s Office persist today.

The office continues to be understaffed, the report concluded, without enough people to ensure an investigator is present to participate in every homicide investigation in the city, potentially undermining public trust and jeopardizing legal cases.

If more stringent record-keeping and custody policies had been in place, the report suggested, remains might not have ended up languishing at the Medical Examiner’s Office for decades. But even just five years ago, the contents of the box were described only as “items found in move box.”

6. Next up: Fixing the Medical Examiner’s Office and remembering victims.

The Philadelphia Medical Examiner’s Office is one of the few in an American big city that is not accredited, and the report urged the city to get going on the process, which could take years.

The Philadelphia Department of Public Health stated in a response to the report that some recommendations are already being implemented. “We are committed to working with the families of the victims to identify a respectful plan for how to handle the remains,” the agency said.

The report’s authors spoke with relatives of the people killed in the 1985 bombing. Several mentioned wanting a formal apology from present and former city and state officials. Debbie Davis, Michael Africa Jr., and Michael Davis Sr. — all members of the Africa family, the surname adopted by many MOVE members — also requested reparations for survivors, some of which could go to a memorial for the victims of the bombing. They also asked that the bombing be included in city schools curricula and a scholarship be established for the children and grandchildren of the survivors.

Read the full report here: