By Cassie Watson; posted 30 July 2016.
The Coroner’s Inquest: A Brief History
By the nineteenth century coroners had been investigating sudden or unexplained deaths for over six centuries. In a legal inquiry known as an inquest, a coroner and jury viewed the body of the deceased, examined witnesses, and reached conclusions about the cause and manner of death – whether natural, accident, suicide or homicide. But there were relatively few coroners in England and Wales: about 330 served a fast-growing national population in which several hundred thousand people died annually. How did they decide which deaths to investigate?
It depended on circumstances. Inquests were supposed to be held in cases of death from obvious violence or which occurred in prison, but other potentially criminal cases were distinguished from the mundane at a local level – coroners could not act until formally notified by a member of the public. To function effectively, the system required popular opinion to reveal evidence of foul play, and came to rely on parish officers to act as middlemen between local inhabitants and coroners who might live miles away. Once the necessary notification, “which regularly ought to be from the proper or peace officer of the parish, place, or precinct where the body lies dead” had been made, the coroner was legally obligated to hold an inquest. And therein lay a problem: inquests incurred costs which it fell to the counties to reimburse.
From 1752 to 1860, when coroners became salaried officials, they were paid per inquest “duly held” (£1 rising to £1.6s.8d in 1837) plus travel expenses of nine pence per mile (one way only). Parish officers were paid for notifications, summoning witnesses and jurors, renting premises and arranging inquests. In 1836 the Medical Witnesses Act authorised coroners to pay a doctor up to £2.2s to perform a post-mortem and give evidence, while the introduction of civil registration in 1837 led to increased numbers of inquests because causes of death had to be certified. As expenditure rose, cost-conscious county magistrates began to scrutinize, and sometimes reject, coroners’ claims for payment, on the grounds that certain inquests had been unnecessary.
In their work on suicide, both Olive Anderson and Victor Bailey noted that post-mortems tended to be ordered more often by urban coroners than by rural ones. According to Anderson,
“Town coroners, moreover, received a high proportion of their cases from public hospitals, and upon these they had the benefit of free medical evidence, since until 1926 no doctor whose duty it had been to attend the deceased was entitled to be paid for giving evidence at an inquest upon his or her body.”
But this wasn’t enough to keep costs down, and disputes between coroners and magistrates were probably most intense during the 1840s and 1850s. The introduction of the new police from the mid-1830s offered magistrates a welcome way to cut costs: the inquest-related tasks formerly done by parish constables were delegated to the police as part of their regular duties and so the coroner’s officer emerged as the formal intermediary between coroners and their constituents. This was most obvious after 1856, when the County and Borough Police Act established county constabularies and finally swept away the parish constables;but the process evidently began earlier.
In November 1842 an inquest was held on the body of John Hunter, a 37-year-old Mancunian who had died from arsenic poisoning. Although controversial in its day, it is not the crime but one of the witnesses that is relevant here:
“Isaac Philipson, police inspector and coroner’s officer, visited the house on 29 November to see if it was a case for an inquest, and she [the victim’s wife] told him deceased’s death was expected and he’d been dying from his toes and finger ends for many days.”
Philipson didn’t believe this and Mary Hunter was charged with murder, tried, and acquitted. Isaac Philipson, for whom this was the second poisoning case of 1842, disappeared into history. Who was he?
Early in 1839 the Manchester Borough Watch Committee was formed to oversee the creation of a new Manchester Borough Police force, and its records show that in July a coroner’s officer, Inspector William Sickle, was appointed at a weekly salary of 27s. Six months later the job was being done by a constable, and in October 1842 it passed to PC Isaac Philipson, who had joined the force the previous month. This promotion brought a pay rise of 10s per week, but it ended badly two years later when he “tried to resign in controversial circumstances” and was dismissed. Then the salary of the coroner’s officer was lowered to 24s.
Philipson’s fall from grace awaits its historian: although there is a substantial historiography on coroners, we know much less about the coroner’s officer. Although the Manchester coroner seems actively to have encouraged the position, others were less happy at being forced to work exclusively with the police – which was the scenario that emerged in the wake of the 1856 Act.
We can see how this happened in Berkshire and Oxfordshire, two of the last counties to establish a constabulary (February 1856 and March 1857, respectively). In July 1857 the Chief Constable of the Berkshire force wrote to the county coroners to ask them not to pay the police for organising inquests, but to bill the county treasurer. One of the Oxfordshire magistrates noted that this letter had quickly had the desired effect: by intimating that all unnecessary expenses would be disallowed, the police in Berkshire were now always employed by the coroners. Correspondence shows that the issue was one of national importance and that although some coroners were unhappy with this new arrangement, they had little choice in the matter. The police thus gained an important role in inquest procedure: coroner’s officers tended to be constables or sergeants who decided in practice whether an inquest should be held.
The Work of a Coroner’s Officer
Coroner’s officers are of interest to the history of death investigation because they had the power to rule out the need for medical evidence in cases of accident and suicide. Surviving depositions show that the coroner for the city of Oxford at the turn of the twentieth century, Henry Frank Galpin, was quite careful in conducting inquests, a large proportion of which were held in the Radcliffe Infirmary and thus included testimony from the house surgeon. Although the depositions are brief, it is clear that Galpin was concerned by the deaths of young children and sought medical confirmation of whether they were well cared for, particularly if they were insured. Where families alleged that poor medical care had contributed to death, the coroner explored the medical facets of the case thoroughly. But in some cases of suicide the coroner’s officer, Sergeant John Owen Cross, provided the only semi-medical evidence on offer.
When 57-year-old Joshua Fathers was found drowned in the Oxford Canal in January 1901, the inquest heard testimony from his wife, a publican, the man who found his body, and Cross, who testified that there were “no marks of violence” and no suicide note. Although coroner’s officers could be highly experienced, and this type of testimony was probably common, it adds a further dimension to the history of death investigation, since it was not a doctor or community consensus but a single police officer who determined that it was a case of suicide.
Cross took on an even greater medical role the following month, when a child was killed by a train while playing on tracks near the station. His testimony sounds just like that of a qualified medical practitioner, with two important exceptions: he neither states the cause of death nor that it is his professional opinion that particular medical indicators caused death.
“I received the body of the deceased into my presence on Saturday the 16th. The skull of the body was smashed to pieces. There was a large hole in the left of the head. Most of the brains were missing. The left upper arm was broken. All the ribs below the 4th on the left were broken. The front part of the pelvis was smashed. The thigh was almost cut off at the groin. The left leg was smashed about 3 inches above the top of the boot. The right thigh was broken. Deceased was disembowelled.”
There was also a sketch of the scene and testimony from the train driver and various eye witnesses. The boy’s death was plainly an accident, and the inquisition (the formal record of an inquest) listed the cause of death as “died from being hit by a passing train of the GWR”.
It is uncertain how typical this sort of medicalized testimony by a coroner’s officer was, although coroners and their juries had long been accustomed to making decisions about the necessity for expensive medical or scientific evidence. The historical arguments about the diligence with which homicide was investigated continue: the role of coroners and the police have been noted, but the debate might now be further advanced by a detailed study of the Victorian coroner’s officer. In London, their emergence as full-time investigators streamlined inquest proceedings and, combined with greater use of expert witnesses, meant that inquest juries “had their minds made up for them more often than before.” This is a process which, it is to be hoped, future research will illuminate more clearly in a national context.
 For the history of the office of coroner, see P.J. Fisher, “The politics of sudden death: the office and role of the coroner in England and Wales, 1726-1888” (unpublished PhD thesis, University of Leicester, 2007), available online at British Library EthOS, http://ethos.bl.uk/SearchResults.do; and I.A. Burney, Bodies of Evidence: Medicine and the Politics of the English Inquest, 1830-1926 (Baltimore, 2000).
 Edward Umfreville, Lex Coronatoria: or, the Law and Practice of the Office of Coroner, rev. edn. (Bristol, 1822), 167.
 P. Fisher, An Object of Ambition? The Office and Role of the Coroner in Two Midland Counties, 1751-1888 (Leicester, 2003), 29; J.D.J. Havard, The Detection of Secret Homicide: A Study of the Medico-legal System of Investigation of Sudden and Unexplained Deaths (London, 1960), 37-66.
 O. Anderson, Suicide in Victorian and Edwardian England (Oxford, 1987); V. Bailey, “This Rash Act”: Suicide Across the Life Cycle in the Victorian City (Stanford, CA, 1998).
 Anderson, Suicide, 27.
 On the new police see D. Taylor, The New Police in Nineteenth-Century England (Manchester, 1997).
 The National Archives [TNA], PL 27/11, box 2 (Lancashire), Regina v. Mary Hunter, 1842.
 TNA, PL 27/11, box 2 (Lancashire), Regina v. Francis Bradley, 1842.
 Gerard Lodge, “Manchester Borough Police 1839 – July 1842”, http://www.manchester-family-history-research.co.uk/new_page_33.htm.
 Gerard Lodge, “Manchester Borough Police Force second part July 1842 – Dec 1843”, http://www.manchester-family-history-research.co.uk/new_page_34.htm. Quoted by permission.
 Oxfordshire History Centre [OHC], COR VIII/3, As to coroners summoning juries and witnesses etc through medium of county police, 1857.
 OHC, Coroner/City/1901 (Accl 1344), inquest 21 January 1901 on the body of Joshua Fathers.
 OHC, Coroner/City/1901 (Accl 1344), inquest 18 February 1901 on the body of Frederick Henry Mobey.
 Ibid. This is not a medical cause of death (which was traumatic brain injury), but a statement about the manner of death. The GWR was the Great Western Railway (company, 1833-1948).
 For a brief summary, see Fisher, “Politics of sudden death”, 235-248.
 Anderson, Suicide, 257.
[Image courtesy of Wellcome Library, London, A juror protesting that the subject of a coroner’s inquest is alive , 1826.]