About Coroner’s Inquests

Some Notes About Coroner’s Inquests


The Coroner

A Coroner is a locally appointed official, holding long-standing medical or legal knowledge, who is charged to investigate any sudden, questionable or violent death.

When such a death occurred, a constable of the parish was required to summon together thirteen reputable men to act as the jury, to view the body and hear the evidence from the witnesses who had been called by the Coroner on police advice.

The inquest would often take place on the same day, or within a day or so, and in a local establishment, such as a hotel or a manorial house. In Salisbury City many were held in the Council House, or in the Infirmary where some cases died, but in small parishes or remote villages they may have been held in a cottage local to the scene of death, this decision resting with the Coroner. After 1902 inquests were not allowed to be held in licensed premises, though sometimes there would be no other place available.

Role of the Jury

The jury is there to hear the evidence and ultimately make the final decision. This decision is often swayed for them by the guidance of the Coroner in summing up. Where the newspaper reports vary from the actual Inquest report held in records offices, is in the cut and thrust of what was said. The Coroner’s report will stick to answers and facts, the newspaper will report conversation and cross-questioning, often painting more of a picture than official documentation would allow.

The members of the jury were allowed to ask a question of a witness in order to clarify a point, and would occasionally stray from the point of the inquest, which, as the Coroner would make clear to them, is simply to find on the cause of death.

Many of the jury would likely be local tradesmen, who were obliged by the Coroner to leave their business for some hours at short notice, and who may have resented the interruption to their day, and so wish for a speedy resolution. In tragic cases, particularly where the death of a breadwinner has left a widow and children, the jury gave their nominal fees to the suffering relict.

A foreman of the jury would be elected, and in the city tended to be a prominent person or councillor, such as the developer Mr Scamell.

Medical Witnesses

These were generally local doctors or practitioners, or surgeons at the Salisbury Infirmary, or other medical specialists who happened to be passing at the time of death. Their role was to examine the body and report their opinion on cause of death, or, in the case of their being a material witness, to give expert testimony to that effect.

Whilst the Coroner and the jury would try to extrapolate some of the circumstances surrounding the death, the medical witness was there to testify to the actual cause of final death. Medicine was not the advanced science we see today, and a doctor then was not capable of testing and diagnosing as modern physicians can. In some cases it seems that the doctor in the case is generalising or making a guess, but similarly they tended to keep their methodology to theirselves.

People may have died from a whole gamut of possible circumstances, but the medical witness was not there to sum up a persons recent life, only the final moments of it. In almost every death one could say the cause was syncope – failure of the heart’s action – and sometimes that seemed to be the sum contribution the doctor was capable of making. There were of course any number of untreatable infectious diseases.

Causes of Death

In many cases the cause of death was reasonably obvious. Where a person of a certain age had collapsed dead, most doctors of the day were unable to do much more than pronounce that the person died from failure of the heart’s action, or, supposing the person to have been moderately healthy, a post mortem examination may be undertaken, when the doctor would sum up the likeliest cause.

Accidents were many and various, particularly on the roads and railways, anywhere around horses and all wheeled vehicles. There were a smaller but still significant number of accidents involving falling down stairs. Some drownings were accidental, but many were also deliberate. Suicide sometimes took place in the cold silent water at night, but also on the metals of the permanent ways.

In a case of suicide sufficient evidence was required for such a verdict, though not all cases are clear cut, as in the case of the man who stepped in front of a steam roller (Charles Wiltshire 1912), or in a number of self-shooting cases when the gun lying nearby was the only evidence. Evidence of a persons state of mind played a role here, the jury often finding that a person suffered temporary insanity at the moment of the action.

In the most serious cases where foul play was suspected, the jury were responsible for deciding between manslaughter and murder, and in such a finding the Coroner was obliged to commit a prisoner for trial. This also applied to the deaths of young babies, particularly when the mother was single and in domestic service, and it was in her interest not to reveal her condition.

Some Brief Notes on Different Case Types

Railway Inquests

These often had a peculiar tendency to be tetchy affairs. This is partly because the railway companies – employing legions of men and allowing hundreds of them to die every year in terrifying accidents – were highly protective of their reputations. An inquest of a railway accident was sometimes attended by several railway officials, local heads of the Permanent Way Department, of the Railway Police and of the Locomotive Department. Where there was even a hint of wrongdoing or negligence on the part of the company, the lowly railway engine driver, shunter, platelayer or yardsman, would find himself in the witness box facing his grim-faced employers, knowing his job may be on the line if he said what he wanted to say. Such influence was not brought to bear in all railway cases, but it is evident in a number of the ones in this study.

In 1902 new regulations were enacted by the Board of Trade to tighten safety on the railways, eg: It became illegal to move trucks by means of props or poles or with a rope or chain attached to a vehicle moving on an adjacent line.

The last rule related to providing adequate light and look-out for those men working on the lines – in 1901 ninety five men were killed and 117 injured whilst working in the permanent way, 164 were killed and 300 injured crossing lines, and 114 killed and 240 injured in and about stations. The terrifying case late in the dark evening of Herbert Pearce in 1913 displays the fact that lighting and safety for men working on the tracks was still perilously inadequate a decade later.

The railway companies were understandably anxious not to take too much blame for these enormous casualties, but the greatest fault did undoubtedly lie with them. However, in reading some of these accounts it is also evident that many men took crazy and needless risks jumping on and off moving vehicles, walking home along the line, or taking shortcuts. Doubtless they were under pressure to do so.

With regard to one or two technicalities, I can state the following. An Up platform is that giving trains to the major station, as the Down receives trains down from said station. At Salisbury, on the London & South Western Railway, their Up platform (for Waterloo) was behind St Paul’s Road, and their Down platform was our current station. This was also the case at Templecombe, Somerset.

In Salisbury the first railway was the Great Western, with its’ wide gauge running from Westbury down via Warminster to Salisbury. The LSWR came from Andover into the eastern side of Salisbury later on with its’ four-feet gauge. Where we hear talk of the “four-feet way,” that refers to the actual tracks carrying live vehicles. The “six-feet way” refers to the standard gaps between sets of tracks where men would stand when couplings, which could still be highly dangerous

Fire and Burning

In a time when everyone lived by a coal or wood fire, and read by gas lamps and candles, and when matches could be struck alight against any rough surface, burning was a common cause of death. There are a number of cases of elderly people or the disabled drooping across the fire in their sleep, and waking up in a ball of flames.

More distressing are the numerous deaths of babies and small children. Two major contributory factors in these deaths were a lack of proper fireguards and the wearing of flannelette clothing. Again and again the Coroner and jurymen would bemoan the lack of protection from open fires because the parents or landlords had not provided suitable fireguards. Flannelette clothing was not the cause of burning, but this popular new cotton fabric – because of its fibrous nature – caught flames and spread them very quickly, all the more terrifying when it was largely used for baby clothes. Illness of a parent in these hard-working times often meant that the children were largely unsupervised, and accidents in the home became much more likely, adding to the parent’s woes.

Many of these cases are pitiable and moving, but one is almost comical in its tragedy. In the case of 1910, Mr William Lewis attended the Victoria Park Ice Skating Carnival dressed from head to foot in cotton wool to represent an Arctic explorer. Whilst waiting to go on the ice, he lit a cigarette…. .

Roads and Lanes

Roads were just as much an ever present danger then as they are now. More so, in respect that this was a time of change, when horses and their various loads mixed with farm animals alongside keen and somewhat reckless cyclists. There were various steam-driven engines hauling huge loads, and of course, the roads themselves were still largely undefined, unlit and unsurfaced. There were rules of the road, but children and animals knew them not.

Cars and motor-cycles were just about to make their bloody mark on the roads of the nation, but children were equally the victims of horses and carts as they were later of cars. A little girl, Gladys Lorenza Dafter, ran against the wheel-box of a passing cart in Devizes Road in 1906 and fell down dead from the impact. From the witness’ graphic description , one can almost see this younger child – head down – determinedly run across after her playmates. The crowd of mourners and children who proceeded up Devizes Road would match those who attended the well-remembered funeral of little Edwin ‘Teddy’ Haskell two years later,

In spite of the cold weather it was a long time before the crowd had departed, indeed new white snow and old brown earth had been filled in above the coffin before the last was gone.”


Suicides were a regular occurrence then as now, though the causes were a little different. In some cases they were a conscious decision based on the knowledge that there was simply nothing left. The case of Henry John Smith in 1905 who had a final drink with his last pennies before putting his head on the railway line, or the case of Henry Farley in 1910, an old shepherd whose employer had given him notice to leave – which included leaving his tied cottage – and who rather than end his days in the Union Workhouse chose to hang himself in the doorway of the outhouse.

Suicide and Illegitemacy

Illegitemacy was a highly controversial subject in certain strata of Victorian and Edwardian society, and can be seen or suspected to be the cause of suicide in a number of cases.

The bearing of a base-born child was often not a great problem to the lower working class, where the child would be loosely adopted by the mothers parents – this can be seen time and again in the census entries of the period.

But for many girls, however, the only available work was to go into service as a house-maid, chamber-maid or parlour-maid, and in such positions the moral stature of the girl was viewed very strictly. If she found herself pregnant, she would be given notice, and if her parents would not or could not take her back, desperate times lay ahead. The case of Elsie Kenchington in 1908 clearly shows the immense pressure this teenage girl was under, and her desperate attempts not to reveal her condition.

Girls of middle-class origin would often live in households where illegitemacy was severely frowned upon, and there are a number of cases of suicide – mostly through drowning or railway-trespass – that one suspects are due to this cause, although the Coroner and witnesses shy away from naming it openly. In cases like this, the Coroner will often ask if she had been seeing a boy, but rarely will the Coroner or jurymen venture into the realm of asking about the deceased’s condition.


There are a number of cases where an act of stupidity or violence led to a death, and the jury brought in a verdict of Murder. The Coroner would then pass a warrant for the accused’s trial in the County Assizes. Several of these cases, such as the Stephen Day case in 1904, are a moment of hotheadedness carried to the worst outcome, and the price paid by the accused in the Day case is seen the following year.

However, there were also one or two insane murders, such as that by Frederick Jefferies, though none worse perhaps than the long-forgotten Peter Head case of 1905, in which the father calmly brought his six children from school, took them for a walk in the woods, and murdered them and himself.

Journalistic Technique

The reporting of a Coroner’s inquest by a local newspaper like the Salisbury Times was very much subject to the demands of the day, particularly if there was more important news at hand, such as long rambling accounts of Liberal Party Dinners, Railwayman’s Dinners and the like. That said, the Salisbury Times was very much the paper of the labouring class in Salisbury, and made a point of filling its pages with local news items of general interest.  Stories of a cow down a well or a horse crashing into a shop shared the columns with small items about an accident in the street or amazing items such as a toddler climbing up a thirty-foot ladder.

News was also carried from elsewhere if it was of interest, and thus we find Coroner’s inquests not just for Salisbury City, Wiltshire, and parts of Hampshire, Dorset and Somerset, but also inquests featuring a train from Salisbury, or of someone who used to live in the city.

When there was a lot of news flying about the reports of inquests could be quite contracted, a bare one or two paragraphs summing up the gist of the evidence. But in most cases, particularly when the cases were local, the evidence was reported pretty thoroughly, and answers quoted as verbatim, though one cannot be totally reliant on accuracy.

The difference between the Coroner’s actual report and the journalistic copy is in what was actually said on the day. In some cases the jury might ask potentially awkward questions of a witness, and seek to pursue the possible negligence of a railway company or the possible inability of a doctor to a degree beyond what the Coroner would care for. None of this would appear in the Coroner’s report.

Where an account contains the phrase “By the Coroner/Foreman, etc..”, this means that that the following sentence is evidence elicited from a witness by this person.



©  www.salisburyinquests.wordpress.com, 2011. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to   www.salisburyinquests.wordpress.com with appropriate and specific direction to the original content.

I acknowledge with thanks the permission of Salisbury Journal to reproduce their materials in this blog.


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